Regina E. Roller

European undergraduate curriculum in geriatric medicine developed using an international modified Delphi technique

Introduction: the rise in the number of older, frail adults necessitates that future doctors are adequately trained in the skills of geriatric medicine. Few countries have dedicated curricula in geriatric medicine at the undergraduate level. The aim of this project was to develop a consensus among geriatricians on a curriculum with the minimal requirements that a medical student should achieve by the end of medical school. Methods: a modified Delphi process was used. First, educational experts and geriatricians proposed a set of learning objectives based on a literature review. Second, three Delphi rounds involving a panel with 49 experts representing 29 countries affiliated to the European Union of Medical Specialists (UEMS) was used to gain consensus for a final curriculum. Results: the number of disagreements following Delphi Rounds 1 and 2 were 81 and 53, respectively. Complete agreement was reached following the third round. The final curriculum consisted of detailed objectives grouped under 10 overarching learning outcomes. Discussion: a consensus on the minimum requirements of geriatric learning objectives for medical students has been agreed by European geriatricians. Major efforts will be needed to implement these requirements, given the large variation in the quality of geriatric teaching in medical schools. This curriculum is a first step to help improve teaching of geriatrics in medical schools, and will also serve as a basis for advancing postgraduate training in geriatrics across Europe.

Thromboprophylaxis with 60 mg enoxaparin is safe in hip trauma surgery

BACKGROUND Little information is available concerning dosage and optimal initiation of thromboprophylactic therapy with low-molecular-weight heparin (enoxaparin) in nonelective hip surgery. The aim of our prospective study was to evaluate the incidence of clinically apparent deep vein thrombosis (DVT), pulmonary embolism (PE), and major hemorrhage in patients receiving thromboprophylaxis with enoxaparin undergoing hip surgery after hip fracture. METHOD From 946 consecutive patients admitted with hip fractures, 897 were operated on and received enoxaparin according to the following regimen: Preoperative heparinization from time of admission onwards. Administration of 60 mg enoxaparin, in two doses (20 and 40 mg subcutaneously), during the first 5 days postoperatively. Prophylaxis for a minimum of 5 weeks (40 mg daily). RESULTS Clinical signs of DVT were present in 37 patients (4.2%), who all underwent venography. In five patients, DVT was confirmed (0.6%). None of these patients suffered from PE. Another four patients (0.4%) developed clinical signs of PE, and suspected diagnosis was confirmed by computed tomographic scan in two (0.2%). No deaths because of PE were observed. Major hemorrhage occurred in 42 patients (4.7%), there was one death from hemorrhage caused by an intracerebral event. No case of heparin-induced thrombocytopenia type II was observed. CONCLUSION Thromboprophylaxis with 60 mg enoxaparin daily, in split doses, starting before surgery, is safe and appropriate in patients with hip fractures. Clinically apparent DVT and PE are rarely observed, and bleeding complications are comparable to those occurring with a conventional thromboprophylactic regimen.

Serum albumin, subjective global assessment, body mass index and the bioimpedance analysis in the assessment of malnutrition in patients up to 15 years after liver transplantation.

Wagner D, Adunka C, Kniepeiss D, Jakoby E, Schaffellner S, Kandlbauer M, Fahrleitner‐Pammer A, Roller RE, Kornprat P, Müller H, Iberer F, Tscheliessnigg KH. Serum albumin, subjective global assessment, body mass index and the bioimpedance analysis in the assessment of malnutrition in patients up to 15 years after liver transplantation.
Clin Transplant 2011: 25: E396–E3400.

The influence of elevated levels of C-reactive protein and hypoalbuminemia on survival in patients with advanced inoperable esophageal cancer undergoing palliative treatment

Inflammation perpetuates individual tumor progression resulting in decreased survival in cancer patients. The aim of our study was to evaluate the influence of elevated levels of C‐reactive protein (CRP) as well as low levels of albumin on patients with inoperable esophageal carcinoma.

Long-term quality of life of liver transplant recipients beyond 60 years of age

Due to ameliorated surgery as well as better immunosuppression, the recipient age after liver transplantation has been extended over the past years. This study aimed to investigate the health related quality of life after liver transplantation in recipients beyond 60 years of age. The SF-36 was used to evaluate the recipients’ health-related quality of life as standardized tool. It comprises 36 items that are attributed to 8 subscales attributed to 2 components: the physical component score and the mental component score. Differences in the health-related quality of life between the included aged recipients and age-matched general population as well as among female and male recipients. Aged recipients showed significantly lower scores in physical functioning (29 vs. 76, p = 0.001), role physical (42 vs. 73, p = 0.003), bodily pain (34 vs. 71, p = 0.003), general health (28 vs. 59, p = 0.001), vitality (25 vs. 61, p = 0.001), social functioning (36 vs. 87, p = 0.001), role emotional (46 vs. 89, p = 0.001) as well as the physical component score (28 vs. 76, p = 0.001). Aged female recipients showed lower results as compared to males in social functioning, physical functioning, role physical, and social functioning (p = 0.03 respectively) but comparable results in the remaining. Quality of life seems to be an issue among aged recipients and should be assessed on a regular basis.

The Graz Malnutrition Screening (GMS): a new hospital screening tool for malnutrition.

Despite the significant impact of malnutrition in hospitalised patients, it is often not identified by clinical staff in daily practice. To improve nutritional support in hospitals, standardised routine nutritional screening is essential. The Graz Malnutrition Screening (GMS) tool was developed for the purpose of malnutrition risk screening in a large hospital setting involving different departments. It was the aim of the present study to validate the GMS against Nutritional Risk Screening (NRS) and Mini Nutritional Assessment-short form (MNA-sf) in a randomised blinded manner. A total of 404 randomly selected patients admitted to the internal, surgical and orthopaedic wards of the University Hospital Graz were screened in a blinded manner by different raters. Concurrent validity was determined by comparing the GMS with the NRS and in older patients (70+ years) with the MNA-sf additionally. According to GMS, 31·9 or 28·5 % of the admitted patients were categorised as at ‘risk of malnutrition’ (depending on the rater). According to the reference standard of NRS, 24·5 % of the patients suffered from malnutrition. Pearson’s r values of 0·78 compared with the NRS and 0·84 compared with the MNA showed strong positive correlations. Results of accuracy (0·85), sensitivity (0·94), specificity (0·77), positive predictive value (0·76) and negative predictive value (0·95) of GMS were also very high. Cohen’s κ for internal consistency of the GMS was 0·82. GMS proves to be a valid and reliable instrument for the detection of malnutrition in adult patients in acute-care hospitals.

Polypharmacy and pain treatment

SummaryPain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug–drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.ZusammenfassungSchmerzen betreffen besonders ältere und chronisch kranke Bevölkerungsgruppen. Häufig findet sich die Schmerztherapie als Ergänzung zu einer bereits bestehenden Polypharmazie. Neben unerwünschten Arzneimittelwirkungen sind es vor allem Interaktionen, welche es zu beachten gibt. Die Gruppe der nichtsteriodalen Antirheumatika (NSAR) hat das größte Gefahrenpotential. Im Vordergrund stehen gastrointestinale, kardiovaskuläre und renale Effekte sowie Wirkungen auf das Gerinnungssystem. Paracetamol hat neben der bekannten (in hohen Dosen) toxischen Wirkung auf die Leber, ähnliche Interaktionen wie die NSAR, allerdings in einem geringeren Ausmaß. Metamizol ist nach der aktuellen Studienlage besser als sein Ruf, das Interaktionspotential ist als gering anzusehen. Im Bezug auf Tramadol sowie auch einige stark wirksame Opioide (insbesondere Pethidin) sind vor allen das Serotonin-Syndrom und die ZNS dämpfende Wirkung zu nennen. Auf Grund des erheblichen Gefahrenpotentials bei einer bestehenden Polypharmazie ist es in vielen Fällen ratsam, bei der Auswahl der Analgetika vom WHO-Stufenschema in der Schmerzbehandlung abzusehen.Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.

Serum cystatin C is an easy to obtain biomarker for the onset of renal impairment in heart transplant recipients.

OBJECTIVE With the increasing longevity of heart transplant recipients, the long-term effects of cyclosporine on renal function have become more evident. Highly sensitive, early, and effective monitoring of posttransplant renal function is still being researched. This study aimed to evaluate the prognostic value of cystatin C for patients after heart transplantation. METHODS Seventy-three long-term recipients of a heart transplant more than 5 years before the study start were included in the analysis with a follow-up of 4 years. Serum creatinine, renal glomerular filtration rate calculated by the Modification of Diet in Renal Disease formula, and serum cystatin C levels were collected, and risk factors for renal dysfunction were assessed. Statistical analysis was performed for all patients. RESULTS Univariate analysis showed a prognostic impact of antihypertensive medication and onset of diabetes (P < .001) on renal failure after transplantation. Multivariate analysis yielded cystatin C measured at the study start as a superior prognostic parameter for all time points (area under the receiver operating characteristic 12 months: 0.963; 24 months: 0.910; 48 months: 0.949) compared with the conventionally used creatinine levels. CONCLUSIONS Our results showed an enormous potential of serum cystatin C as an early prognostic and easy to obtain biomarker for renal dysfunction after heart transplantation.

Management and therapy of atrial fibrillation in geriatric patients

Among geriatric patients, atrial fibrillation is the most common cardiac arrhythmia. In patients over 80 years of age, the prevalence rises to approximately 10%. Atrial fibrillation is associated with serious health implications, including a 2-fold increase in mortality risk and a 5-fold increase in stroke risk. In contrast to these facts, the current guidelines on the management of atrial fibrillation of the European Society of Cardiology (ESC) contain only a short paragraph on these patients. Many relevant clinical aspects go without any comment. Thus, the purpose of our paper is to discuss those special needs of geriatric patients and their physicians which are not mentioned in the guidelines of the ESC. In our review, we discuss rhythm versus rate control, oral anticoagulation, outcome, prevention, falls, adherence, polypharmacy, dementia, nursing home patients, frailty, and geriatric assessment in consideration of geriatric patients. An extended search of the literature on Pubmed served as the basis for this review. Individual aspects of each geriatric patient should be considered when managing these complex patients; however, the complexity of each case must not lead to an individualized therapy that is not in accordance with current guidelines and the literature. A large number of papers which help us to answer most of the clinical questions regarding the management of trial fibrillation in geriatric patients have already been published.

Polypharmazie und Schmerztherapie

SummaryPain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug–drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.ZusammenfassungSchmerzen betreffen besonders ältere und chronisch kranke Bevölkerungsgruppen. Häufig findet sich die Schmerztherapie als Ergänzung zu einer bereits bestehenden Polypharmazie. Neben unerwünschten Arzneimittelwirkungen sind es vor allem Interaktionen, welche es zu beachten gibt. Die Gruppe der nichtsteriodalen Antirheumatika (NSAR) hat das größte Gefahrenpotential. Im Vordergrund stehen gastrointestinale, kardiovaskuläre und renale Effekte sowie Wirkungen auf das Gerinnungssystem. Paracetamol hat neben der bekannten (in hohen Dosen) toxischen Wirkung auf die Leber, ähnliche Interaktionen wie die NSAR, allerdings in einem geringeren Ausmaß. Metamizol ist nach der aktuellen Studienlage besser als sein Ruf, das Interaktionspotential ist als gering anzusehen. Im Bezug auf Tramadol sowie auch einige stark wirksame Opioide (insbesondere Pethidin) sind vor allen das Serotonin-Syndrom und die ZNS dämpfende Wirkung zu nennen. Auf Grund des erheblichen Gefahrenpotentials bei einer bestehenden Polypharmazie ist es in vielen Fällen ratsam, bei der Auswahl der Analgetika vom WHO-Stufenschema in der Schmerzbehandlung abzusehen.Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.