Venous thromboembolism in Cushing syndrome: results from an EuRRECa and Endo-ERN survey.

Background: Patients with Cushing syndrome (CS) are at increased risk of venous thromboembolism (VTE). Objective: The aim was to evaluate the current management of new cases of CS with a focus on VTE and thromboprophylaxis. Design and methods: A survey was conducted within those that report in the electronic reporting tool (e-REC) of the European Registries for Rare Endocrine Conditions (EuRRECa) and the involved main thematic groups (MTG's) of the European Reference Networks for Rare Endocrine Disorders (Endo-ERN) on new patients with CS from January 2021 to July 2022. Results: Of 222 patients (mean age 44 years, 165 females), 141 patients had Cushing disease (64%), 69 adrenal CS (31%), and 12 patients with ectopic CS (5.4%). The mean follow-up period post-CS diagnosis was 15 months (range 3-30). Cortisol-lowering medications were initiated in 38% of patients. One hundred fifty-four patients (69%) received thromboprophylaxis (including patients on chronic anticoagulant treatment), of which low-molecular-weight heparins were used in 96% of cases. VTE was reported in six patients (2.7%), of which one was fatal: two long before CS diagnosis, two between diagnosis and surgery, and two postoperatively. Three patients were using thromboprophylaxis at time of the VTE diagnosis. The incidence rate of VTE in patients after Cushing syndrome diagnosis in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Conclusion: Thirty percent of patients with CS did not receive preoperative thromboprophylaxis during their active disease stage, and half of the VTE cases even occurred during this stage despite thromboprophylaxis. Prospective trials to establish the optimal thromboprophylaxis strategy in CS patients are highly needed. Significance statement: The incidence rate of venous thromboembolism in our study cohort was 14.6 (95% CI 5.5; 38.6) per 1000 person-years. Notably, this survey showed that there is great heterogeneity regarding time of initiation and duration of thromboprophylaxis in expert centers throughout Europe.

Cost-Effectiveness of Including a Nurse Specialist in the Treatment of Urinary Incontinence in Primary Care in the Netherlands.

OBJECTIVE: Incontinence is an important health problem. Effectively treating incontinence could lead to important health gains in patients and caregivers. Management of incontinence is currently suboptimal, especially in elderly patients. To optimise the provision of incontinence care a global optimum continence service specification (OCSS) was developed. The current study evaluates the costs and effects of implementing this OCSS for community-dwelling patients older than 65 years with four or more chronic diseases in the Netherlands. METHOD: A decision analytic model was developed comparing the current care pathway for urinary incontinence in the Netherlands with the pathway as described in the OCSS. The new care strategy was operationalised as the appointment of a continence nurse specialist (NS) located with the general practitioner (GP). This was assumed to increase case detection and to include initial assessment and treatment by the NS. The analysis used a societal perspective, including medical costs, containment products (out-of-pocket and paid by insurer), home care, informal care, and implementation costs. RESULTS: With the new care strategy a QALY gain of 0.005 per patient is achieved while saving €402 per patient over a 3 year period from a societal perspective. In interpreting these findings it is important to realise that many patients are undetected, even in the new care situation (36%), or receive care for containment only. In both of these groups no health gains were achieved. CONCLUSION: Implementing the OCSS in the Netherlands by locating a NS in the GP practice is likely to reduce incontinence, improve quality of life, and reduce costs. Furthermore, the study also highlighted that various areas of the continence care process lack data, which would be valuable to collect through the introduction of the NS in a study setting.

[Nutrition and nutritional status of female somatic nursing home patients]. / Voeding en voedingstoestand van vrouwelijke somatische verpleeghuispatiënten.

OBJECTIVE: To determine if the intake of energy and particular nutrients is adequate among elderly non-demented nursing home patients, and to identify possible causes of a marginal status. SETTING: A nursing home, neighbouring service flat and a group of independently living elderly in Zeist, the Netherlands. DESIGN: Descriptive cross-sectional study. METHOD: Data were collected about habitual food consumption, anthropometry and indicators of nutritional status from 51 female nursing home patients (response 65%), 29 elderly women living in service flats (response 56%) and 52 independently living elderly women. Comparisons were made among the groups, with the recommended dietary allowance and with cut off values. RESULTS: The mean daily energy intake of 5.9 MJ (SD: 1.4) by the group of nursing home patients was lower than the recommended allowance (7.8 MJ). Mean values for the anthropometric measurements hardly varied among the groups. This suggested that the low energy intake was in accordance with the actual energy requirement. Especially among the nursing home women low blood levels were frequently seen of folic acid, pyridoxine, 25-hydroxy-vitamin D, vitamin C and selenium. A lower food consumption and unfavourable food choices were considered to be mainly responsible. Low mobility and pathological processes may also play a part. CONCLUSION: Low blood levels among non-demented nursing home patients were caused by low food consumption, unfavourable food choices and probably by health status. Prevention may include: more physical activity (whenever possible), giving information to patient and nurse, supplying food with higher nutrient density, presenting more menu choices, reporting to physician or dietician when food offered is not eaten.

Vitamin C status in elderly women: a comparison between women living in a nursing home and women living independently.

The vitamin C status in blood fractions in 135 elderly women aged 65 years and older was studied within the framework of the Dutch Nutrition Surveillance System. Mean (+/- standard deviation) vitamin C intake (mg/day) was lower among women living in a nursing home (54 +/- 27 mg/day) than among women living in service flats (97 +/- 55 mg/day) and women living independently (132 +/- 44 mg/day). (Service flats are apartments in which the rent includes housekeeping and, when ordered, meal service.) Marginal vitamin C values (< 23 mumol/L) in blood fractions and even levels as low as those found in clinical scurvy (< 11 mumol/L) were frequently observed. In the nursing home, 35% of the women had plasma vitamin C values below 11 mumol/L, and 23% had values between 11 and 23 mumol/L. Blood levels were not significantly affected by age, smoking status, or use of particular drugs but were strongly (r = .47 or, after logarithmic transformation, r = .64) associated with daily intake of vitamin C. Low intake of vitamin C resulted from an overall low food consumption and selective restriction of food products rich in vitamin C. Vitamin C losses caused by food preparation practices and distribution in the nursing home's catering system reduced actual vitamin C intake levels but these losses were not substantially greater than those that are assumed to occur as a result of preparation practices by women living independently.

Marginal nutritional status among institutionalized elderly women as compared to those living more independently (Dutch Nutrition Surveillance System).

The nutritional status (assessed by anthropometric indices, and biochemical and hematological variables in blood) of three groups of elderly women (aged > or = 65 years) was evaluated within the framework of the Dutch Nutrition Surveillance System. The groups were composed of women living in a nursing home (n = 51), women living in service flats and receiving their dinners from the nursing home kitchen (n = 29), and women living independently (n = 52). Mean blood levels of folate, pyridoxal 5'-phosphate, 25-hydroxyvitamin D, alpha-tocopherol, vitamin C, albumin, selenium and total cholesterol were significantly (p < 0.05) lower among nursing home women. Among these women a biochemical deficiency was frequently found for 25-hydroxyvitamin D (73%), pyridoxal 5'-phosphate (57%), vitamin C (38%), selenium (30%) and folate (28%). These nutritional risks were largely independent of each other. Since folate and pyridoxal 5'-phosphate were associated with several clinicochemical indicators, health status may be an important determining factor for this unfavorable situation. Low 25-hydroxyvitamin D concentrations were associated with limited exposure to ultraviolet radiation and nonusage of vitamin D supplements. We conclude that dietary intake variables are not the only determinants of a marginal nutritional status among nursing home women. Use of foods with a high nutrient density should be encouraged, whereas other preventive measures are needed to improve vitamin D status.

Institutionalized elderly women have lower food intake than do those living more independently (Dutch Nutrition Surveillance System).

The habitual intake of energy and nutrients (assessed through dietary history) among elderly women (aged 65 and over) living in a nursing home (n = 54), elderly women living in service flats and receiving their dinners from the nursing home kitchen (n = 29), and elderly women living independently (n = 52) was evaluated within the framework of the Dutch Nutrition Surveillance System. Intake of energy and nutrients was lowest among women in the nursing home and highest among those living independently. Almost all differences in absolute intake found were significant, both unadjusted and adjusted for age. In the nursing home the intake of energy and nutrients was lower at higher age. In qualitative terms the differences among the groups of women were less striking. Mean daily intakes of iron, vitamin A, thiamin, vitamin B6 and vitamin C were below the Dutch recommended dietary allowances (RDAs) among the nursing home women. Several interrelationships among nutrient intakes were found, low intake levels clustering somewhat among elderly subjects. Our data indicate that these nutritional risks are due to a lower food intake resulting in a lower intake of energy and nutrients, and owing to differences in food choice resulting in a lower nutrient density. We conclude that it is difficult to design a diet containing all essential nutrients at the RDA level in a nursing home with residents who have a relatively low intake of energy, especially among those at higher age.

Urinary and faecal incontinence in community-residing elderly women.

The prevalence of urinary and faecal incontinence was investigated in a sample of 1049 women aged 60 years and over in the municipality of Amstelveen, the Netherlands; 719 postal histories were completed. The overall prevalence of urinary incontinence was 23.5%. Daily urine loss was reported by 14.0% of all women. In women aged 60 to 84 years and 85 years and over 4.2% and 16.9% were faecally incontinent, respectively. In all age groups poor mobility and frequency were associated with urinary incontinence. Urgency was independently associated in women aged 60-85 years as was nocturia in women aged 85 years and over.

Interhemispherical comparisons in the processing of contour and random texture sinewave stereograms.

Contour and random texture stereograms were developed, using continuously variable, vertically oriented, sinewave horizontal disparities and variable texture densities. The contours were both computer printed and generated, and presented on a dual-beam oscilloscope; the textures were generated on a UNIVAC-to-Calcomp plotter, photographed, and then presented as slides, via rear-view polarized screens, in both static and dynamic modes. By means of fixation control, in normal subjects, the images in the right and left visual fields (thus: left and right visual cortices) were studied either separately or together. Parameters such as apparent depth, rate of depth-phi-motion, target density (matching and mismatching), depth ripple rate, Panum's horizontal fusion-disparity limits, and imposed monocular vertical prismatic imbalance, were studied for the separate hemispheres. In all but a few instances, the results show comparable, thus symmetrical, performances for right and left visual cortices. In those few instances where we could say that clear inter-cortical differences were found, they were found with both contour and texture targets. Furthermore, the density range of the targets (from 0.5 down to 0.005) was chosen so as to cover the phenomenal and physical range from true textures, at the high density end, to single disparate dots, at the low disparity end. But no sharp flex points were found, for any of several parameters, when moving from textured to dot targets. Although generally, observer and hemispherical variance were greater with the higher densities, the curves (with density) were ogival or S-shaped in form and never discontinuous. These results are discussed in the context of two previous findings in the literature. We cannot support the claim that there is somehow a difference in the way in which the visual cortex processes localized dot or contour targets from the way in which it processes pattern or texture targets. Secondly, the literature tends increasingly to support the contention that right occipital injuries hinder the processing of texture stereograms but not that of dot or contour stereograms. Since we could find only a scattered enhancement of right hemispherical prowess in normal vision, with both sorts of stereograms, this suggests that, - should these effects be reliably found in such patients, - they would have a different and non-congenital basis.