Summary
Background
The lack of objective diagnostic criteria renders pyoderma gangrenosum (PG) a diagnosis of exclusion. The diagnostic approaches proposed to date have not been systematically ...evaluated. Thus, PG remains a challenging and frequently misdiagnosed disorder.
Objectives
To develop and assess a comprehensive, yet clinically practicable, sensitive diagnostic scoring system for PG.
Methods
Clinical history and images of a total of 60 participants with previously confirmed PG located on the lower extremity and a control cohort of 50 patients with venous leg ulcers were retrospectively evaluated by expert teams at two tertiary dermatological centres specializing in wound care using a newly developed diagnostic scoring system composed of 10 criteria.
Results
The three major diagnostic criteria are rapidly progressing disease, assessment of relevant differential diagnoses and a reddish‐violaceous wound border (prevalent in 98% of patients with PG). Minor criteria (evident in 61–95% of patients with PG) include amelioration by immunosuppressant drugs, characteristically irregular shape of ulceration, extreme pain > 4/10 on a visual analogue scale and localization of lesion at the site of the trauma. Three additional criteria (observed in up to 60% of patients with PG) encompass suppurative inflammation in histopathology, undermined wound borders and systemic disease associated. A total score value of 10 points or higher indicates a high likelihood of PG and differentiates PG from venous leg ulcers. The initial letters of the above‐listed criteria form the acronym PARACELSUS.
Conclusions
The PARACELSUS score represents a novel, easily implementable, effective and sensitive diagnostic tool for PG.
What's already known about this topic?
Pyoderma gangrenosum (PG) represents a diagnosis of exclusion.
Objective and systematically evaluated diagnostic approaches for patients with suspected PG are lacking.
What does this study add?
A comprehensive and practicable diagnostic scoring system for PG was developed and evaluated by expert teams at two leading tertiary dermatological centres specializing in wound care. The initial letters of the score criteria form the acronym PARACELSUS.
A total score of 10 points or higher indicates a high likelihood of PG and differentiates PG from venous leg ulcers.
The PARACELSUS score is an effective and easily implementable diagnostic tool for PG.
Respond to this article
Linked Editorial: Schreml. Br J Dermatol 2019; 180:438–439.
Plain language summary available online
The Mini-Nutritional Assessment (MNA) is a validated assessment instrument for nutritional problems, but its length limits its usefulness for screening. We sought to develop a screening version of ...this instrument, the MNA-SF, that retains good diagnostic accuracy.
We reanalyzed data from France that were used to develop the original MNA and combined these with data collected in Spain and New MEXICO: Of the 881 subjects with complete MNA data, 151 were from France, 400 were from Spain, and 330 were from New MEXICO: Independent ratings of clinical nutritional status were available for 142 of the French subjects. Overall, 73.8% were community dwelling, and mean age was 76.4 years. Items were chosen for the MNA-SF on the basis of item correlation with the total MNA score and with clinical nutritional status, internal consistency, reliability, completeness, and ease of administration.
After testing multiple versions, we identified an optimal six-item MNA-SF total score ranging from 0 to 14. The cut-point score for MNA-SF was calculated using clinical nutritional status as the gold standard (n = 142) and using the total MNA score (n = 881). The MNA-SF was strongly correlated with the total MNA score (r = .945). Using an MNA-SF score of > or = 11 as normal, sensitivity was 97.9%, specificity was 100%, and diagnostic accuracy was 98.7% for predicting undernutrition.
The MNA-SF can identify persons with undernutrition and can be used in a two-step screening process in which persons, identified as "at risk" on the MNA-SF, would receive additional assessment to confirm the diagnosis and plan interventions.
The frailty syndrome has recently attracted attention of the scientific community and public health organizations as precursor and contributor of age-related conditions (particularly disability) in ...older persons. In parallel, dementia and cognitive disorders also represent major healthcare and social priorities. Although physical frailty and cognitive impairment have shown to be related in epidemiological studies, their pathophysiological mechanisms have been usually studied separately. An International Consensus Group on “Cognitive Frailty” was organized by the International Academy on Nutrition and Aging (I.A.N.A) and the International Association of Gerontology and Geriatrics (I.A.G.G) on April 16th, 2013 in Toulouse (France). The present report describes the results of the Consensus Group and provides the first definition of a “Cognitive Frailty” condition in older adults. Specific aim of this approach was to facilitate the design of future personalized preventive interventions in older persons. Finally, the Group discussed the use of multidomain interventions focused on the physical, nutritional, cognitive and psychological domains for improving the well-being and quality of life in the elderly. The consensus panel proposed the identification of the so-called “cognitive frailty” as an heterogeneous clinical manifestation characterized by the simultaneous presence of both physical frailty and cognitive impairment. In particular, the key factors defining such a condition include: 1) presence of physical frailty and cognitive impairment (CDR=0.5); and 2) exclusion of concurrent AD dementia or other dementias. Under different circumstances, cognitive frailty may represent a precursor of neurodegenerative processes. A potential for reversibility may also characterize this entity. A psychological component of the condition is evident and concurs at increasing the vulnerability of the individual to stressors.
Introduction
The use of a simple, safe, and easy to perform assessment tool, like gait speed, to evaluate vulnerability to adverse outcomes in community-dwelling older people is appealing, but its ...predictive capacity is still questioned. The present manuscript summarises the conclusions of an expert panel in the domain of physical performance measures and frailty in older people, who reviewed and discussed the existing literature in a 2-day meeting held in Toulouse, France on March 12–13, 2009. The aim of the IANA Task Force was to state if, in the light of actual scientific evidence, gait speed assessed at usual pace had the capacity to identify community-dwelling older people at risk of adverse outcomes, and if gait speed could be used as a single-item tool instead of more comprehensive but more time-consuming assessment instruments.
Methods
A systematic review of literature was performed prior to the meeting (Medline search and additional pearling of reference lists and key-articles supplied by Task Force members). Manuscripts were retained for the present revision only when a high level of evidence was present following 4 pre-selected criteria: a) gait speed, at usual pace, had to be specifically assessed as a single-item tool, b) gait speed should be measured over a short distance, c) at baseline, participants had to be autonomous, community-dwelling older people, and d) the evaluation of onset of adverse outcomes (i.e. disability, cognitive impairment, institutionalisation, falls, and/or mortality) had to be assessed longitudinally over time. Based on the prior criteria, a final selection of 27 articles was used for the present manuscript.
Results
Gait speed at usual pace was found to be a consistent risk factor for disability, cognitive impairment, institutionalisation, falls, and/or mortality. In predicting these adverse outcomes over time, gait speed was at least as sensible as composite tools.
Conclusions
Although more specific surveys needs to be performed, there is sufficient evidence to state that gait speed identifies autonomous community-dwelling older people at risk of adverse outcomes and can be used as a single-item assessment tool. The assessment at usual pace over 4 meters was the most often used method in literature and might represent a quick, safe, inexpensive and highly reliable instrument to be implemented.
OBJECTIVES: The objective of this study is to assess the nutritional status, measured by the MNA, in community-dwelling elderly individuals with dementia and to identify clinical risk factors for ...nutritional risk or malnutrition. DESIGN: Cross-sectional analysis of a cluster randomized clinical trial (Nutrialz). SETTING: Community-dwelling individuals attending dementia clinics. PARTICIPANTS: 940 individuals. MEASUREMENTS: The clinical scales assessed were Mini Nutritional Assessment (MNA), Eating Behaviour Scale (EBS), Charlson comorbidity index, Clinical Dementia Rating (CDR), Mini-Mental State Examination (MMSE), Basic Activities of Daily Living (BADL) score, Instrumental Activities of Daily Living (IADL) score, Neuropsychiatric Inventory Questionnaire (NPI-Q), Cornell depression scale and Zarit Caregiver Burden Interview. RESULTS: 5.2% of participants were classified as being malnourished, 42.6% as being at risk of malnutrition and 52.2% as well nourished. Malnutrition by type of dementia was more frequent in Lewy bodies dementia (18.2%) than in the other types. Worse nutritional status is significantly related to more advanced age and worse cognitive, functional and behavioural profile, as well as increased burden for caregivers. Presence of behavioural symptoms is significantly related to worse nutritional level for all NPI-Q symptoms but depression, exaltation, lack of inhibition and irritability. The items more strongly related to malnutrition are appetite/feeding and hallucinations. Dependence in any basic or instrumental ADL is significantly related to higher risk of malnutrition. Dependence on feeding is a strongly related risk factor, while food preparation is only a moderate one. A logistic regression model to predict at risk/malnutrition kept as significant risk factors EBS (Odds Ratio (OR) 0.84, 95%CI 0.78 to 0.91), Cornell (OR 1.12, 95%CI 1.09 to 1.16), the number of dependent BADL (OR 1.29, 95%CI 1.17 to 1.42), age (OR 1.04, 95%CI 1.02–1.06), MMSE (OR 0.95, 95%CI 0.92 to 0.98) and Charlson (OR 1.18, 95%CI 1.05 to 1.34). A similar model built for prediction of malnutrition retained as significant covariables only EBS, Cornell and the number of dependent BADL. CONCLUSION: These results will allow a better understanding of the clinical stage previous to malnutrition. An adequate diagnosis and treatment of identified modifiable factors like functional impairment, eating behaviours and depression could delay or avoid malnutrition.
Melatonin is a hormone secreted by the pineal gland. It displays a very marked nycthohemeral rhythm, which is entrained to the light dark cycle. The secretion spreads over 8-10 hours, with a maximum ...around 3-4 a.m. Melatonin plays the role of an endogenous synchronizer which regulates circadian rhythms, especially the sleep/wake and temperature rhythms. Acute melatonin administration reduces sleep latency, increases theta/alpha power and spindle activity (soporific activity). Fast-release melatonin preparations showed inconstant effects in insomnia. Melatonin displays a short blood half-life, a fast turn over and undergoes a high first-pass hepatic metabolism. More than 80% is excreted exclusively in the urine as 6-sulfatoxymelatonin. The individual's capacity to produce the endogenous hormone, the decline in circadian clock output and the increase in complaints of poor sleep quality at older age led to develop a prolonged-release melatonin preparation to mimic the endogenous secretion in patients. This reviews provides data on physiological and pharmacological melatonin effects related to sleep and summarizes trials published about Circadin
efficacy and tolerance in insomnia. Preliminary therapeutic data on other indications are given. The main clinically relevant benefits are improvements in sleep quality and latency, next-day morning alertness and quality of life. The response develops over several days. An oral 2-mg dose once daily, for 3 months, is generally well tolerated with no rebound, withdrawal or 'hangover' effects and no safety concerns on concomitant therapy with antihypertensive, antidiabetic, lipid-lowering or anti-inflammatory drugs. Untoward effects of hypnotics on cognition, memory, postural stability and sleep structure are not seen with Circadin
. Given as a first-line prescription, with 13 weeks' posology and the lack of rebound effects, Circadin
has the potential to improve quality of life in insomnia patients aged 55 years and older and avoid long-term use of hypnotics.
The master biological clock situated in the suprachiasmatic nuclei of the anterior hypothalamus plays a vital role in orchestrating the circadian rhythms of multiple biological processes. Increasing ...evidence points to a role of the biological clock in the development of depression. In seasonal depression and in bipolar disorders it seems likely that the circadian system plays a vital role in the genesis of the disorder. For major unipolar depressive disorder (MDD) available data suggest a primary involvement of the circadian system but further and larger studies are necessary to conclude. Melatonin and melatonin agonists have chronobiotic effects, which mean that they can readjust the circadian system. Seasonal affective disorders and mood disturbances caused by circadian malfunction are theoretically treatable by manipulating the circadian system using chronobiotic drugs, chronotherapy or bright light therapy. In MDD, melatonin alone has no antidepressant action but novel melatoninergic compounds demonstrate antidepressant properties. Of these, the most advanced is the novel melatonin agonist agomelatine, which combines joint MT1 and MT2 agonism with 5-HT(2C) receptor antagonism. Adding a chronobiotic effect to the inhibition of 5-HT(2C) receptors may explain the rapid impact of agomelatine on depression, since studies showed that agomelatine had an early impact on sleep quality and alertness at awakening. Further studies are necessary in order to better characterize the effect of agomelatine and other novel melatoninergic drugs on the circadian system of MDD patients. In summary, antidepressants with intrinsic chronobiotic properties offer a novel approach to treatment of depression.
Prospective observational study.
To evaluate melatonin secretion, daytime sleepiness and sleep disorders in patients with spinal cord injuries (SCI), and their association with lesion level.
...Specialized neuro rehabilitation hospital in France METHODS: Prospective observational study of patients aged over 18 hospitalized in for spinal cord injury. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PQSI), daytime sleepiness with the Epworth Sleepiness scale (ESS), and melatonin secretion by 24 h urinary dosage of 6-sulphatoxy-melatonin.
213 patients were screened, 21 patients were included: 17 complete (AIS A) and 4 lesions (AIS B), 76% of traumatic origin with 12 tetraplegic and 9 paraplegic, mean 10 (range 0.5-40) years after injury. Mean age was 46.8 ± 14.7 years, mean BMI 23.56 ± 4.1 and men outnumbered women (15 vs 6). Melatonin secretion was analyzed by 24 h secretion and by secretion profile. Comparing retained vs abolished secretion, only 23% (4/17) of patients with a lesion above T8 retained melatonin secretion, compared to 80% (4/5) with a lesion below T8 (p = 0.022). Non significant differences were found in secretion profile in patients who retained secretion: no patient with a lesion above T8 had a normal secretion profile compared to 50% with a lesion below T8 and in the impact of partial vs total lesions above T8 in whom 17% (2/12) of complete ASIA-A lesions and 50% (2/4) of incomplete lesions retained secretion.
Lesions of the spinal cord above T8 are strongly associated with abolition of melatonin secretion.
Objectives
The European Working Group on Sarcopenia in Older People (EWGSOP) has proposed different methods and cut-off points for the three parameters that define sarcopenia: muscle mass, muscle ...strength and physical performance. Although this facilitates clinical practice, it limits comparability between studies and leads to wide differences in published prevalence rates. The aim of this study was to assess how changes in cut-off points for muscle mass, gait speed and grip strength affected sarcopenia prevalence according to EWGSOP criteria.
Methods
Cross-sectional analysis of elderly individuals recruited from outpatient clinics (n=298) and nursing homes (n=276). We measured muscle mass, grip strength and gait speed and assessed how changes in cut-off points changed sarcopenia prevalence in both populations.
Results
An increase from 5.45 kg/m
2
to 6.68 kg/m
2
in the muscle mass index for female outpatients and nursing-home residents increased sarcopenia prevalence from 4% to 23% and from 9% to 47%, respectively; for men, for an increase from 7.25 kg/m
2
to 8.87 kg/m
2
, the corresponding increases were from 1% to 22% and from 6% to 41%, respectively. Changes in gait speed and grip strength had a limited impact on sarcopenia prevalence.
Conclusion
The cut-off points used for muscle mass affect the reported prevalence rates for sarcopenia and, in turn, affect comparability between studies. The main factors influencing the magnitude of the change are muscle mass index distribution in the population and the absolute value of the cut-off points: the same difference between two references (e.g., 7.5 kg/m
2
to 7.75 kg/m
2
or 7.75 kg/m
2
to 8 kg/m
2
) may produce different changes in prevalence. Changes in cut-off points for gait speed and grip strength had a limited impact on sarcopenia prevalence and on study comparability.
Background
Few data are available about the frequency of incisional hernia in an emergency subcostal laparotomy. Our objective is to analyze the incidence of incisional hernia after emergency ...subcostal laparotomy and evaluate if prophylactic mesh could help prevent it.
Methods
This study is a monocentric retrospective analysis following STROBE guideline statements of all patients who underwent an emergency subcostal laparotomy between January 2011 and July 2017 in our University Hospital. We compared complications and incidence of incisional hernia between patients who received sutures (Group S;
N
= 203) and patients with prophylactic onlay mesh (Group M;
N
= 80). A multivariate risk factor analysis of incisional hernia was performed. An incisional hernia-estimated risk calculator equation was created.
Results
A total of 283 patients were analyzed. There were 80 patients in Group M and 203 in Group S. In short-term outcomes, length of surgery (213 ± 115 min vs 165 ± 73.3 min,
P
= 0.001) and hospital stay (16.4 ± 18.7 vs 11.6 days ± 13.4,
P
= 0.038) were longer in Group M. Long-term follow-up was conducted in 207 patients with a mean follow-up time of 39.3 ± 23 months. Incisional hernia was detected in 29 (19.1%) patients in Group S but in only two (3.8%) patients in Group M (
P
= 0.008). In the multivariate analysis, a risk factor analysis included wound infection (4.91 HR (2.12–11.4);
P
< 0.001), previous hernia repair (2.86 HR (1.24–6.61);
P
= 0.014), and shock (2.64 HR (1.01–6.93);
P
= 0.048).
Conclusions
The incidence of incisional hernia after emergency subcostal laparotomy is high. Risk factors are wound infection, shock, and previous hernia surgery. The use of prophylactic mesh augmentation was safe and reduced the incidence of incisional hernia.
PDF
