[Focusing on intersectorality-strategies and current research projects for the care of geriatric people]

In view of the demographic change, the need for intersectoral care of the aging population has already been identified. The strategies for implementation are diverse and address different approaches, each of which requires different sectors to overlap. This article provides an overview of already completed and ongoing projects for the care of geriatric patients. It becomes apparent that the development of networks as an indispensable basis for intersectoral care cannot be measured in terms of direct intervention effects and therefore makes it difficult to prove the cost-benefit. It is also evident that some research projects fail to be implemented into standard care due to financial and staff shortages.Do we need a rethinking in Germany or less innovation-related funding lines for better implementation and research of existing concepts? International role models such as Japan show that cost reduction for the care of the aging population should be considered in the long term, which requires increased financial volumes in the short term. For a sustainable implementation of cross-sectoral approaches into everyday life, research should therefore reorganize tight and/or entrenched structures, processes, and financing. By linking the countless existing projects and integrating ideas from different sectors, future demands of intersectoral geriatric care may be achieved.

Sex-Specific Associations between Serum IL-16 Levels and Sarcopenia in Older Adults

Epidemiological studies of older adults have suggested a differential sex-specific prevalence of sarcopenia, which is a condition characterized by a progressive loss of skeletal muscle mass and function. Recently, we collected serum samples from 80 fully evaluated older adults and identified CXCL12α as a sex-independent serum marker of sarcopenia. Here, we used this serum collection to find potential sex-specific serum markers via the simultaneous quantification of 34 inflammatory cytokines/chemokines. The appendicular skeletal muscle index (ASMI) was used as a decisive criterion for diagnosing sarcopenia. A Pearson correlation analysis revealed a negative correlation between ASMI and serum IL-16 in females only (p = 0.021). Moreover, women with sarcopenia exhibited significantly higher IL-16 (p = 0.025) serum levels than women in a control group. In contrast, males with sarcopenia had lower IL-16 (p = 0.013) levels than males in a control group. The further use of Fisher's exact test identified obesity (p = 0.027) and high serum levels of IL-16 (p = 0.029) as significant risk factors for sarcopenia in females. In male older adults, however, malnutrition (p = 0.028) and low serum levels of IL-16 (p = 0.031) were the most significant risk factors for sarcopenia. The differential sex-specific associations of IL-16 in older adults may contribute to the development of more precise regression models for future research and elucidate the role of IL-16 in the progression of sarcopenic obesity.

Unsaturated Long-Chain Fatty Acids Activate Resident Macrophages and Stem Cells in a Human Skeletal Muscle Tissue Model

Phenotypically heterogeneous populations of tissue-resident macrophages and stem cells play important roles in the regeneration of the skeletal muscle tissue. Previous studies using animal and cell culture models implied a beneficial effect of fatty acid (FA) species on tissue regeneration. Here, we applied a human experimental model using excised muscle tissues from reconstructive surgeries to study the effects of FAs on resident macrophages and stem cells in the natural environment of human skeletal muscle tissue. Muscle tissue samples from 20 donors were included in this study. The expression of 34 cytokines/chemokines was determined, using multiplex protein analysis. The phenotypes of macrophages and stem cells were determined immunohistochemically. The numbers of CD80+ macrophages correlated with the expression levels of IL-1α, IL-1RA, IL-8, IL-17A, and MCP-1, while the PAX7+ and MyoD+ stem cell counts were positively correlated with the expression level of CXCL12α, a recognized chemoattractant for muscle stem cells. Treatment of additional tissue sections with FAs revealed that CD80+ or MARCO+ macrophages- and PAX7+ or MyoD+ stem cells were simultaneously increased by unsaturated long-chain FAs. Taken together, this is the first experimental demonstration of a coordinated activation of macrophages and stem cells in human skeletal muscle tissue.

Assessment of psychological and physical stressors among nurses in different functional areas before and during the COVID-19 pandemic: a cross-sectional study

BACKGROUND

The COVID-19 (coronavirus disease) pandemic placed a great burden on all health-care resources, especially nurses. The prevalence and underlying risk factors of affective symptoms related to the COVID-19 pandemic have been studied primarily among nurses in intensive care units (ICU) and emergency departments. The aim of this study was to identify at-risk nursing areas by examining the psychological and physical stress values of nurses in different functional areas.

METHODS

A questionnaire with standardized items was developed to assess psychological and physical stress values. At least 50 nurses with a minimum work experience of 3 years were recruited from the ward, outpatient clinic (OC), intermediate care (IMC) unit, and operating room (OR) of the University Hospital RWTH Aachen. The participants answered the questionnaire by referring to their perceptions before and during the COVID-19 pandemic. Absolute differences and relative trends in psychological and physical stress values were compared within and across functional areas.

RESULTS

The ward and OR nurses experienced significant increases in workload (p < 0.001 and p = 0.004, respectively) and time stressors (p < 0.001 and p = 0.043, respectively) during the COVID-19 pandemic. Regardless of functional area, the nurses showed strong tendencies toward increases in subclinical affective symptoms. After adjustments for age, sex, working in a shift system, the treatment of patients with COVID-19, and the impact of the COVID-19 pandemic on personal life, the values for working with pleasure decreased significantly among the ward (p = 0.001) and OR nurses (p = 0.009) compared with the OC nurses. In addition, the ward (p < 0.001) and OR nurses (p = 0.024) were significantly more likely to express intent to leave their profession than OC nurses.

CONCLUSIONS

The IMC nurses showed good adaptation to the exacerbated situation caused by the COVID-19 pandemic. The ward nurses, followed by the OR nurses, were the most vulnerable to mental and physical exhaustion, which threatened the nurses' resilience and retention in the wake of the COVID-19 pandemic. Therefore, intervention programs must specifically address the professional and emotional needs of ward and OR nurses to prepare the health-care system for future crises.

Continuation of Geriatric Discharge Medication in Primary Care and its Association with Rehospitalizations - A Cohort Study

Transition of care in geriatric patients is a complex and high risk process, particularly the continuation of discharge medication in primary care. We aimed to determine how general practitioners' management of geriatric patients' discharge medication is associated with rehospitalizations. A prospective monocentric cohort study was done in an acute geriatric inpatient clinic with six-months follow-up. Acutely hospitalized patients ≥ 70 years old with functional impairment and frailty currently taking medications were followed up after hospital discharge and continuation (n=27) or change (n=44) of discharge medication by the General Practitioner was determined. Outcomes were rehospitalizations, days spent at home and time until recurrent rehospitalizations. 71 patients (mean age 82 years, 46 women [65%]) were followed up for six months after hospital discharge. In a negative binomial regression model, the rehospitalization rate after three months was 3.8 times higher in participants whose discharge medication was changed (p = 0.023). The effect did not persist over six months. Patients who were continued on their discharge medication were rehospitalized significantly later and/or less often during the six months observation period, statistically measured by a recurrent events survival model (HR 0.267, p = 0.003). In conclusion, continuation of discharge medication after an acute hospitalization in a specialized geriatric clinic could prevent early rehospitalizations.

Associations of Serum CXCL12α and CK Levels with Skeletal Muscle Mass in Older Adults

Sarcopenia, a condition characterized by gradual loss of skeletal muscle mass and function, is a complex diagnosis; the decisive criterion in this diagnosis is the measurement of appendicular skeletal muscle index (ASMI). To identify potential serum markers predictive of sarcopenia in older adults, we evaluated correlations between ASMI, clinical data, and 34 serum inflammation markers in 80 older adults. Pearson's correlation analyses confirmed that ASMI was positively correlated with nutritional status (p = 0.001) and serum creatine kinase (CK) (p = 0.019) but negatively correlated with serum CXCL12α (p = 0.023), a chemoattractant for muscle stem cells. In the case group, ASMI was negatively correlated with serum interleukin (IL)-7 (p = 0.024), a myokine expressed and secreted from skeletal muscle cells in vitro. Multivariate binary logistic regression analyses identified four risk factors for sarcopenia in our study: advanced age (p = 0.012), malnutrition (p = 0.038), low serum CK levels (p = 0.044), and high serum CXCL12α levels (p = 0.029). Low CK and high CXCL12α levels serve as combinatorial serum markers of sarcopenia in older adults. The linear correlation between ASMI and CXCL12α levels may facilitate the development of new regression models for future studies on sarcopenia.

Spatiotemporal gait parameters in young individuals wearing an age simulation suit compared to healthy older individuals

INTRODUCTION

Aging is accompanied by changes in muscle mass, strength and loss of sensory, visual and auditive functions. However, these changes do not occur linearly, most spatiotemporal gait parameters change with aging. Age simulation suits have been invented to give young people an impression of the implications of being older and may be a useful tool in the scientific setting for gerontology research to validate any study concept before it becomes a pilot study. The rationale behind this study was to investigate the effects of an age simulation suit on gait parameters in young healthy adults and to compare the altered gait with healthy older, community-dwelling citizens.

METHODS

Subjects were 14 healthy young adults (6 female) and 8 healthy older (4 female) individuals with a mean (± SD) age of 24.8 ± 3.4 years and 72 ± 1.9 years, respectively. After initial baseline measurements had been taken and a familiarization phase, the younger subjects walked for 15 min without and 15 min with an age simulation suit on an instrumented treadmill. The older subjects walked once for 15 min on the same treadmill without wearing an age simulation suit. The walking speed was self-selected for all subjects.

RESULTS

The age simulation suit reduced the walking speed from 4.1 ± 0.7 km/h to 3.3 ± 0.5 km/h (p < 0.001) in young adults with no differences compared to older adults (2.9 ± 0.6 km/h, p = 0.9). Step width increased from 8.7 ± 2.2 cm to 12.1 ± 2.2 cm (p < 0.001) and did not differ from older participants (11.1 ± 4.3 cm, p = 0.37). The stride length was reduced (132.6 ± 5.9 cm vs 118.1 +-6.6 cm, p < 0.001), but still did not match the old control group (94.5 ± 5.6 cm, p < 0.05). Wearing the suit increased thestride time of young subjects (from 1,152 to 1,316 ms, p < 0.001) and was different compared to the older control group (1,172 ms, p = 0.53). The coefficient of variation (COV) of spatiotemporal parameters did not differ between young (both not wearing the suit and wearing the suit) and older subjects. The standard deviation of lateral symmetry, an in-house marker from the instrumented treadmill that serves as a marker of gait variability, differed between young subjects without the suit and older subjects (5.89 ± 1.9 mm vs 14.6 ± 5.7 mm, p < 0.001) but not between young subjects wearing the suit and older subjects (16.4 ± 7.4 mm vs 14.6 ± 5.7 mm, p = 0.53).

CONCLUSION

Wearing an age simulation suit while walking on a treadmill with a self-selected walking speed alters some, but not all, measured spatiotemporal parameters to approximate a gait pattern similar to that of an older individual.

Short-term zinc supplementation of zinc-deficient seniors counteracts CREMα - mediated IL-2 suppression

Background

Aging is accompanied by a dramatic decline in the interleukin (IL)-2 production capacity of human immune cells, thus making seniors more susceptible to a variety of age-related diseases. A common cause of impaired cytokine production in advanced age is a deficiency of the essential micronutrient zinc. Nevertheless, the molecular mechanisms underlying a zinc deficiency-induced decrease in IL-2 production have not yet been satisfactorily elucidated. Recent animal and in vitro data suggested that the transcription factor cAMP-responsive element modulator (CREM) \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α plays a critical role in T cells´ disturbed IL-2 production in suboptimal zinc conditions. However, its role in the human aging process and the possibility of influencing this detrimental process by short-term zinc supplementation have not yet been evaluated.

Results

Comparing peripheral lymphocytes of 23 young and 31 elderly subjects with either high, intermediate, or deficient zinc status, we observed zinc-dependent regulation of the IL-2 production mediated by the transcription factor CREM \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α. For the first time in humans, we report a mutual relationship between low zinc levels, high CREM \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α expression, subsequent impaired IL-2 production, and vice versa. Remarkably, an average of only 6 days of in vivo zinc supplementation to zinc-deficient seniors was sufficient to rapidly improve zinc status, reverse CREM \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α overexpression, and counteract subsequent low IL-2 production rates.

Conclusions

Our ex vivo and in vivo data identify zinc deficiency-mediated CREM \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\alpha$$\end{document}α overexpression as a key cellular mechanism underlying impaired IL-2 production in the elderly and point toward the use of zinc as a rapidly immune-enhancing add-on nutraceutical in geriatric therapy.

Graphical abstract

During the aging process, there is a progressive decrease in zinc status, which in turn leads to overexpression of the transcription factor CREM\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\mathrm{\alpha }$$\end{document}α in peripheral lymphocytes. CREMα is a negative regulator of the IL-2 gene, the overexpression of which dramatically limits adequate IL-2 production. This deleterious mechanism can be counteracted by short-term oral zinc administration, which can adjust IL-2 production in old, zinc-deficient individuals to a level similar to that of young adults.

Free Fatty Acid Species Differentially Modulate the Inflammatory Gene Response in Primary Human Skeletal Myoblasts

Simple Summary

Epidemiological studies show that obesity increases the risk of muscle mass loss with age, a syndrome called sarcopenic obesity. Obesity leads to increased free fatty acids (FFAs) and excessive fat deposits, which impair the integrity of skeletal muscles by unknown mechanisms. This report indicates that FFAs directly affect human skeletal muscle cell replication and inflammatory gene expression. The structural characteristics of FFAs play a decisive role in triggering both processes. Thus, the characterization of abundant FFA species in the skeletal muscle of obese individuals may become a useful tool to predict the progression of sarcopenic obesity.

Abstract

Age-related loss of skeletal muscle is associated with obesity and inflammation. In animal models, intramuscular fat deposits compromise muscle integrity; however, the relevant fat components that mediate muscular inflammation are not known. Previously, we hypothesized that free fatty acids (FFAs) may directly induce inflammatory gene expression in skeletal muscle cells of obese rats. Here, we examined this hypothesis in primary human skeletal myoblasts (SkMs) using multiplex expression analysis of 39 inflammatory proteins in response to different FFA species. Multiplex mRNA quantification confirmed that the IL6, IL1RA, IL4, LIF, CXCL8, CXCL1, CXCL12 and CCL2 genes were differentially regulated by saturated and unsaturated C16 or C18 FFAs. Fluorescence staining revealed that only saturated C16 and C18 strongly interfere with myoblast replication independent of desmin expression, mitochondrial abundance and oxidative activity. Furthermore, we addressed the possible implications of 71 human receptor tyrosine kinases (RTKs) in FFA-mediated effects. Phosphorylated EphB6 and TNK2 were associated with impaired myoblast replication by saturated C16 and C18 FFAs. Our data suggest that abundant FFA species in human skeletal muscle tissue may play a decisive role in the progression of sarcopenic obesity by affecting inflammatory signals or myoblast replication.

Non-Contact Measurement of Heart Rate Variability in Frail Geriatric Patients: Response to Early Geriatric Rehabilitation and Comparison with Healthy Old Community-Dwelling Individuals - A Pilot Study

INTRODUCTION

Frailty is a central geriatric syndrome characterized by a state of increased physiological vulnerability. As the key components of frailty are difficult to capture in their entirety, easily measurable and reliable surrogate parameters are desirable. Since frailty influences heart rate variability (HRV), HRV may be such a surrogate parameter. HRV is typically acquired by an ECG, which, however, may not be tolerated by all patients; in some, it may even trigger delirium. Therefore, we sought to measure HRV in a non-contact and unobtrusive way through photoplethysmography imaging (PPGI). Using our previously presented HRV estimation algorithm for PPGI, we investigated whether PPGI could reveal (1) HRV differences between frail and non-frail individuals and (2) the influences of early geriatric rehabilitation on HRV.

METHODS

The study involved 10 frail geriatric inpatients undergoing early geriatric rehabilitation and 10 healthy community-dwelling older adults. All participants underwent a comprehensive geriatric assessment. HRV measurements using a PPGI system and a reference ECG were made at the beginning and the end of the rehabilitation. HRV in terms of LF/HF ratio was analysed for both intra-individual changes during the geriatric rehabilitation and differences between frail geriatric patients and healthy community-dwelling individuals.

RESULTS

Across all geriatric patients, the median LF/HF ratio obtained with PPGI was found to be reduced by 0.178 (24.8%) during early geriatric rehabilitation. The assessment at the end of the rehabilitation revealed a simultaneous improvement of the functional state. Moreover, frail geriatric patients had a higher LF/HF ratio than their community-dwelling counterparts. Both observations in PPGI-based HRV were confirmed by the reference. The capability of PPGI to track intra-individual HRV changes was also analysed; a Spearman correlation of ρ = 1.0 between PPGI-based HRV and reference was achieved for 58.8% of the participants.

CONCLUSION

Early geriatric rehabilitation improves the functional state, which is associated with an increased HRV. PPGI is capable of detecting HRV changes/trends in that age group. While the tracking of intra-individual HRV changes is also possible, its reliability needs improvement. Nevertheless, the capabilities demonstrated in our study and the non-contact measurement principle of PPGI emphasize its potential for application in geriatric medicine.

[Innovative geriatric concepts for vascular medicine and vascular surgery]

Entwicklungen und Fortschritte in Gefäßchirurgie und Geriatrie verlaufen bis dato weitgehend unabhängig voneinander; auch im klinischen Alltag der Krankenversorgung gibt es bislang – anders als bei der Alterstraumatologie – kaum Überschneidungen und Synergismen. Dabei wären interdisziplinär umgesetzte geriatrische Konzepte bei der individualisierten Indikationsstellung, Therapiewahl und Prognoseabschätzung in der Gefäßchirurgie sicherlich hilfreich, v. a. bei hochaltrigen Patienten (85+ Jahre). Geriatrische Begrifflichkeiten wie biologisches Alter und Funktionalität sind dabei kein alleiniges Spiegelbild des Gefäßstatus, sondern schließen neben weiteren organspezifischen Komponenten (z. B. Immunologie, muskuloskelettales System etc.) v. a. auch die psychisch-neurokognitive Domäne und sozialmedizinische Kontextfaktoren ein. Eine Beschränkung auf das kalendarische Alter, den Gefäßstatus oder auch schlagwortartige geriatrische Surrogatparameter wie Frailty wird dabei der gesundheitlichen Charakterisierung von alten Menschen nicht gerecht. Im vorliegenden Artikel werden die Gedankengänge an der Schnittstelle zwischen Gefäßchirurgie und Geriatrie am Beispiel des Bauchaortenaneurysmas (BAA) und der peripheren arteriellen Verschlusskrankheit (pAVK) vertieft.

Implementation of a telemedicine geriatric co-evaluation in the emergency department: a prospective pilot study

&nbsp; INTRODUCTION: Complex drug management is a common challenge in the treatment of geriatric patients. Pandemic scenarios, such as the current one (COVID-19), call for a reduction of face-to-face meetings, especially for elderly patients. Therefore, the aim of the present study was to compare the innovative concept of applying telemedical assessment to geriatric patients in the emergency department (ED) with ED standard treatment. The therapeutic recommendations regarding drug management from the two assessments were compared. A special focus was the use of potentially inadequate drugs (PIMs) for geriatric patients according to the &ldquo;Fit for the Aged&rdquo; (FORTA) classification.

METHODS

50 patients (40% female) aged &ge;70 years and assessed with an Identification of Seniors at Risk Score (ISAR score) of &ge;2 admitted to the ED were prospectively enrolled in this study between November 2017 and February 2018. In addition to the standard treatment in the ED, co-evaluation via video transmission was independently carried out by a board-certified geriatrician. Drug recommendations by ED physicians (A) and the geriatrician (B) were compared.

RESULTS

There was a significantly higher frequency of recommendations regarding changes to preexisting medication (p &lt;0.001, n = 50) via geriatric telemedicine in comparison with standard ED treatment. The geriatrician intervened significantly more often than the ED physicians: discontinuation of a drug, p &lt;0.001; start of a new drug, p = 0.004; dose change of a drug, p = 0.001; n = 50). Based on the additional therapy recommendations of the geriatrician, the amount of medication taken by the patient was significantly reduced compared with standard ED treatment (ED assessment t(49) = 0.622 vs geriatrician&rsquo;s assessment t(49) = 4.165; p &lt;0.001; n = 50). Additionally, the number of PIMs was significantly reduced compared with standard medical treatment (p &lt;0.001). The geriatrician changed 53.9% of the drugs (35/65) whereas the ED physicians changed only 12.3% (8/65). Recommendations for immediate drug therapy, however, were made more frequently by ED physicians (p &lt;0.039, n = 50).

DISCUSSION

An early assessment of elderly emergency patients by a geriatrician had a significant impact on the number of drug interventions in the ED. The number of PIMs could be significantly reduced. Whether this also has a positive effect on the further inpatient course needs to be investigated in further prospective studies. The study was retrospectively registered at ClinicalTrials.gov (NCT04148027). &nbsp.

[Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters : A pilot study in a german university hospital]

BACKGROUND

Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable.

OBJECTIVE

The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU).

METHODS

A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model).

RESULTS

In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035).

CONCLUSION

There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

[Evaluation of a simple screening tool for ambulant fall prevention]

BACKGROUND

An individual's risk of falling is generally difficult to detect and it is likely to be underestimated. Thus, preventive measures are challenging and they demand sufficient integration and implementation into aftercare and outpatient management. The Aachen Falls Prevention Scale (AFPS) is a quick and easy tool for patient-driven fall risk assessment. Older adults' risk of falling is identified in a suitable manner and they then have the opportunity to independently assess and monitor their risk of falling.

OBJECTIVES

The aim of the current study was to evaluate the AFPS as a simple screening tool in geriatric trauma patients via the identification of influencing factors, e.g. objective or subjective fall risk, fear of falling (FOF) and demographic data. In this context, we investigated older adults' willingness to take part in special activities concerning fall prevention.

METHODS

Retrospectively, all patients over 70 years of age who received in-hospital fracture treatment between July 2014 and April 2016 were analyzed at a level I trauma center. After identification of 884 patients, participants completed a short questionnaire (47 questions, yes/no, Likert scale) comprising the AFPS. A history of falls in the past year was considered an indicator of a balance disorder. In addition, ambulant patients were invited to participate between July and August 2016.

RESULTS

In total, 201 patients (mean 80.4 years, range 63-97 years) performed a self-assessment based on the AFPS. After steps 1 and 2 of the AFPS had been completed, 95 (47%) participants rated their subjective risk of falling as high (more than 5 points). Of the participants 84 (42%) were objectively classified as "fallers" with significant effects on their AFPS evaluation and rating of their subjective risk of falling. Furthermore, 67% of the participants identified a general practitioner as their main contact person, and 43% of the respondents viewed the AFPS as a beneficial screening tool in fall risk evaluation (8% negative attitudes). Only 12% of the participants could imagine using the AFPS app version as a feasible option.

CONCLUSION

It would be advantageous to pretest at-risk individuals in their environment using a simple self-assessment approach, with the main purpose of identifying potential balance problems. With this approach, cost savings in the healthcare system are possible, combined with a higher health-related quality of life in the geriatric population.

High-fat diet-induced obesity causes an inflammatory microenvironment in the kidneys of aging Long-Evans rats

Background

Obesity is a risk factor for chronic kidney disease (CKD). While the exact mechanisms remain unclear, inflammation may be a consequence of obesity that directly impacts the kidneys. The aim of this study was to examine the inflammatory status of the kidneys and potential ongoing renal damage, i.e., tubular damage and fibrosis after long-term obesity maintained through persistent consumption of a high-fat diet (HFD).

Results

Twenty-four-week-old male Long-Evans (LEV) rats were continuously fed a control diet (CD) or HFD for 51 weeks. The mean body weight was higher in HFD-fed rats than in control diet-fed rats and markedly elevated during the last 24 weeks. Blood analyses revealed no substantial alterations in renal functional parameters by HFD consumption but a substantial increase in creatine kinase, a muscle loss marker. Magnetic resonance imaging (MRI) was utilized to quantify rat quadriceps muscle mass. The data showed that HFD-induced obesity in LEV rats was accompanied by minor decreases in muscle mass and strength at 75 weeks of age. Rat kidney inflammatory status was evaluated using histological and immunohistological techniques. The number of foci with immune cell infiltrates and infiltrating monocytes/macrophages was significantly increased in HFD-fed rat kidneys at week 75. Renal fibrosis parameters, including glomerulosclerosis and tubular damage, were also markedly increased in renal tissues from HFD-fed rats compared to the controls. The significant increase in tubular protein casts in HFD-fed rat tissues indicated that renal function was already disturbed. Rat kidney inflammatory status was further evaluated using the simultaneous profiling of twenty-two inflammatory markers in kidney tissue extracts. Consistently, MCP-1 and eotaxin (CCL11) levels were elevated in obese LEV rat kidneys.

Conclusions

Compared to CD-fed rats, HFD-fed obese LEV rats show significant damage of renal structures with aging. These subtle changes may sensitize the kidneys to the development of progressive CKD.

Electronic supplementary material

The online version of this article (10.1186/s12950-019-0219-x) contains supplementary material, which is available to authorized users.

A Multi-Modal Sensor for a Bed-Integrated Unobtrusive Vital Signs Sensing Array

In this paper, we present a novel unobtrusive multi-modal sensor for monitoring of physiological parameters featuring capacitive electrocardiogram (cECG), reflective photoplethysmogram (rPPG), and magnetic induction monitoring (MI) in a single sensor. The sensor system comprises sensor nodes designed and optimized for integration into a grid-like array of multiple sensors in a bed and a central controller box for data collection and processing. Hence, it is highly versatile in application and suitable for unobtrusive monitoring of vital signs, both in a professional setting and a home-care environment. The presented hardware design takes both inter-modal interference between cECG and MI into account as well as intra-modal interference due to cross talk between two MI sensors in close vicinity. In a lab study, we evaluated a prototype of our new multi-modal sensor with two sensor nodes on four healthy subjects. The subjects were lying on the sensors and exercising with a hand grip in order to increase heart rate and thus evaluate our sensor both during changing physiological parameters as well as a wider range of those. Heart beat intervals and heart rate variability were derived from both cECG and rPPG. Breathing intervals were derived from the MI sensor. For heart beat intervals, we achieved an RMSE of 2.3 ms and a correlation of 0.99 using cECG. Similarly, using rPPG, an RMSE of 18.9 ms with a correlation of 0.99 was achieved. With regard to breathing intervals derived from MI, we achieved an RMSE of 1.12 s and a correlation of 0.90.

The Aachen Falls Prevention Scale: Multi-Study Evaluation and Comparison

Background

Fall risk assessment is a time-consuming and resource-intensive activity. Patient-driven self-assessment as a preventive measure might be a solution to reduce the number of patients undergoing a full clinical fall risk assessment.

Objective

The aim of this study was (1) to analyze test accuracy of the Aachen Falls Prevention Scale (AFPS) and (2) to compare these results with established fall risk assessment measures identified by a review of systematic reviews.

Methods

Sensitivity, specificity, and receiver operating curves (ROC) of the AFPS were calculated based on data retrieved from 2 independent studies using the AFPS. Comparison with established fall risk assessment measures was made by conducting a review of systematic reviews and corresponding meta-analysis. Electronic databases PubMed, Web of Science, and EMBASE were searched for systematic reviews and meta-analyses that reviewed fall risk assessment measures between the years 2000 and 2018. The review of systematic reviews was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. The Revised Assessment of Multiple SysTemAtic Reviews (R-AMSTAR) was used to assess the methodological quality of reviews. Sensitivity, specificity, and ROC were extracted from each review and compared with the calculated values of the AFPS.

Results

Sensitivity, specificity, and ROC of the AFPS were evaluated based on 2 studies including a total of 259 older adults. Regarding the primary outcome of the AFPS subjective risk of falling, pooled sensitivity is 57.0% (95% CI 0.467-0.669) and specificity is 76.7% (95% CI 0.694-0.831). If 1 out of the 3 subscales of the AFPS is used to predict a fall risk, pooled sensitivity could be increased up to 90.0% (95% CI 0.824-0.951), whereas mean specificity thereby decreases to 50.0% (95% CI 0.42-0.58). A systematic review for fall risk assessment measures produced 1478 articles during the study period, with 771 coming from PubMed, 530 from Web of Science, and 177 from EMBASE. After eliminating doublets and assessing full text, 8 reviews met the inclusion criteria. All were of sufficient methodological quality (R-AMSTAR score ≥22). A total number of 9 functional or multifactorial fall risk assessment measures were extracted from identified reviews, including Timed Up and Go test, Berg Balance Scale, Performance-Oriented Mobility Assessment, St Thomas’s Risk Assessment Tool in Falling Elderly, and Hendrich II Fall Risk Model. Comparison of these measures with pooled sensitivity and specificity of the AFPS revealed a sufficient quality of the AFPS in terms of a patient-driven self-assessment tool.

Conclusions

It could be shown that the AFPS reaches a test accuracy comparable with that of the established methods in this initial investigation. However, it offers the advantage that the users can perform the self-assessment independently at home without involving trained health care professionals.

[Hospital pastoral care of people with dementia : A qualitative interview study with professional hospital pastoral carers]

BACKGROUND

Communicating and interacting with persons diagnosed with dementia (PwD) present a challenge to pastoral carers, since most classical pastoral care approaches concentrate on conversation as a medium of relationship formation and do not take limited communication skills into account. This study focuses on the following question: how can hospital-based pastoral carers find appropriate methods of communication and interaction with PwD and provide them with pastoral care?

METHODS

A total of 10 professional pastoral carers participated in the study. Each of these persons had extensive experience with PwD. Data were collected with the use of guideline-based interviews. The interviews were evaluated using Mayring's method of qualitative content analysis.

RESULTS

One of the main challenges faced by the pastoral carers in interacting with PwD was to explore communication strategies based on non-verbal communication, in addition to verbal communication. Pastoral carers need to find alternative communicative approaches, such as biographical, non-verbal, and physical sense-related methods. Clinical pastoral education did not adequately equip these professionals for communicating and interacting with PwD. The interviewed pastoral carers acquired this specific knowledge through independent research of the academic literature, observation of other professionals, dementia-specific training courses, and practical experience.

CONCLUSION

Pastoral carers can make a positive contribution to the holistic care of PwD through their unique communicative and relationship approach to care. It is imperative to develop adequate pastoral care concepts and to integrate methodologies for dealing with PwD into the training curriculum of pastoral carers.

Mortality and cardiorespiratory complications in trochanteric femoral fractures: a ten year retrospective analysis

PURPOSE

Despite intense research and innovations in peri-operative management, a high mortality rate and frequent systemic complications in trochanteric femoral fractures persist. The aim of the present study was to identify predictive factors for mortality and cardio-respiratory complications after different treatment methods in a ten year period at a level I trauma centre.

METHODS

Retrospectively, all patients above 60 years of age with trochanteric femoral fracture between January 2000 and May 2011 were analyzed at a level I trauma centre. Demographic variables, comorbidities, and data regarding the surgical procedures, including required transfusions and post-operative complications, were evaluated, and the in-hospital mortality was recorded. The grade of osteoporosis was classified radiographically using the Singh index.

RESULTS

The in-hospital mortality rate was 8.2% among 437 patients (male/female ratio = 110/327, mean age = 81 years) with extramedullary open (n = 144), intramedullary (n = 166), and extramedullary minimally invasive (n = 125) procedures. Significant influential factors on in-hospital mortality were identified with binary logistic regression analysis: an age of ≥90 years (P = 0.011), male sex (P = 0.003), a high American Society of Anesthesiologists (ASA) grade (3-5, P = 0.042), and a high osteoporosis grade (Singh index 3-1, P = 0.011). A total of 21.5% of the study population suffered cardio-respiratory complications post-operatively. The specific mortality was 28.7% (P < 0.001), which was influenced by a high ASA grade (3-5, P = 0.002) and a high transfusion rate (P = 0.004). Minimally invasive locked plating was associated with increased cardio-respiratory complications (P = 0.031).

CONCLUSIONS

This study identified high patient age, distinctive comorbidities, male sex, and high osteoporosis grade as significant risk factors for increased in-hospital mortality in the treatment of trochanteric femoral fractures. Furthermore, high ASA grade and a liberal transfusion regime led to an increased incidence of cardio-respiratory complications. Patient-specific characteristics, especially osteoporosis grade and pre-existing medical conditions, may assist in the identification of high-risk patients and allow a patient-specific geriatric co-management plan.

Crystal arthritides - gout and calcium pyrophosphate arthritis : Part 3: Treatment

The treatment of gout is based on several principles. Symptom control and termination of the inflammatory process are important early goals, whereas the urate level should be lowered in the long term to prevent further gout attacks and complications. The non-pharmacological approach is based on individually informing the patient on dietary measures and changes of life style. Besides physical measures, such as cold applications on the affected joint, various medications are available for treatment of an acute gout attack. The choice of drug depends on the individual risk profile. If non-steroidal anti-inflammatory drugs (NSAID) and coxibs are chosen it should be taken into account that the use is restricted in patients with renal insufficiency. Moreover, these drugs may have gastrointestinal side effects and are associated with increased cardiovascular morbidity and mortality. Colchicine has gastrointestinal side effects at high dosages but can also be used for differential diagnostics if there is a quick response to treatment. Steroids are an effective alternative and can be given orally or parenterally in patients with dysphagia. Moreover, steroids can be used in cases of renal insufficiency. After symptoms of the acute attack have subsided, urate lowering therapy should be initiated to prevent further attacks. Low-dose urate lowering therapy can be started during an acute gout attack when acute therapy is initiated. Allopurinol is still the medication of choice but its use is restricted in patients with renal insufficiency. A rare but serious side effect is allopurinol hypersensitivity syndrome. Febuxostat can be an alternative in patients who do not tolerate allopurinol. In February 2016, lesinurad, an URAT-1 and OAT-4 inhibitor, was approved in combination with allopurinol or febuxostat. Data on the effectiveness and safety of synthetic uricases and biologicals are still sparse for elderly patients. These substances are reserved for severe cases of gout.

High-Technology Based Gait Assessment in Frail People: Associations between Spatio-Temporal and Three-Dimensional Gait Characteristics with Frailty Status across Four Different Frailty Measures

OBJECTIVE

We analyzed associations between a battery of gait characteristics and frailty status across four different frailty instruments in old patients.

DESIGN

Cross-sectional study.

SETTING

Geriatric wards of a general hospital.

PARTICIPANTS

123 hospitalized patients aged ≥65 years.

MEASUREMENTS

Spatio-temporal and three-dimensional gait characteristics were assessed by an electronic walkway and a shoe-mounted, inertial sensor-based mobile gait analysis system. Frailty status was assessed by the frailty phenotype (FP), Clinical Frailty Scale (CFS), frailty index (FI), and frailty index based on a comprehensive geriatric assessment (FI-CGA).

RESULTS

A reduction in walking speed (FP, FI, FI-CGA), stride length (FP, FI, FI-CGA), maximum toe clearance (FP, CFS, FI, FI-CGA), toe off angle (FP, CFS, FI, FI-CGA), heal strike angle (FI-CGA) and greater stride length variability (FP, CFS, FI, FI-CGA), stride time variability (FP, FI), double support time (FP, FI), and stride width (CFA, FI-CGA) were associated with frailty status across the four frailty instruments (all P < 0.05, respectively). Walking speed (FP, CFS, FI, FI-CGA), stride length (FP, CFS, FI, FI-CGA), maximum toe clearance (FP, CFS, FI, FI-CGA), toe off angle (FP, CFS, FI, FI-CGA), heal strike angle (FP, FI), stride length variability (CFS, FI, FI-CGA), stride time variability (FI), double support time (FP), and stride width (FP, CFS, FI) were related with frailty severity across the four frailty instruments independent of age and sex (all P adjusted < 0.05, respectively).

CONCLUSIONS

Gait changes in frail patients include more than solely a reduction in walking speed.

A comparison of Frailty Indexes Based on a Comprehensive Geriatric Assessment for the Prediction of Adverse Outcomes

OBJECTIVE

To compare the ability of different frailty indexes based on a standardized comprehensive geriatric assessment (FI-CGAs) for predicting adverse outcomes.

DESIGN AND SETTING

Prospective cohort study. Geriatric wards of a general hospital.

PARTICIPANTS

307 hospitalized patients ≥ 65 years.

MEASUREMENTS

The FI-CGA-10D (potential health deficits in ten functional domains), the FI-CGA-10D+CM (aforementioned potential health deficits and co-morbidity burden) and the FI-CGA-MIHD (multiple, individual potential health deficits, including functional deficits, co-morbid diseases, amongst others) were assessed at baseline during the patients` hospital stay. The FI-CGAs were analyzed as categorical (according to a FI-CGA score < and ≥ 0.25) and continuous variables. Patients were followed up over 6 months.

RESULTS

The FI-CGA-10D, FI-CGA-10+CM and the FI-CGA-MIHD predicted 6-month mortality when expressed as categorical (area under the receiver operating characteristic curve (AUC): AUC = 0.611, AUC = 0.637, AUC = 0.616, all p < 0.050, respectively) or continuous variables (AUC = 0.769, AUC = 0.837, AUC = 0.834, all p < 0.001, respectively). AUC comparisons showed that all three FI-CGAs exhibited a comparable ability to predict 6-month mortality when the FI-CGAs were expressed as categorical variables (all p > 0.200) and the FI-CGA-10D+CM and the FI-CGA-MIHD showed a better ability to predict 6-month mortality than the FI-CGA-10D, when the FI-CGAs were expressed as continuous variables (p < 0.001 and p = 0.007, respectively). None of the FI-CGAs predicted any of the other outcomes, i.e., unplanned re-admission to hospital and a fall during follow-up, irrespective of whether the FI-CGAs were expressed as categorical or continuous variables (all p ≥ 0.050).

CONCLUSIONS

The more complex FI-CGAs, i.e., the FI-CGA-10D+CM and the FI-CGA-MIHD, revealed better ability to predict 6 month mortality than the more simple FI-CGA, i.e., the FI-CGA-10D.

Analysis of Rockwood et Al's Clinical Frailty Scale and Fried et Al's Frailty Phenotype as Predictors of Mortality and Other Clinical Outcomes in Older Patients Who Were Admitted to a Geriatric Ward

OBJECTIVES

There are few data regarding the accuracy of short frailty tools as predictors of mortality and other clinical outcomes of older patients admitted to a geriatric ward. We therefore analyzed the accuracy of Rockwood et al's Clinical Frailty Scale and an easy and quick to perform operationalization of Fried et al's frailty phenotype, as predictors of mortality and other clinical outcomes in our cohort of patients.

DESIGN

Prospective analysis with a follow-up period of 6 months.

SETTING AND PARTICIPANTS

307 patients who were 65 years of age or older were included in the study. The patients were assessed in terms of the two frailty measures during their stay in a geriatric ward.

RESULTS

The Clinical Frailty Scale and the frailty phenotype were both suitable for differentiating between patients who died due to any cause from those who survived during follow-up (primary outcome) (area under the ROC curves (AUC) values 0.867 (95% CI 0.807-0.926), p<0.001 and 0.754 (95% CI 0.688-0.821), p<0.001, respectively). Regarding the secondary outcomes: 1. unplanned admission to hospital and 2. a fall during follow-up, the Clinical Frailty Scale discriminated or tended to discriminate between patients to whom these criteria applied and those to whom they did not (AUC=0.569 (95% CI 0.502-0.636), p=0.046 and AUC=0.574 (95% CI 0.501-0.647), p=0.071, respectively). The frailty phenotype did not show such a differentiation when applied to secondary outcomes (AUC=0.500 (95% CI 0.432-0.568), p=0.994 and AUC=0.518 (95% CI 0.439-0.598), p=0.658, respectively).

CONCLUSIONS

Both short frailty instruments are suitable predictors of mortality in older patients who were admitted to a geriatric ward. The Clinical Frailty Scale, but not the frailty phenotype, predicted at least some of the secondary outcomes, i.e., the outcome unplanned admission to hospital during follow-up.

Prevalence of sarcopenia in Germany and the corresponding effect of osteoarthritis in females 70 years and older living in the community: results of the FORMoSA study

Background

Although sarcopenia represents a challenging burden for health care systems around the world, its prevalence in the elderly population varies widely. The primary aim of the study was to determine the prevalence of sarcopenia in community-dwelling (CD) German women aged 70 years and older; the secondary aim was to assess the effect of osteoarthritis (OA) on sarcopenia prevalence in this cohort.

Methods

A total of 689 Caucasian females 18–35 years old and 1,325 CD females 70 years+ living in Northern Bavaria, Germany, were assessed during the initial phase of the FORMoSA research project. Anthropometry, total and regional muscle mass, were assessed by segmental multifrequency Bioelectrical Impedance Analysis. Further 10 m walking speed and handgrip strength were evaluated to apply the European Working Group on Sarcopenia in Older People definition of sarcopenia. Covariates were determined by questionnaires and interviews.

Results

Applying the algorithm of the European Working Group on Sarcopenia in Older People of two standard deviations below the mean value for appendicular skeletal muscle mass of a reference cohort of the young cohort (5.66 kg/m²), low gait speed (≤0.8 m/s), and low grip strength (<20 kg), the prevalence of sarcopenia in CD German females 70 years and older was 4.5% (70–79 years: 2.8% vs ≥80 years: 9.9%; P<0.001). Participants with OA at the hip and lower limbs (n=252) exhibited significantly higher rates of sarcopenia (OA: 9.1 vs non-OA: 3.5%). Of importance, anthropometric, demographic, health, and lifestyle parameters (except exercise participation) of our cohorts corresponded with Bavarian or German data for CD women 70 years+.

Conclusion

The prevalence of sarcopenia in CD German females 70 years+ is relatively low. However, participants with OA at the hip or lower limbs were at increased risk for sarcopenia.

Sarcopenic obesity and complex interventions with nutrition and exercise in community-dwelling older persons--a narrative review

One of the many threats to independent life is the age-related loss of muscle mass and muscle function commonly referred to as sarcopenia. Another important health risk in old age leading to functional decline is obesity. Obesity prevalence in older persons is increasing, and like sarcopenia, severe obesity has been consistently associated with several negative health outcomes, disabilities, falls, and mobility limitations. Both sarcopenia and obesity pose a health risk for older persons per se, but in combination, they synergistically increase the risk for negative health outcomes and an earlier onset of disability. This combination of sarcopenia and obesity is commonly referred to as sarcopenic obesity. The present narrative review reports the current knowledge on the effects of complex interventions containing nutrition and exercise interventions in community-dwelling older persons with sarcopenic obesity. To date, several complex interventions with different outcomes have been conducted and have shown promise in counteracting either sarcopenia or obesity, but only a few studies have addressed the complex syndrome of sarcopenic obesity. Strong evidence exists on exercise interventions in sarcopenia, especially on strength training, and for obese older persons, strength exercise in combination with a dietary weight loss intervention demonstrated positive effects on muscle function and body fat. The differences in study protocols and target populations make it impossible at the moment to extract data for a meta-analysis or give state-of-the-art recommendations based on reliable evidence. A conclusion that can be drawn from this narrative review is that more exercise programs containing strength and aerobic exercise in combination with dietary interventions including a supervised weight loss program and/or protein supplements should be conducted in order to investigate possible positive effects on sarcopenic obesity.

[We cannot care alone: volunteers in dementia care at Nürnberg General Hospital]

BACKGROUND

People with dementia have specific care needs especially in an acute care setting. Professionals in clinical routine have limited capacities in meeting the needs of dementia patients as far as communication, interaction and orientation are concerned.

AIMS

For 2 years, the Department of Internal Medicine and Geriatrics at Nürnberg General Hospital has hosted volunteers in dementia care who accompany and visit people with dementia during their acute care stay. We present the organization of the volunteer training program, training content, and preliminary evaluation results.

METHODS

We chose a mixed methods approach for research and evaluation. Baseline data, motivational profile of volunteers, paper and pencil data on attitudes, skills and knowledge before and after training were assessed.

RESULTS

Preliminary results show a positive effect on attitudes, skills, and knowledge after volunteer training. Volunteers and professionals need continual support and education to enable volunteers to act as an integrative part of the acute geriatric care team.

CONCLUSION

The admission to an acute care setting is often frightening and confusing for dementia patients. Trained volunteers have the potential to make the hospital stay more pleasant for people with dementia.

Olive oil attenuates the cholesterol-induced development of nonalcoholic steatohepatitis despite increased insulin resistance in a rodent model

It is indefinite whether nonalcoholic steatohepatitis (NASH) results as by-product from general metabolic perturbations and adipokine dysregulations or whether defined dietary factors also play a pathogenetic role. Here, we examine the effects of a modification of dietary lipids in a NASH inducing diet on metabolic changes as well as hepatic steatosis, inflammation, and fibrosis in rats. Male Wistar rats were fed with variations of the atherogenic diet (AD), which induces pathophysiological changes resembling human NASH. Dietary variants (AD without cholesterol, cholate, or choline; change of neutral fat to olive oil or coconut oil) were fed for 8 weeks. Insulin resistance, adipokine profile, liver histology, and lipid content as well as expression of proinflammatory and profibrogenic genes were examined. AD led to clear signs of hepatic steatosis and inflammation together with an increase in TNF and collagen type 1 expression. AD without cholesterol showed markedly less liver damage without changes of insulin action and adipokine profile. AD with olive oil and AD without cholate clearly attenuated hepatic inflammation, whereas fat deposition and features of the metabolic syndrome were increased in these animals. Insulin resistance and hepatic fat deposition per se do not cause significant hepatic inflammation in this rodent model. However, dietary cholesterol is an important causal agent for the development of NASH. Olive oil plays a protective role in this respect, which might be due to the high content of monounsaturated fatty acids.

[Translational research in geriatrics? A plea based on current biomedical key publications]

Contemporary geriatric research focuses mainly on observational clinical studies and epidemiological surveys and the translation of basic scientific results from biogerontology into a clinical context is often neglected. Following a definition of translational research the article gives an overview of recent key publications in experimental biogerontology with a special emphasis on their relevance for clinical geriatrics. The topics dealt with include age-induced loss of skeletal muscle (sarcopenia), the aging immune system (immunosenescence) and neurodegenerative disorders (Alzheimer's and Parkinson's disease).

Dietary folic acid activates AMPK and improves insulin resistance and hepatic inflammation in dietary rodent models of the metabolic syndrome

The AMP activated kinase plays an important role in metabolic control, and pharmacologic enhancement of AMPK activity is used to improve insulin resistance. We hypothesized that high dose of folic acid supplementation might improve insulin sensitivity and hepatic inflammation and examined this by a dietary intervention in (a) the high fat fed rat model of the metabolic syndrome, which shows sole hepatic steatosis as well as (b) in rats fed with a high cholesterol, high cholate diet inducing nonalcoholic steatohepatitis (NASH). Male Wistar rats were fed with folic acid supplemented (40 mg/kg) high fat diet [based on lard, fat content 25% (wt/wt)] or NASH inducing diet (containing 15% fat, 1.25% cholesterol, 0.5% sodium cholate). Metabolic profiling was performed by measuring the animals' visceral fat pads, fasting plasma glucose, insulin, and adipokines as well as in vivo insulin tolerance tests. Hepatic steatosis and inflammation were analyzed semiquantitatively by histological analysis. Folic acid supplementation reduced visceral obesity and improved plasma adiponectin levels. In vivo insulin sensitivity was improved, and in HF-FA rats folic acid increased activation of hepatic AMPK. Further, folic acid supplementation improved hepatic inflammation in animals fed with NASH-inducing diet. Dietary folic acid improved parameters of insulin resistance and hepatic inflammation in rodent models. This might be due to an increased AMK activation.

Systematic analysis of the insulinotropic and glucagonotropic potency of saturated and monounsaturated fatty acid mixtures in rat pancreatic islets

BACKGROUND

Blood contains a mixture of different fatty acids (FFAs) with palmitate and oleate as major components whose molar ratio is dependent on dietary habits. Based on the theory of lipotoxicity for the development of type 2 diabetes such variances in the FFA composition might interfere with lipotoxic effects on the endocrine pancreas.

METHODS

Using different ratios of FFA mixtures with palmitate and oleate, we have looked at FFA specific effects on the secretion of mature insulin and glucagon in isolated rat pancreatic islets.

RESULTS

The insulinotropic potency of the oleate dominated FFA solutions was stronger than that of the palmitate dominated FFA mixtures. Conversely, the glucagonotropic potency was stronger in the palmitate dominated FFA mixtures. Palmitate and oleate similarly contributed to an impaired release of mature insulin at 16.7 mM of glucose.

CONCLUSION

Based on the present IN VITRO data, FFA specific differences in terms of glucagonotropic and insulinotropic potency appear rather slight. For the IN VIVO situation, it may be assumed that the dietary influence of saturated and monounsaturated fatty acids on hyperproinsulinemia or hyperglucagonemia are rather secondary for the development of type 2 diabetes.

[Surgical resection of the thyroid and parathyroid glands]

The main indication for surgery of the thyroid gland is the resection of nodular, suspicious or hyperfunctioning tissue. Following thyroidectomy, L-thyroxine therapy is initiated adjusted to the remnant thyroid function. To prevent recurrence of a multinodular goiter, supplementation with iodine is strongly recommended. The management of patients with differentiated thyroid cancer depends on risk stratification. Although large prospective studies are missing, low-risk patients probably do not benefit from total thyroid ablation and lifelong thyroxine suppression therapy. As a result of impaired parathyroid function or resection of the parathyroid glands for hyperparathyroidism, acute or chronic hypocalcaemia can develop. If treatment with oral calcium is insufficient, the addition of a vitamin D analogue is necessary. This requires close monitoring to avoid renal or other hypercalcaemic complications.

[Clinical pathways--practical aid for the physician? Example: clarification of the suspicion of tuberculosis]

Guidelines, clinical pathways and clinical algorithms are popular instruments nowadays to ensure quality as well as the economic efficiency of medical work. These terms themselves, however, are frequently defined only in a diffuse way. Thus, medical standard procedures often complicate clinical workflows more than to facilitate decision making in everyday life. In our department, feasible standardized approaches have been generated in the form of structured text documents, which on the one hand can aid clinical decision making at the bedside and on the other hand serve as medical sketches for the generation of operational treatment paths on an interdisciplinary level. Structure and content of such an instructional text are exemplified here using our standardized document for the diagnostic approach when tuberculosis is suspected.

Defining high-fat-diet rat models: metabolic and molecular effects of different fat types

High-fat (HF)-diet rodent models have contributed significantly to the analysis of the pathophysiology of the insulin resistance syndrome, but their phenotype varies distinctly between different studies. Here, we have systematically compared the metabolic and molecular effects of different HF with varying fatty acid compositions. Male Wistar rats were fed HF diets (42% energy; fat sources: HF-L - lard; HF-O - olive oil; HF-C - coconut fat; HF-F - fish oil). Weight, food intake, whole-body insulin tolerance and plasma parameters of glucose and lipid metabolism were measured during a 12-week diet course. Liver histologies and hepatic gene expression profiles, using Affymetrix GeneChips, were obtained. HF-L and HF-O fed rats showed the most pronounced obesity and insulin resistance; insulin sensitivity in HF-C and HF-F was close to normal. Plasma omega-3 polyunsaturated fatty acid (omega-3-PUFA) and saturated fatty acid (C(12)-C(14), SFA) levels were elevated in HF-F and HF-C animals respectively. The liver histologies showed hepatic steatosis in HF-L, HF-O and HF-C without major inflammation. Hepatic SREBP1c-dependent genes were upregulated in these diets, whereas PPARalpha-dependent genes were predominantly upregulated in HF-F fed rats. We detected classical HF effects only in diets based on lard and olive oil (mainly long-chain, saturated (LC-SFA) and monounsaturated fatty acids (MUFA)). PUFA- or MC-SFA-rich diets did not induce insulin resistance. Diets based on LC-SFA and MUFA induced hepatic steatosis with SREBP1c activation. This points to an intact transcriptional hepatic insulin effect despite resistance to insulin's metabolic actions.

Association between serum ferritin and the insulin resistance syndrome in a representative population

OBJECTIVE

Unexplained hepatic iron overload with increased serum ferritin (SF) values has been associated with the insulin resistance syndrome (IRS), defined by the presence of one or more of the following criteria: increased body mass index (BMI), diabetes, hyperlipidemia or hypertension. However, as yet the association between IRS and SF in a representative population has not been investigated.

METHODS

The study subjects participated in a nationwide epidemiological survey on metabolic disorders in the adult German population. The 1200 probands included in this study are representative of the German population. To eliminate major causes of secondary iron overload, 114 (9.5%) subjects with excessive alcohol consumption and 16 (1.5%) subjects with serological evidence for hepatitis B or C were excluded. For all remaining 1070 probands, complete clinical data of SF, HbA1c, known diabetes, BMI, cholesterol, high-density lipoprotein-cholesterol and blood pressure were available.

RESULTS

SF values were significantly increased in men and women with high BMI (> 25 kg/m2), increased cholesterol (> 200 mg/dl), and increased systolic (> 160 mmHg) blood pressure, in women with diabetes, and in men with increased diastolic (> 95 mmHg) blood pressure. Furthermore, there was a significant correlation between the number of IRS criteria and SF.

CONCLUSIONS

This study shows a significant correlation between SF and the presence of IRS criteria in a large representative population. Interestingly, the severity of the IRS seems to be associated with increased SF levels suggesting a causal connection. Further studies are required to investigate the pathophysiological mechanism and consequences of increased SF levels in patients with IRS.

Efficient analysis of hepatic glucose output and insulin action using a liver slice culture system

BACKGROUND

Liver slices have been reported to retain histological integrity and metabolic capacity for over 24 hours in flask culture systems, and they have been used for pharmacological and toxicological studies before. However, whether this method is suitable to measure hepatic glucose output is unknown.

METHODS

Precision-cut liver slices were prepared from fresh male rat liver. After high-glucose pre-incubation (11.2 mmol/l), medium was changed to low-glucose conditions (0.5 mmol/l). Glucose and lactate levels as well as aspartate aminotransferase activity were monitored for 50 minutes with or without addition of insulin (600 pmol/l) and/or epinephrine (0.5 micromol/l). Slice potassium content and histology were examined to prove liver viability.

RESULTS

We observed a stable glucose production from the liver slices of 0.3-0.4 micromol/g liver/min. Epinephrine increased (by 82+/-30%) and insulin decreased (by 80+/-8%) liver slice glucose output. Significant signs of ischemia were not detected.

CONCLUSIONS

Hepatic glucose release can be reliably measured in a liver slice culture system, and it is regulated by major hormone systems. This method may be helpful for further characterization of direct insulin action and resistance in a complex tissue as the liver; however, pharmacological applications such as the analysis of drug effects on hepatic glucose metabolism can also be envisioned.

Insulin-sparing effects of troglitazone in rat pancreatic islets

Thiazolidinediones (TZDs) have been suggested to act beneficially on pancreatic islet function and on beta-cell viability but data concerning direct effects on isolated islets are controversial. Therefore, we have examined parameters of pancreatic insulin and glucagon secretion and biosynthesis in TZD-exposed rat pancreatic islets under physiological glucose level conditions and under conditions of glucolipotoxicity. Primary rat islets were incubated for 2.5 h with or without troglitazone (10 microM) in 5.6 mM glucose (standard glucose levels) and 16.7 mM glucose (high glucose levels); a subgroup was additionally treated with oleate (200 microM) to simulate acute glucolipotoxicity. Insulin and glucagon secretion, intracellular content and their respective mRNAs were quantified. Newly synthesized insulin was determined by pulse-labeling experiments. Troglitazone reduced insulin secretion at standard and high glucose levels by about one-third (P<or=0.05). Insulin content was decreased at 5.6 mM glucose but increased at 16.7 mM glucose by the presence of troglitazone (P<or=0.05). Newly synthesized insulin mRNA and preproinsulin mRNA decreased by about 20% at standard glucose levels (P<or=0.05). Glucagon secretion was augmented by troglitazone in islets under high glucose conditions by an additional 50% (P<or=0.05). No clear beneficial troglitazone effects were observed under glucolipotoxic conditions. The reduced insulin secretion and biosynthesis at standard glucose levels can be interpreted as an insulin-sparing effect. Troglitazone effects were less pronounced at high glucose alone or in combination with oleate. From a clinical point of view, these results indicate a greater benefit of troglitazone for beta-cell function in hyperinsulinemic, but normoglycemic patients with insulin resistance or early type 2 diabetes without major insulin secretion deficits and/or pronounced hyperglycemia.

Definition and characterization of relative hypo- and hyperleptinemia in a large Caucasian population

The adipocyte-derived hormone, leptin, has been implicated in the regulation of appetite, weight gain and glucose homeostasis as well as in liver fibrogenesis, hematopoiesis and immune function. No previous reports have clearly defined pathologically elevated or decreased serum leptin levels for Caucasian adults. The aim of this study was to define and characterize subjects with relative hyper- and hypoleptinemia in a large population-based German cohort. Percentiles of leptin levels by body mass index (BMI) were calculated from 4971 adult Germans, and the participants with leptin levels above the 95th and below the 5th percentile were defined as relatively hyperleptinemic and relatively hypoleptinemic, respectively, for their BMI. These participants were compared with the intermediate group with respect to anthropometric and clinical data and parameters of glucose and iron metabolism, lipid status, renal, adrenal and reproductive function. Relatively hyperleptinemic participants (HL) showed higher insulin, c-peptide, and total cholesterol levels than the hypoleptinemic subjects; in males, ferritin levels were higher and testosterone levels lower in the HL group. In conclusion, we report the first percentile curves for serum leptin by BMI in a large Caucasian population. Relatively low leptin values may be associated with a lower metabolic risk than relatively high serum leptin values.

The Pro115Gln polymorphism within the PPAR gamma2 gene has no epidemiological impact on morbid obesity

The peroxisome-proliferator-activated receptor gamma2 (PPAR gamma2) is a transcriptional key regulator of adipocyte differentiation. PPAR gamma2 can be inactivated by phosphorylation of a serine residue at position 114. A point mutation leading to an amino acid exchange at position 115 (Pro115Gln) was shown to preclude serine phosphorylation and to consecutively accelerate adipocyte differentiation emphasizing the pathophysiological relevance of this mutation. So far, four markedly obese heterozygote carriers of the Pro115Gln mutation (body mass index 37.9-47.3 kgxm (-2)) have been identified in a circumscribed study population. In order to evaluate the epidemiological relevance of the Pro115Gln mutation in morbid obesity we screened the DNA of all subjects with a body mass index greater than 35 kgxm (-2) who had participated in a nationwide German epidemiological field survey. There was no homozygote or heterozygote carrier of the Pro115Gln polymorphism among them. We conclude that the Pro115Gln polymorphism within the PPAR gamma2 gene has no relevant epidemiological impact on morbid obesity in Germany. It needs further investigation whether this polymorphism might play a role in related metabolic disorders.

Hepatocyte growth factor stimulates proliferation of pancreatic beta-cells particularly in the presence of subphysiological glucose concentrations

We investigated the role of hepatocyte growth factor (HGF) in beta-cell growth and its complex intracellular signal transduction pathways. Cell proliferation was measured in the beta-cell line INS-1 using [3H]thymidine incorporation. Activation of mitogenic signaling proteins was assessed using co-immunoprecipitation, immunoblot analysis and specific protein activity inhibitors in proliferation assays. HGF (1 x 375 nM) increased INS-1 cell proliferation in the presence of 3-24 mM glucose up to 45-fold vs unstimulated controls. HGF exceeded the effect of glucose alone (2 x 2-fold at 3 mM glucose and 1 x 7-fold in the presence of 15 mM glucose). The HGF-induced INS-1 cell proliferation was further increased by addition of IGF-I or GH. Stimulation with HGF activated the JAK-2/STAT-5 pathway with a subsequent activation of phosphatidylinositol-3'-kinase (PI3'K). PI3'K activation was necessary for HGF- and glucose-stimulated INS-1 cell proliferation. The effect of PI3'K was mediated via 70 kDa S6 kinase and protein kinase B, which showed maximum activation in the presence of 3-6 mM glucose. Protein kinase C was essential for HGF-induced INS-1 cell proliferation. The HGF effect was also mediated at low glucose concentrations via insulin receptor substrate 4 (IRS-4) whereas other IRS proteins did not show any activation. High glucose concentrations also showed an increased IRS-4/PI3'K binding and therefore activation. In conclusion, beta-cell proliferation is mediated via complex interacting signal transduction pathways. HGF, in contrast to other growth factors, seems to be of importance particularly in the presence of low glucose concentrations and therefore takes a special role in this complex concert.

Intracellular depletion of insulin by oleate is due to an inhibited synthesis and not to an increased secretion

In the polyclonal rat pancreatic beta-cell line INS-1, immunoreactive insulin (IRI, insulin and its precursors) and C-peptide (surrogate marker for mature insulin) were quantified after a 1-h incubation at 16.7 mM glucose with or without oleate. Oleate caused a 20% decrease (P <or= 0.01) and a shift towards mature insulin (P <or= 0.01) in intracellular IRI. As IRI secretion was significantly (P <or= 0.01) diminished in the presence of oleate at hyperglycemic conditions the loss of intracellular IRI had to be due to other reasons which was then examined by focussing on newly synthesized, radiolabelled IRI*. Thereby, oleate caused a 50% decrease in newly synthesized intracellular IRI* (P <or= 0.01) and-contrary to the findings in complete intracellular IRI-a shift towards immature insulin precursors. Taken together, exposure of INS-1 cells to oleate induces an intracellular lack of uncompletely processed IRI. This is due to an inhibited biosynthetic supply which can not compensate for intracellular IRI-degradation and (to a neglible extent) for insulin secretion.