Elderly Patient Population Research Articles

Aesthetic outcome of simple cuticular suture distance from the wound edge on the closure of linear wounds on the head and neck: A randomized evaluator blinded split-wound comparative effect trial

Little data support the optimal distance of cuticular suture placement from the wound edge to achieve the most cosmetically appealing scar. To compare Patient and Observer Scar Assessment Scale (POSAS) scores for cutaneous sutures spaced 2mm versus 5mm from the wound edge in head and neck defects repaired via linear closure. Fifty patients were enrolled in this randomized, evaluator blinded, split-scar study. Surgical wounds were repaired with cuticular sutures 2mm from the wound edge on one side and 5mm on the other. POSAS scores and scar width were compared 3months postoperatively. The sum observer POSAS score for this study had a mean (SD) of 16.06 (6.49) on the 2-mm side and 15.82 (6.83) on the 5-mm side (P=.807). Similarly, no difference was seen between scar width with a mean (SD) of 0.100cm (0.058cm) on the 2-mm side and with mean (SD) 0.100cm (0.076cm) on the 5-mm side (P=.967). Linear repairs were studied on head and neck defects after extirpation of cutaneous malignancies, resulting in a homogeneous elderly white patient population. Cuticular sutures placed 2 or 5mm from the wound edge did not result in different cosmetic outcomes in linear closures on the head and neck.

Safety of body contouring surgery in an aging patient population

The fastest-growing age group undergoing cosmetic procedures are those over age 60, i.e. the aging patient group. While advanced age is a known predictor for increased surgical complications, the effects of age on complications in specific plastic procedures have yet to be thoroughly investigated. To determine the relationship between increased age and risk of surgical complications following body contouring procedures, specifically: abdominoplasty, brachioplasty, mastopexy, bilateral reduction, and thigh lift. A retrospective analysis of all patients undergoing body contouring procedures of the categories mentioned above between 2000–2018 at a tertiary university medical center. Patients were divided into two age groups: those below and those above, age 60. Data analysis included: demographics, underlying medical conditions, procedure type, and occurrence of postoperative complications (according to the Clavien-Dindo classification system). 803 body contouring procedures were identified, with 12% performed on the aging population. Aging patients had more underlying medical conditions than the younger ones. While the distribution of procedure type was similar in both groups, mastopexy was more common in aging patients. Of the 107 procedures identified as having complications, 37 were classified as grade I, 38 as grade II, and 32 as grade III. As a categorical variable, no relationship was found between the age of the patients and an increased risk of postoperative complications (age cut-off as 60). However, as a continuous variable, increased age did increase the overall risk of postoperative complications, although no optimal age as a cut-off point was identified. In multivariant analysis, diabetes mellitus with abdominoplasty was identified as a risk factor for postoperative complications. Conclusions: When undergoing body contouring procedures, we found that patients over the age of 60 are not at increased risk for postoperative complications than those under that age. Although age as a continuous variable was found to increase the overall postoperative complications, no optimal age could be defined as a cut-off point.

Treatment Discontinuation in Patients With Muscle-Invasive Bladder Cancer Undergoing Chemoradiation

PurposeChemoradiation (CRT) is a definitive treatment option for muscle-invasive bladder cancer (MIBC). Despite its effectiveness, CRT is underused, in part owing to concerns of tolerability and the need for integrated multidisciplinary care. We investigated factors associated with and the impact of treatment discontinuation in patients with MIBC treated with CRT. Methods and MaterialsIn the US Veterans Affairs’ national database, we identified patients with urothelial histology, MIBC (T2-4a/N0-3/M0) diagnosed between 2000 and 2018 and treated with definitive-intent CRT. The primary endpoint of discontinued radiation was evaluated in a multivariable logistic regression. Secondary endpoints of 30-day and 90-day mortality, overall mortality, and nonbladder cancer mortality were evaluated in multivariable models. ResultsOf 369 veterans with MIBC who underwent CRT, 30 patients (8.1%) did not complete radiation. The most common reasons for treatment discontinuation included comorbidities or infections necessitating hospital admission (63.3%) and treatment intolerance or declining performance status (26.7%). In multivariable logistic regression, variables associated with radiation discontinuation were creatinine clearance ≤ 50 (odds ratio [OR], 3.93; 95% CI, 1.63-9.50; P = .002), incomplete transurethral resection of bladder tumor (TURBT) (OR, 3.16; 95% CI, 1.15-8.63; P = .02), and nonpreferred chemotherapy (OR, 3.31; 95% CI, 1.31-8.36; P = .01). In the cohort that discontinued radiation, 30-day mortality was 33.3% and 90-day mortality was 50.0%, with the majority of deaths attributed to nonbladder cancer causes. No patient or tumor variables were associated with either endpoint. In the cohort that completed radiation, 30-day mortality was 2.7% and 90-day mortality was 6.8%. In multivariable analysis, radiation discontinuation was associated with worse overall mortality (hazard ratio [HR], 2.48; 95% CI, 1.36-4.50; P = .003) and worse nonbladder cancer mortality (HR, 2.32; 95% CI, 1.24-4.34; P = .008). ConclusionsWith a low rate of treatment discontinuation, CRT is an effective and feasible treatment option for the typically elderly and comorbid population of patients with MIBC. In addition to identified predictors of treatment discontinuation (poor renal function, incomplete TURBT, etc.), further research is required to develop evidence-based guidelines for optimal patient selection.

Safety and Early Efficacy of Involved Field SBRT for Nodal Oligo-Recurrent Prostate Cancer

<h3>Purpose/Objective(s)</h3> Following definitive treatment for localized prostate cancer a subset of men will unfortunately develop recurrent disease. Newer PET agents have demonstrated that most early recurrences occur in the abdominopelvic nodal basins. The optimal treatment strategy for this patient population is unknown but likely includes a combination of systemic therapy, surgery and/or radiation therapy. For radiation therapy, the optimal treatment volume, fractionation schedule and dose remain unanswered questions. We report early outcomes for patients treated with involved field SBRT for nodal oligo-recurrent prostate cancer. <h3>Materials/Methods</h3> Between January 2018 and January 2020, 21 patients with nodal oligo-recurrent prostate cancer treated with involved field SBRT at a single academic institution were eligible for inclusion in this analysis. Detection of recurrence was ascertained by imaging including: Axumin PET/CT (66%) or MRI/CT (34%) following a PSA rise. All patients were treated with five-fraction involved field SBRT to a dose of 27.5-30 Gy. The treatment volume for involved field was defined as the nodal basin containing the gross nodal disease as well as the immediately adjacent nodal basins. Oligo-recurrence was defined as any volume of disease that could be safely treated within an involved field. Acute and late toxicity data was defined as any treatment related toxicity occurring <b>≤</b> 90 days and > 90 days following treatment, respectively. Toxicity was graded using Common Terminology Criteria for Adverse Events version 4.0. PSA response was defined as any decrease in the PSA following treatment. Local recurrence was defined as any new or growing lesion within the treatment field following treatment. Local control was calculated using the Kaplan-Meier method. <h3>Results</h3> The median pre-salvage PSA was 7.2 ng/ml. The median follow-up for all patients was 25 months (11 – 36 months). The most common acute side effect was grade 1 diarrhea (n = 7, 33%). Acute grade 2 GI toxicity occurred in 14% of patients (n = 3). Two patients had late low grade pelvic pain and 1 patient had late grade 2 lower extremity limb edema. There were no late grade 2+ GI side effects. No grade 3+ side effects occurred at any time following treatment. 88% of patients had a PSA response following treatment. The local control at 1 and 2 years was 100% and 94%, respectively. <h3>Conclusion</h3> With the widespread adoption of novel PET agents the group of patients with oligo-recurrent nodal disease is likely to increase significantly. The optimal combination of local and systemic therapy in this patient population is the subject of ongoing clinical investigation. With a favorable toxicity profile, high rates of local control and PSA response, involved field SBRT represents a feasible as well as convenient local therapy treatment option for an elderly patient population.

Autologous arteriovenous fistulas in octa- and nonagenarians

Conventional wisdom has argued for refraining from performing autologous fistulas on elderly population with the rationale that they may not live long enough to benefit from them. However, with aging patient population and increasing prevalence of end-stage renal disease, one has to question if physicians should really be holding advanced age against offering dialysis access to patients who otherwise may be considered an acceptable risk for tolerating an elective operation. It is compounded by the fact that majority of the fistulas can be performed under local anesthesia or nerve block. In the retrospective analysis of over 300,000 patients in the USRDS database, Arhuidese at al1Arhuidese I.J. King R.W. Elemuo C. Agbonkhese G. Calero A. Malas M. Age based outcomes of autogenous fistulas for hemodialysis access.J Vasc Surg. 2021; 74: 1636-1642Abstract Full Text Full Text PDF Scopus (1) Google Scholar found a trend in progressive decrease in primary, primary assisted, and secondary patency in octa- and nonagenarians. This difference may very well be attributable to increased incidence of coexisting comorbidities in elderly; however, a cause-and-effect relationship cannot be established based on the retrospective nature of this analysis. The key take-away point from this analysis is that patients over 80 years of age had primary patency rates of over 35% at 1 year and up to 18% at 5 years. For elderly patient population on hemodialysis, dialysis catheter infections can be catastrophic, and if an autogenous fistula can be successfully created to mitigate the risk of catheter-related infections, it can be of significant benefit to this cohort of patient population. It is the need of the hour that vascular surgeons should individualize the decisions about dialysis access creation to individual patients, regardless of their ages. Decision to proceed with an elective operation to create dialysis access should be made after a careful consideration of risks and benefits of the proposed procedure, including a thorough review of the existing comorbidities. Age in itself should not be used to determine the risk-benefit ratio for elective procedures. Published literature on other vascular surgery procedures has shown that modified frailty index, which takes many coexisting factors, in addition to age, into account, is a better tool to assess the perioperative morbidity and mortality. With increasing proportion of elderly population, we will have to make these decisions more frequently in the near future and getting familiar with tools like modified frailty index will be of immense value for practicing vascular surgeons. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Age-based outcomes of autogenous fistulas for hemodialysis accessJournal of Vascular SurgeryVol. 74Issue 5PreviewHemodialysis (HD) dependence and autogenous fistula use for HD span the spectrum of age. This study examines age-related outcomes of autogenous fistulas for HD access in a large population-based cohort of patients. Full-Text PDF

Efficacy of Ultrasound Guided Foam Sclerotherapy of Incompetent Ankle Perforators on Healing of Chronic Venous Ulcers with Deep Venous Reflux. (A Comparative Study)

Abstract Background Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency, but the treatment of underlying venous disease to relieve venous hypertension appears to improve wound healing and to decrease recurrence. Benefits of saphenous ablation have been well demonstrated; however, evidence for the treatment of incompetent perforating veins is less clear. Objective To assess the benefit of ultrasound-guided sclerotherapy (USGS) of incompetent perforator on healing of chronic venous ulcers. Patients and Methods This is a prospective cohort study which is a double arm clinical study to assess the healing rate for patients after USGFS vs standard compression therapy of patients with incompetent perforators veins within 6 month. Results Our preliminary data add further weight to the suggestion that eradication of SVR by means of UGFS improves CVU outcomes when compared to compression alone. In this regard, UGFS appears to be more effective more than compression therapy does, therefore, appear the more attractive option in this elderly patient population. Furthermore, the follow-up data presented here does suggest long-term healing following UGFS probably requires careful follow-up and, if required. Encouraged by these promising early results the authors have embarked upon a larger study to look at the role of UGFS in the treatment of CVU in greater depth. Conclusion Ultrasound guided foam sclerotherapy of perforator incompetent veins is a welltolerated and effective outpatient procedure. This study presents a patient cohort with limited exclusion criteria, allowing a representative cross section of VLU in general. Because of its higher healing rate and lower RR compared to other therapeutic options, and the improvement in quality of life that it brings, this minimally invasive, easily repeatable procedure may become the treatment of choice for VLU. Foam sclerotherapy is a simple procedure, compared to surgical intervention, no hospitalization, no anesthesia, can be done in outpatient clinic and the patient can return home after 45 min and no work off period. The relative freedom from serious complications and its evident success, makes this modality as a possible candidate for being the first line treatment for venous ulcers.

215 - ECN Awards: Anticholinergic Burden: A Study in a Psychiatry of Later Life Cohort

BackgroundMedications with anticholinergic activity are widely prescribed for a variety of medical, surgical, and psychiatric illnesses. There is strong evidence that the cumulative anticholinergic properties of such medications (i.e., the anticholinergic burden) contributes to significant longer-term adverse effects, including dementia, impaired mobility, and increased mortality. Despite this, the anticholinergic burden is often not given due consideration when cliniciansprescribe or review medications in routine clinical practice. This is of particularrelevance in services working with elderly patient populations, who are both more likely to experience polypharmacy and more vulnerable to medication adverse effects. Greater awareness of the risks of anticholinergic prescribing may lead to improvements in longer-term cognitive and physical functioning,and subsequently decreased disease burden on individuals and society as a whole.Objectives/AimsTo identify and quantify anticholinergic burden among all patients currentlyattending a rural Psychiatry of Later Life service.MethodsThis was a cross-sectional observational study. Chart reviews were carried out on all patients open to the service at the time of the study in November 2020. Each patient’s medication regime was analysed to calculate its overall score onthe Anticholinergic Effect on Cognition Scale (AEC), using an online tool developed by South London and Maudsley NHS Foundation Trust. Other variables such as each patient’s age, sex, and cognitive status (categorized as no cognitive impairment; mild cognitive impairment (MCI); or dementia) were also documented. Data was anonymised on collection. AEC scores of 2 or morewere deemed to be at threshold for ‘review and withdraw or switch’ of medications.ResultsA total of 80 patients were included in the study (48 female; mean age 77 [SD = 6.5] years). 45% of patients had a documented diagnosis of dementia, 11%had a documented diagnosis of MCI and 44% had no documented cognitive impairment. Overall, the majority of patients (53.75%) were found to have an AEC score of 2 or greater (AEC range 0-6, mean 2.5 [SD = 1.5]). Of patients with a diagnosis of dementia, 58% were found to have an AEC of 2 or greater.ConclusionsThe possible detrimental effects of prescribed medication on cognition and physical health are likely under-recognised in routine clinical practice. Greaterawareness of the anticholinergic properties of a wide variety of commonly prescribed medication may lead to more selective and informed prescribing.Abstract has been accepted for a poster presentation at the British Association for Psychopharmacology Summer Meeting (July 2021), and at the European College of Neuropsychopharmacology Annual Congress (October 2021).

A drug utilization study of oral anticoagulants in five representative cities of China between 2015 and 2019.

Oral anticoagulants (OACs), including warfarin and newer direct-acting OACs (DOACs), have been used for decades to prevent thromboembolic diseases. A drug utilization study was performed to determine the prescribing patterns of OACs. Data were extracted from the Cooperation Project of Hospital Prescription Analysis in China. A total of 455,490 prescription records from 43 tertiary hospitals in five cities of China (Beijing, Shanghai, Guangzhou, Hangzhou and Chengdu) were selected for inclusion. Quarterly trends of defined daily doses (DDDs) and defined daily dose cost (DDDC) from 1 January 2015 to 31 December 2019 were calculated. Warfarin was the most widely used OAC with DDDs between 189,982 and 176,323 from the first quarter (Q1) of 2015 to the fourth quarter (Q4) of 2019, whereas the use of DOACs increased rapidly during this period. DDDs of rivaroxaban increased from 5409 in Q1 of 2015 to 125,800 in Q4 of 2019, whereas the DDDC declined from 160.5 to 45.7. From Q1 of 2018, rivaroxaban became the most prescribed OAC, surpassing warfarin, in patients diagnosed with deep vein thrombosis. In addition, the DDDs of rivaroxaban exceeded those of warfarin in patients diagnosed with non-valvular atrial fibrillation since the second quarter (Q2) of 2019. DDDs in outpatients and inpatients increased by 80.6% and 71.4%, respectively, and the DDDC for outpatients in Q4 of 2019 was 6.7-fold higher than that in Q1 of 2015. Among patients of all ages, the DDDs in elderly patients increased from 36.8% in Q1 of 2015 to 59.4% in Q4 of 2019. Moreover, the departments of cardiology and cardiothoracic surgery prescribed the majority of the OACs. In this study, we describe OAC prescription patterns in China. DOACs, especially rivaroxaban, contribute to the continuous increase in the use of OACs. In the investigated population of China, outpatients and elderly patients were observed to be administered the highest proportion of DOACs.

The significant impact of Coronavirus disease 2019 (COVID-19) on in-hospital mortality of elderly patients with moderate to severe traumatic brain injury: A retrospective observational study

BackgroundTraumatic brain injury (TBI) is one of the main causes of death and disability among the elderly patient population. This study aimed to assess the predictors of in-hospital mortality of elderly patients with moderate to severe TBI who presented during the Coronavirus disease 2019 (COVID-19) pandemic. MethodsIn this retrospective analytical study, all elderly patients with moderate to severe TBI who were referred to our center between March 2nd, 2020 to August 1st, 2020 were investigated and compared against the TBI patients receiving treatment during the same time period within the year 2019. Patients were followed until discharge from the hospital or death. The demographic, clinical, radiological, and laboratory test data were evaluated. Data were analyzed using SPSS-21 software. FindingsIn this study, 359 elderly patients were evaluated (n = 162, Post-COVID-19). Fifty-four patients of the cohort had COVID-19 disease with a mortality rate was 33.3%. The patients with COVID-19 were 5.45 times more likely to expire before discharge (P < 0.001) than the TBI patients who were not COVID-19 positive. Other variables such as hypotension (OR, 4.57P < 0.001), hyperglycemia (OR, 2.39, P = 0.002), and use of anticoagulant drugs (OR, 2.41P = 0.001) were also associated with in-hospital death.According to the binary logistic regression analysis Age (OR, 1.72; 95% CI: 1.26–2.18; P = 0.033), Coronavirus infection (OR, 2.21; 95% CI: 1.83–2.92; P = 0.011) and Glasgow Coma Scale (GCS) (OR, 3.11; 95% CI: 2.12–4.53; P < 0.001) were independent risk factors correlated with increased risk of in-hospital mortality of elderly patients with moderate to severe TBI. ConclusionOur results showed that Coronavirus infection could increase the risk of in-hospital mortality of elderly patients with moderate to severe TBI significantly.

Acute Appendicitis in the Elderly: A Literature Review on an Increasingly Frequent Surgical Problem.

With increased life expectancy and the growing total population of elderly patients, there has been rise in the number of cases of acute appendicitis in elderly people. Although acute appendicitis is not the most typical pathological condition in the elderly, it is not uncommon. Most of these patients require surgical treatment, and as with any acute surgical pathology in advanced age, treatment possibilities are affected by comorbidities, overall health status, and an increased risk of complications. In this literature review we discuss differences in acute appendicitis in the elderly population, with a focus on clinical signs, diagnostics, pathogenesis, treatment, and results.

Transcatheter mitral valve therapies: State of the art.

Mitral regurgitation (MR) is one of the most prevalent valvular pathologies in the developed world. There continues to be a growing population of aging patients with MR who may be too high risk for surgical management. The rapid adoption and remarkable success of transcatheter aortic valve replacement (TAVR) generated enthusiasm for transcatheter mitral valve therapies; however, the complex anatomy and pathophysiology of the mitral valve confers several unique challenges for a fully percutaneous approach. Nevertheless, several devices are under development and in various phases of preclinical or clinical testing, both for transcatheter mitral valve replacement and repair. MitraClip (Abbott Vascular), which has received FDA approval, is the most established percutaneous repair strategy and has been performed in over 80,000 patients as of 2019. The following article serves as a review of the available and upcoming devices for the various etiologies of mitral valvular disease, as well as the unique challenges and potential complications of transcatheter mitral valve intervention.

Stools for Stools-combining a multi-disciplinary approach with conservative measures to reduce constipation in the elderly inpatient population

Introduction: Constipation is a common cause of morbidity in the elderly. Its management is particularly challenging in the inpatient population where many factors exacerbate constipation. We describe a Quality Improvement Project to reduce constipation in a Care of the Elderly ward, including conservative measures to complement medical treatment. Aims: To increase bowel motion frequency to at least once every two days in elderly inpatients, and to increase bowel chart documentation. Methods: Weekly monitoring of ward inpatients. Measurements taken were: days since last bowel motion, laxatives prescribed, documentation on bowel charts and ward rounds, and episodes of diarrhea. A new intervention was introduced every two weeks, over a total of 10 weeks. Interventions: The 4 interventions introduced were: 1) Recording bowel motions at the daily ‘Board Round’ Multi-Disciplinary Meeting. 2) Ward staff education sessions. 3) Footstools for use with commodes and toilets. 4) High-fibre foods for patients with constipation. Results: Bowel motion frequency improved, with 100% of patients moving bowels every 2 days from a baseline of 66.6%. Ward round and bowel chart documentation improved to 100% and 92.9% (from 41.6% and 33.3%). Laxative prescriptions increased from 50% to 78.6%, with no increase in episodes of diarrhea. Conclusions: Constipation improved with our interventions but was accompanied by increased laxative prescriptions, which carry a risk of side effects. Our next steps will be to optimize our conservative measures to reduce laxative prescriptions, and to this end, we have developed high-fiber snack boxes to aid constipation in elderly patients.

Primary treatment and recent survival trends in patients with primary diffuse large B-cell lymphoma of central nervous system, 1995-2016: A population-based SEER analysis.

This retrospective cohort study aimed to evaluate primary treatment and recent survival trends in patients with primary diffuse large B-cell lymphoma of central nervous system (CNS) from 1995 to 2016. Using the SEER data, patients diagnosed with non-HIV-associated primary central nervous system lymphoma (PCNSL)-diffuse large B-cell lymphoma (DLBCL) aged ⩾18 years between 1995 and 2016 were identified. The year of diagnosis was divided into the time period-1 (1995-2002), the time period-2 (2003-2012), and the time period-3 (2013-2016). Chi-square tests, the Kaplan-Meier method, log-rank test, and Cox regression model were used in the analysis. Overall, 3760 patients were included. Both the use of radiotherapy alone and the application of combined chemoradiotherapy decreased significantly, following the wider use of chemotherapy alone during 1995-2016. There was a significant improvement in PCNSL cause-specific survival (CSS) (period-1: 13 months vs. period-2: 19 months vs. period-3: 41 months, p<0.001). Survival of patients aged above 70 years did not change from the time period-1 to the time period-2 (p=0.101). However, there was an increase in CSS from the time period-2 to the time period-3 in the elderly patients (period-2: 5 months vs. period-3: 9 months, p<0.001). On multivariable analyses, diagnosed in the time period-3 was significantly and independently associated with better CSS (hazard ratio 0.577, 95% confidence interval 0.506-0.659, p<0.001). Our analysis shows the use of radiotherapy in the treatment of PCNSL has waned over the study span. There was a significant improvement in CSS during 1995-2016, which reflected developments in treatment over time. The elderly patient population also gained a significant CSS benefit in the most recent period.

Heterogeneity in treatment effects across diverse populations.

Differences in patient characteristics, including age, sex, and race influence the safety and effectiveness of drugs, biologic products, and medical devices. Here we provide a summary of the topics discussed during the opening panel at the 2018 Johns Hopkins Center for Excellence in Regulatory Science and Innovation symposium on Assessing and Communicating Heterogeneity of Treatment Effects for Patient Subpopulations: Challenges and Opportunities. The goal of this session was to provide a brief overview of FDA-regulated therapeutics, including drugs, biologics and medical devices, and some of the major sources of heterogeneity of treatment effects (HTE) related to patient demographics, such as age, sex and race. The panel discussed the US Food and Drug Administration's role in reviewing and regulating drugs, devices, and biologic products and the challenges associated with ensuring that diverse patient populations benefit from these therapeutics. Ultimately, ensuring diverse demographic inclusion in clinical trials, and designing basic and clinical research studies to account for the intended patient population's age, sex, race, and genetic factors among other characteristics, will lead to better, safer therapies for diverse patient populations.

Predictors for one-year outcomes of cardiorespiratory fitness and cardiovascular risk factor control after cardiac rehabilitation in elderly patients: The EU-CaRE study.

Studies on effectiveness of cardiac rehabilitation (CR) in elderly cardiovascular disease patients are rare, and it is unknown, which patients benefit most. We aimed to identify predictors for 1-year outcomes of cardiorespiratory fitness and CV risk factor (CVRF) control in patients after completing CR programs offered across seven European countries. Cardiovascular disease patients with minimal age 65 years who participated in comprehensive CR were included in this observational study. Peak oxygen uptake (VO2), body mass index (BMI), resting systolic blood pressure (BPsys), and low-density lipoprotein-cholesterol (LDL-C) were assessed before CR (T0), at termination of CR (T1), and 12 months after start of CR (T2). Predictors for changes were identified by multivariate regression models. Data was available from 1241 out of 1633 EU-CaRE patients. The strongest predictor for improvement in peak VO2 was open chest surgery, with a nearly four-fold increase in surgery compared to non-surgery patients. In patients after surgery, age, female sex, physical inactivity and time from index event to T0 were negative predictors for improvement in peak VO2. In patients without surgery, previous acute coronary syndrome and higher exercise capacity at T0 were the only negative predictors. Neither number of attended training sessions nor duration of CR were significantly associated with change in peak VO2. Non-surgery patients were more likely to achieve risk factor targets (BPsys, LDL-C, BMI) than surgery patients. In a previously understudied population of elderly CR patients, time between index event and start of CR in surgery and disease severity in non-surgery patients were the most important predictors for long-term improvement of peak VO2. Non-surgery patients had better CVRF control.

Interventional occlusion of left atrial appendage in patients with atrial fibrillation. Gender-related outcomes in the German LAARGE Registry.

Gender-based differences in atrial fibrillation have been identified, but limited data exist for patients undergoing left atrial appendage occluder (LAAO) implantation. This study reports gender-related periprocedural and 1-year outcomes of the prospective, multicenter German left atrial appendage occlusion registry (LAARGE). LAARGE enrolled 641 patients who were scheduled for LAAO implantation from July 2014 to January 2016 in 38 hospitals in Germany. The data collected included demographics, clinical characteristics, details of implantation, and outcome. Efficacy and safety at 1-year follow-up were assessed by the occurrence of thrombembolic and bleeding events, as well as mortality. Of 638 patients undergoing LAAO implantation 38.9% were female and 61.1% male. Females were older (76.4 ± 8.2 [females] vs. 75.6 ± 7.7 [males], p = .042) and had a higher stroke risk (CHA2 DS2 -VASc score: 4.9 ± 1.5 vs. 4.3 ± 1.5, p < .001). In contrast, males suffered more often from coronary artery (33.1% vs. 53.8%, p < .001) and vascular disease (18.5% vs. 31.0%, p < .001). Technical success was high and similar for both genders (98.4% vs. 97.2%, p = .33). Severe periprocedural complications (6.9% vs. 3.1%, p = .032) occurred more often in females. At 1-year follow-up the rates of all-cause stroke (0.5% vs. 1.3%, p = .65) and severe bleeding (0.0% and 1.0%, p = .29) were low and comparable between the genders. Also, one-year all-cause mortality (9.2% vs. 13.1%, p = .14) did not differ significantly. LAARGE documented in this elderly patient population undergoing LAAO implantation a higher rate of severe periprocedural complications in females. At 1-year follow-up similar efficacy and safety outcomes were observed for both genders.

Conceptually plausible Bayesian inference in interval timing.

In a world that is uncertain and noisy, perception makes use of optimization procedures that rely on the statistical properties of previous experiences. A well-known example of this phenomenon is the central tendency effect observed in many psychophysical modalities. For example, in interval timing tasks, previous experiences influence the current percept, pulling behavioural responses towards the mean. In Bayesian observer models, these previous experiences are typically modelled by unimodal statistical distributions, referred to as the prior. Here, we critically assess the validity of the assumptions underlying these models and propose a model that allows for more flexible, yet conceptually more plausible, modelling of empirical distributions. By representing previous experiences as a mixture of lognormal distributions, this model can be parametrized to mimic different unimodal distributions and thus extends previous instantiations of Bayesian observer models. We fit the mixture lognormal model to published interval timing data of healthy young adults and a clinical population of aged mild cognitive impairment patients and age-matched controls, and demonstrate that this model better explains behavioural data and provides new insights into the mechanisms that underlie the behaviour of a memory-affected clinical population.

Bullous Pemphigoid: Diagnosis, Treatment, and Management

Bullous pemphigoid, a rare autoimmune chronic skin disorder characterized by blistering, urticarial lesions (hives), and itching, is the most common among all pemphigoid diseases. BP has been growing in prevalence over the past two decades primarily due to an increasing elderly patient population and exposure to certain medication classes, such as dipeptidyl peptidase-IV (DDP-IV) inhibitors or “gliptins,” that are associated with bullous pemphigoid onset. Both of these factors contributing to a rise in potential BP cases underscores the need for health care providers in dermatology to be familiar with the clinical presentation, causes, diagnostic tools, and treatments for this condition. This article describes clinical manifestations, causes, diagnostic work-up, and treatment for BP, and includes a patient vignette to further illustrate disease presentation and management.

Age as an Independent Predictor of Adult Spinal Cord Stimulation Pain Outcomes

Introduction: Spinal cord stimulation (SCS) is an efficacious chronic pain treatment most commonly used in middle-aged patients. Results from previous studies that investigated SCS′ effects in older patient populations have been equivocal. We examine whether SCS outcomes correlate with age. Methods: We retrospectively examined prospectively collected outcomes from 189 patients who underwent SCS at Albany Medical Center between 2012 and 2020. The patients completed the Numerical Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) preoperatively and 1 year postoperatively. The mean percent change in each outcome was determined and compared via a regression analysis to determine relationships between patient age and each respective outcome metrics. Demographics were compared between patients aged under 65 versus those aged 65 and older via χ² tests. Results: All subjects demonstrated the expected improvement on NRS, BDI, PCS, and MPQ from baseline to 1-year follow-up, with several demonstrating statistically significant changes: NRS-worst pain (18.66%, p < 0.001), NRS-least pain (26.9%, p < 0.001), NRS-average pain (26.9%, p < 0.01), NRS-current pain (26.4%, p < 0.001), ODI (19.6%, p < 0.001), PCS (29.8%, p < 0.001), and MPQ (29.4%, p < 0.001). There was no significant difference between patients aged under 65 versus those aged 65 and older based on lead type (p = 0.454). Six patients (3.1%) had lead migration, one of whom was 65 or older. Regression analysis revealed improvements in MPQ-sensory and MPQ-affective scores as age increased (p < 0.001, R² = 0.09; p = 0.046, R² = 0.05, respectively). Age did not correlate with NRS, ODI, BDI, or PCS. Diagnosis, spinal level of SCS, and lead type were not found to influence any respective outcome measure based on covariate analysis. Conclusion: This study represents the largest study where age was correlated to specific pain, depression, and disability outcomes following SCS. We provide evidence that SCS outcomes are equivalent, or better, in older patients following SCS. Based on these findings, SCS is a viable option for treatment of chronic pain in elderly patient populations.

Emphasizing the Nurse Practitioner Role in Addressing Unique Challenges Associated with Benzodiazepine use among the Elderly

Aim: The aim of this paper is to discuss the use of benzodiazepine medications among the elderly, and the role of a nurse practitioner within this patient population. &#x0D; Background: Benzodiazepines are well known to have a negative impact on the mobility of elderly patients and to contribute to increased falls. These medications also have an impact on elderly patients’ ability to perform activities of daily living and to drive. Nurse practitioners offer holistic care to elderly patients. This includes prescribing medications, monitoring therapy, deprescribing medications and identifying opportunities for safe alternatives to treat a variety of conditions.&#x0D; Methods: This paper presents a narrative review focused on the effect of benzodiazepine medications on the elderly patient population, with an emphasis on the use of benzodiazepines in insomnia. &#x0D; Conclusions: Findings of this review confirm the known risks associated with the use of benzodiazepines in the elderly and that these medications should be carefully considered in ongoing management. The conclusions of this review support the use of nurse practitioners in the enhancement of the healthcare of the elderly through the continuum of assessment, monitoring, deprescribing of benzodiazepine medications when appropriate, as well as opportunities to implement alternative treatments.