High-risk Elderly Patients Research Articles

Breast-Conserving Surgery Under Local Anesthesia in Elderly Patients with Severe Cardiorespiratory Comorbidities: A Hospital-Based Case-Control Study

Introduction: We report the feasibility and safety of local anesthesia (LA) in patients having breast-conserving surgery (BCS). Methods: 37 patients with American Society of Anesthesiologists (ASA) score of 4 having BCS under LA and 54 age-matched subjects with ASA score of 3-4 having BCS under general anesthesia (GA) were included. Patients were retrospectively evaluated for the follow-up duration, duration of surgery, postoperative satisfaction scores (1-10), complication and survival time for locoregional recurrence and overall survival rates. Results: The mean follow-up duration was 55.09 ± 13.49 months (range 38-104) in GA group, and 58.7 ± 15.5 months (range 20-99) in LA group. There was a significant difference in the duration of surgery (p < 0.001). In the LA group, 5 patients (13.5%) had minor complications including seroma, wound infection or hematoma, whereas 6 patients (11.1%) had minor complications in the GA group (p > 0.05). The re-excision rate due to positive tumor margins was 5.4% (2 patients) in the LA group and 5.5% in the GA group, respectively. The locoregional recurrence-free survival and overall survival rate was not different between 2 groups (p = 0.192, p = 0.93). Conclusion: BCS under LA seemed to be effective and safe in selected high-risk elderly patients.

Outcome comparison of different therapy procedures in surgical high-risk elderly patients with severe aortic stenosis

Objective: To compare the outcome of surgical high-risk elderly patients with severe aortic stenosis(SAS) treated by different therapy procedures, including transcatheter aortic valve implantation(TAVI), surgical aortic valve replacement(SAVR), and drug therapy. Methods: We retrospectively analyzed the clinical data of 242 surgical high-risk elderly (age ≥65 years old) SAS patients hospitalized in Fuwai Hospital between September 2012 and June 2015. According to the treatment method, patients were divided into TAVI group (81 cases), SAVR group (59 cases) and drug therapy group (102 cases). The primary end point was all-cause mortality at 1 year post procedure, and secondary end point included cardiac function class(NYHA), vascular complication, valvular function, non-fatal myocardial infarction, new atrial fibrillation, stroke, bleeding, pacemaker implantation, acute renal failure, and readmission. We used the Kaplan-Meier method to estimate survival function based on follow up data and survival was compared between groups with the use of the log-rank test. Results: (1) In the baseline data, there were statistically significant difference among 3 groups for the age, left ventricular ejection fraction, cardiac function class Ⅲ and Ⅳ, rates of combined diabetes, chronic renal failure, mild and moderate mitral regurgitation (P<0.01 or 0.05). The risk score of the Society of Thoracic Surgeons(STS) was 7.28±4.98 in the TAVI group, and 5.67±3.49 in the SAVR group(P=0.036). (2) The perioperative rates of pacemaker implantation(11.3%(9/81) vs. 0, P=0.025) and mild paravalvular regurgitation(29.6%(24/81) vs.1.7%(1/59), P<0.001) were significantly higher in TAVI group than in SAVR group.(3)The rate of rehospitalization was significantly lower in TAVI group than in SAVR group(3.0%(2/67) vs. 22.7%(10/44) P=0.005) and the rate of pacemaker implantation was significantly higher in TAVI group than in SAVR group(17.5 (12/67) vs. 0, P=0.008) after 1 year. The rates of death from any cause in the TAVI (5.8%(4/67)) and SAVR group (11.4%(5/44)) were significantly lower than that in the drug therapy group (54.9%(50/91), both P<0.05) after 1 year and was similar between TAVI group and SAVR group(P=0.622). (4) The rates of cardiac function classⅠandⅡ increased and Ⅲ and Ⅳ decreased in TAVI and SAVR group after 1 year when compared with base line(P<0.001). The rates of cardiac function class Ⅱ, and Ⅲ increased , class Ⅰ and Ⅳ decreased in drug therapy group after 1 year compared with base line (P=0.020). (5)The survival rates after 1 year were significantly higher in the TAVI group and SAVR group than in the drug therapy group(log-rank test, P<0.001), and the difference was similar between TAVI group and SAVR group (log-rank test, P=0.062). Conclusion: In surgical high-risk elderly patients with SAS, the prognosis of drug therapy was poor, and TAVI and SAVR were associated with similarly improved rates of survival after 1 year, although there were significant differences in periprocedural complications between TAVI and SAVR groups.

Literature Review of Postoperative Delirium in Geriatric Patients After Elective Gastrointestinal Cancer Surgery

Purpose: Increasing number of older adults are receiving cancer surgeries especially for gastrointestinal cancers, which brings forth attention to age-related postoperative complication prevention. Postoperative delirium (POD) is a common complication that rises after surgical procedures involving general anesthesia, largely in the elderly population. Due to its sudden onset and fluctuating symptoms, POD often goes underdiagnosed and undertreated even though it may lead to various adverse outcomes. POD in GI cancer surgical elderly patients is poorly understood in terms of prevalence, pathophysiology, assessment, treatment and nursing management. We aimed to identify available literature and investigate study results to broaden our understanding of geriatric GI cancer POD. Methods: The search process involved six databases to identify relevant studies abided by inclusion criteria. Results: Eleven studies were selected for this review. Geriatric POD is closely related to frailty and surgical complications. Frailty increases vulnerability to surgical stress and causes cerebral changes that affect stress-regulating neurotransmitter proportions, brain blood flow, vascular density, neuron cell life and intracellular signal transductions. These conditions of frailty result in increased risks of surgical complications such as blood loss, cardiovascular events and inflammation, which all may lead to the POD. Mini Metal State Examination (MMSE), Confusion Assessment Method (CAM) and Delirium Rating Scale-revised-98 (DRS-R-98) are recommended for POD assessment to identify high-risk patients. Conclusion: The POD prevalence ranged from 8.2% to 51.0%. The multifactorial causative mechanism suggests nurses to identify high-risk elderly GI-cancer surgical patients by reviewing patient-specific factors and surgery-specific factors. Key Words: Delirium; Gastrointestinal cancer; Elderly; Review 국문주요어: 섬망, 위장암, ë ¸ì¸, 리뷰

Cathepsin K-targeted sub-micron particles for regenerative repair of vascular elastic matrix.

Proactive screening of high risk elderly patients now enables early detection of Abdominal Aortic Aneurysms (AAAs). Current management of small, growing AAAs is limited to passive, imaging based growth monitoring. There are also no established drug-based therapeutic alternatives to surgery for AAAs, which is unsuitable for many elderly patients, and none which can achieve restore disrupted and lost elastic matrix in the AAA wall, which is essential to achieve growth arrest or regression. We seek to test the feasibility of a regenerative therapy based on localized, one time delivery of drug-releasing Sub-Micron-sized drug delivery polymer Particles (SMPs) that are also uniquely chemically functionalized on their surface to also provide them pro-elastin-regenerative & anti-matrix degradative properties, and also conjugated with antibodies targeting cathepsin K, an elastolytic enzyme that is highly overexpressed in AAA tissues; the latter serves as a modality to enable targeted binding of the SMPs to the AAA wall following intravenous infusion, or intraoartal, catheter-based delivery. Such SMPs can potentially stimulate structural repair in the AAA wall following one time infusion to delay or prevent AAA growth to rupture. The therapy can provide a non-surgical treatment option for high risk AAA patients.

Propensity Matched Comparison of Surgical Aortic Valve Replacement With Transcatheter Aortic Valve Implantation: A Single Centre Experience

Purpose: Transcatheter aortic valve implantation (TAVI) for aortic stenosis has been increasing, as demonstrated in the UK TAVI Registry Report. As TAVI patients are normally high-risk elderly patients, we undertook a propensity-matched study to compare outcomes of surgical aortic valve replacement (sAVR) with TAVI in order to exclude the confounding differences between patient groups that normally have surgery versus those with transcatheter procedures. Methodology: A retrospective review of our institution's aortic surgery database with propensity score matching was undertaken to compare outcomes of sAVR versus TAVI. Data for this database is prospectively entered. Results: There were 2,102 sAVR and 260 TAVI performed between 2008-2016 with significant differences in most of their preoperative characteristics such as EuroSCORE (6.0 vs 17.3) and age (72 vs 84 years). After propensity score matching, there were 179 patients in each group with no significant differences in their preoperative characteristics. There were no significant differences between groups with respect to in-hospital mortality (4.5% in each group), stroke (1.7% sAVR vs 2.2% TAVI), postoperative myocardial infarction (0.1% vs 0%) or pacemaker implantation (3.4% vs 3.9%). Hospital (11 vs 7 days) and critical care (3 vs 2 days) length of stay were higher in the sAVR group. There was a significant difference between groups in actuarial survival rates at 1-year (89.6% (sAVR) and 85.0% (TAVI)) and 5 years (62.7% and 43.2%). Conclusion: In our institution, in-hospital short-term outcomes are comparable between sAVR and TAVI. However, long-term survival is more favourable in those having a surgical approach to valve replacement than transcatheter routes.

Risk factors for gallbladder contractility after cholecystolithotomy in elderly high-risk surgical patients.

ObjectiveCholecystolithiasis is a common disease in the elderly patient. The routine therapy is open or laparoscopic cholecystectomy. In the previous study, we designed a minimally invasive cholecystolithotomy based on percutaneous cholecystostomy combined with a choledochoscope (PCCLC) under local anesthesia.MethodsTo investigate the effect of PCCLC on the gallbladder contractility function, PCCLC and laparoscope combined with a choledochoscope were compared in this study.ResultsThe preoperational age and American Society of Anesthesiologists (ASA) scores, as well as postoperational lithotrity rate and common biliary duct stone rate in the PCCLC group, were significantly higher than the choledochoscope group. However, the pre- and postoperational gallbladder ejection fraction was not significantly different. Univariable and multivariable logistic regression analyses indicated that the preoperational thickness of gallbladder wall (odds ratio [OR]: 0.540; 95% confidence interval [CI]: 0.317–0.920; P=0.023) and lithotrity (OR: 0.150; 95% CI: 0.023–0.965; P=0.046) were risk factors for postoperational gallbladder ejection fraction. The area under receiver operating characteristics curve was 0.714 (P=0.016; 95% CI: 0.553–0.854).ConclusionPCCLC strategy should be carried out cautiously. First, restricted by the diameter of the drainage tube, the PCCLC should be used only for small gallstones in high-risk surgical patients. Second, the usage of lithotrity should be strictly limited to avoid undermining the gallbladder contractility and increasing the risk of secondary common bile duct stones.

The Effect of Unilateral Spinal Anaesthesia and Psoas Compartment with Sciatic Block on the Postoperative Pain Management in Total Knee Artroplastic Surgery.

Purpose. This study was designed to investigate the effects of peripheral nerve block methods, applied through unilateral spinal anaesthesia on elderly patients to undergo total knee arthroplasty, on perioperative hemodynamic parameters and postoperative analgesia period. Materials and Method. 60 patients were randomly divided into two groups in the study. In group USA spinal anaesthesia was performed. In group PCS it was applied on psoas compartment block and sciatic nerve block. Results. Significantly higher intraoperative 60th and 90th minute mean arterial pressure values were ascertained in the PCS group compared to the USA group. The decrease observed in the 5th, 10th, and 20th minute MAP values in the USA group was statistically significant according to the control MAP value. Concerning within group comparisons, the decrease in 5th, 10th, and 20th minute heart rate values in the USA group was statistically significant compared with the control measurement value. The mean beginning time of sensory and motor blocks in the PCS group was found to be at a significantly advanced level compared with that in the USA group. Conclusions. The PCS block technique using bupivacaine hydrochloride ensured a higher haemodynamic efficiency in the perioperative period in high-risk elderly patients undergoing total knee arthroplasty. This trial is registered with ClinicalTrials.gov Identifier: NCT03021421.

Frailty Assessment in Cardiac Surgery: A New Paradigm in Preoperative Risk Stratification

Introduction: Existing risk stratification tools, such as the STS model, are useful in quantifying a patient's preoperative risk of adverse surgical outcomes, however their accuracy and use are limited in complex, elderly and potentially frail patients. This pilot study aimed to evaluate five different frailty scores in their prediction of 30-day postoperative mortality or major morbidity. Methods: Between August 2015 and February 2016, a prospective cohort of patients aged 70 years and over and scheduled for cardiac surgery was recruited from the Royal Prince Alfred Hospital Medical Centre. Five frailty scores were generated for each patient, including gait speed, grip strength, FORECAST, MMSE and MFS scores. Primary endpoint data included 30-day postoperative mortality and major morbidity, comprising stroke, renal failure, deep sternal wound infection, prolonged ventilation and reoperation. Results: From an overall cohort of 31 patients, there was shown to be a small but significant decrease in gait speed over five metres in patients suffering overall mortality or major morbidity (4.99 ± 0.74 secs vs 4.18 ± 0.92 secs, p = 0.0201). When patients were stratified into normal and slow gait speed groups based on a cut-off time of five seconds, a chi-squared test showed a significantly increased rate of overall morbidity in the slow gait speed group (p = 0.0284). There was no significant difference in STS-PROMM scores between groups stratified by gait speed, suggesting that slow gait may be an independent risk factor for major morbidity. Conclusions: The significant correlation between slow gait speed and postoperative morbidity in this cohort suggests a potential role for gait speed testing alongside existing risk models to identify high-risk elderly patients prior to cardiac surgery.

Rockall Score Larger Than 7 as a Reliable Criterion for the Selection of Indications for Preventive Transarterial Embolization in a Subgroup of High-Risk Elderly Patients After Primary Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding.

BackgroundTransarterial embolization (TAE) is an alternative procedure to repeat endoscopy or surgical intervention in the case of re-bleeding after primary endoscopic treatment. The aim of the study was to assess the Rockall score as a criterion for TAE in the case of re-bleeding after endoscopic treatment of non-variceal upper gastrointestinal bleeding (NVUGIB).MethodsOut of the 673 patients who underwent emergent endoscopic hemostasis due to NVUGIB, 111 had a high risk of re-bleeding having a Forrest I-IIb ulcer and the Rockall score ≥ 5. From 111 patients, 37 accepted preventive TAE (PE+ group). The control group consisted of 74 patients who underwent standard treatment (PE- group).ResultsThere were no differences in the demographic status between both groups, nor in the main clinical data on admission. The performance of TAE resulted in a significantly lower re-bleeding rate (1 (4.8%) vs. 11 (33%), P = 0.018). No patient who underwent TAE with the Rockall score ≥ 7 required surgery, resulting in only one re-bleeding episode (P = 0.004). Mortality reached 5% and 11% in the PE+ and PE- groups accordingly.ConclusionThe Rockall score ≥ 7 could be a reliable predictor of re-bleeding after primary endoscopic hemostasis as one criterion for the selection of indications for preventive TAE.

Sarcopenia: a new predictor of postoperative complications for elderly gastric cancer patients who underwent radical gastrectomy

BackgroundA geriatric assessment is needed to identify high-risk elderly patients with gastric cancer. However, the current geriatric assessment has been considered to be either time-consuming or subjective. The present study aimed to investigate the predictive effect of sarcopenia on the postoperative complications for elderly patients who underwent radical gastrectomy. Materials and methodsWe conducted a prospective study of patients who underwent radical gastrectomy from August 2014 to December 2015. Computed tomography–assessed lumbar skeletal muscle, handgrip strength, and gait speed were measured to define sarcopenia. ResultsSarcopenia was present in 69 of 240 patients (28.8%) and was associated with lower body mass index, lower serum albumin, lower hemoglobin, and higher nutritional risk screening 2002 scores. Postoperative complications significantly increased in the sarcopenic patients (49.3% versus 24.6%, P < 0.001), compared with nonsarcopenic patients. The multivariate analysis demonstrated that sarcopenia (odds ratio: 2.959, 95% CI: 1.629-5.373, P < 0.001) and the Charlson comorbidity index ≥2 (odds ratio: 3.357, 95% CI: 1.144-9.848, P = 0.027) were independent risk factors for postoperative complications. ConclusionsSarcopenia, presented as a new geriatric assessment factor, was a strong and independent risk factor for postoperative complications of elderly patients with gastric cancer.

Effective Combination of CPX-351 with FLT3 Inhibitors in AML Blasts Harboring the FLT3-ITD Mutation

Introduction: CPX-351 (Vyxeos), a liposomal combination of cytarabine and daunorubicin co-encapsulated at a synergistic 5:1 molar ratio, has recently been shown to be significantly more efficacious than the standard of care, 7+3 administration regimen of free (non-liposomal) cytarabine + daunorubicin in treating elderly high-risk AML patients, including patients with the FLT3-ITD mutation. We previously exposed AML blasts from primary patient samples to CPX-351 ex vivo and found that samples harboring FLT3-ITD were significantly more sensitive to CPX-351 and also demonstrated enhanced drug uptake. We hypothesized that dysregulated FLT3 signaling results in upregulated liposome uptake pathways, leading to increased cell death and overall sensitivity to CPX-351. Furthermore, we wanted to examine the effect of combining CPX with existing FLT3 inhibitors (e.g. quizartinib or midostaurin).Methods: To examine drug uptake dynamics, we exposed AML cell lines (including MOLM-13 and MOLM14 that contain FLT3-ITD, and ME1 that contains mutant, activated FLT3) to varying concentrations of CPX-351, with or without pre-treatment of quizartinib and midostaurin. We measured cell viability and intracellular daunorubicin fluorescence, an indicator of drug uptake, by flow cytometry and using a fluorescent plate reader. Additionally, we performed synergy analyses on the cytotoxic activity in these cells, adding CPX-351 and FLT3 inhibitors in combination at different exposure sequences followed by measurement of cell viability and daunorubicin fluorescence.Results: We observed that cell lines containing FLT3-ITD or FLT3-activating mutation were more sensitive to CPX-351, and exhibited increased drug uptake, compared to cell lines with other genetic abnormalities. Interestingly, we observed that pre-treatment with quizartinib for 16 hrs produced a population of cells (approximately 50% of the total population) that exhibited decreased daunorubicin fluorescence, indicating that prolonged FLT3 inhibition may decrease CPX-351 uptake. Consistent with this, in synergy studies we observed robust synergy when combining CPX-351 with FLT3 inhibitors simultaneously or with CPX-351 exposure scheduled 24 hours prior to FLT3 inhibitor exposure. However, exposure to FLT3 inhibitors 24 hours prior to CPX-351 administration was less synergistic and even antagonistic at certain doses.Conclusions: These results provide additional supportive evidence that FLT3 activation results in increased uptake of CPX-351, which is consistent with results from the CPX-351 Phase III trial in which FLT3-ITD+ patients survived significantly longer when treated with CPX-351 compared to 7+3 chemotherapy. We also show that combining CPX-351 with existing FLT3 inhibitors can elicit a synergistic response when administered in dosing regimens where FLT3 inhibition does not precede CPX-351 treatment. Cumulatively, our data support further testing of CPX-351 in combination with FLT3 inhibitors for treating AML patients with genetic dysregulation of FLT3 signaling. DisclosuresTardi:Jazz Pharmaceuticals: Employment. Mayer:Jazz Pharmaceuticals: Employment.

Results of a compression pin alongwith trochanteric external fixation in management of high risk elderly intertrochanteric fractures.

Background:External fixation is a well-known procedure for the management of intertrochanteric fractures in very elderly high-risk patients. A new compression pin that can be adapted to all fixators was designed to provide inter fragmentary compression. In the present study, its effects on the fracture stability and healing were evaluated.Materials and Methods:Thirty-one patients treated using compression pin and thirty-six patients treated using standard pins were evaluated retrospectively between January 2009 and July 2014. Patients were evaluated according to age, gender, duration of preoperative period, duration of operation time, American Society of Anesthesiologists (ASA) scores, and immediate postoperative and final femoral neck angle measurements. The stability of the fixation was evaluated by calculating the secondary varus angulation after weight bearing.Results:Thirty one patients (82.1 ± 6.1 years old) comprised the compression pin group, and 36 patients (83.33 ± 6.24 years old) comprised the standard pin group. From the time of weight bearing to healing time, 1.0 ± 1.25° (0–4) and 2.5 ± 1.8° (0–9) of secondary varus angulation in the compression pin and standard pin groups were measured, respectively (P = 0.000). With weight bearing, 2 of 31 (6%) and 9 of 36 (25%) patients in the compression and standard pin groups, respectively, had >4° of secondary varus angulation. In the compression pin group, 13 fractures were unstable, but only 2 (15%) of them had >4° of secondary varus angulation. In the standard pin group, 19 fractures were unstable, and 7 (37%) of them had >4° of secondary varus angulation.Conclusions:Treatment of very elderly, high risk patients’ with intertrochanteric fractures with external fixation is effective. Compression pin maintained stability better than standard pins after weight bearing, especially for unstable intertrochanteric fractures.

Magnetically-responsive, multifunctional drug delivery nanoparticles for elastic matrix regenerative repair

Proactive screening of high risk elderly patients now enables early detection of abdominal aortic aneurysms (AAAs). There are no established drug-based therapeutic alternatives to surgery for AAAs, which is unsuitable for many elderly patients, and none which can achieve restore disrupted and lost elastic matrix in the AAA wall, which is essential to achieve growth arrest or regression. We have developed a first generation design of polymer nanoparticles (NPs) for AAA tissue localized delivery of doxycycline, a modified tetracycline drug at low micromolar doses at which it provides both pro-elastogenic and anti-proteolytic benefits that can augment elastic matrix regenerative repair. The nanocarriers themselves are also uniquely chemically functionalized on their surface to also provide them pro-elastin-regenerative & anti-matrix degradative properties. To provide an active driving force for efficient uptake of intra-lumenally infused NPs to the AAA wall, in this work, we have rendered our polymer NPs mobile in an applied magnetic field via co-incorporation of super-paramagnetic iron oxide NPs. We demonstrate that such modifications significantly improve wall uptake of the NPs with no significant changes to their physical properties and regenerative benefits. Such NPs can potentially stimulate structural repair in the AAA wall following one time infusion to delay or prevent AAA growth to rupture. The therapy can provide a non-surgical treatment option for high risk AAA patients.

Improvement of quality of life following transcatheter aortic valve implantation in the elderly: a multi-centre study based on the Polish national TAVI registry.

Transcatheter aortic valve implantation (TAVI) is an effective therapeutic method for elderly high-risk patients with symptomatic severe aortic stenosis, not eligible for surgical treatment. The aim of the study was to evaluate short-term changes in elderly people's quality of life following TAVI, based on the POL-TAVI registry. One hundred and eighty-four octogenarians' and nonagenarians' samples from the POL-TAVI database were included in the study. The quality of life status was assessed with EQ-5D-3L questionnaire at baseline and after one-month follow-up. The mean of patients' age was 84 (80-93) years. Logistic EuroSCORE mean was 19.83% (3.48-83.94%), and transaortic mean gradient was 54.99 (19.0-149.0) mm Hg. At baseline, up to 24.50% of patients declared severe problems in performing usual activities. 13.60% felt extreme pain or discomfort; 9.80% were unable to wash and dress by themselves; 8.20% were extremely anxious or depressed; and 7.10% of the patients in the study were confined to bed. After 30 days the percentage of patients declaring severe problems in each dimension did not exceed 4.00%. The comparison between quality of life data at baseline and after one-month follow-up showed a significant improvement in each of five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (p < 0.001). Patients' quality of life was increasing regardless of gender (female vs. male), the type of anaesthesia (general vs. local), and the type of procedure (TA vs. TF). Short-term quality of life in the elderly subjects was significantly improved after one-month follow-up following TAVI.

Individualized vs. group exercise in improving quality of life and physical activity in patients with cardiac disease and low exercise capacity: results from the DOPPELHERZ trial

Purpose: Important goals of cardiac rehabilitation maintenance programs (CMP) are to increase leisure time physical activity (LTPA) and improve health-related quality of life (HRQoL). Elderly patients with cardiac disease and low exercise capacity are simultaneously the most severely affected and have the most to gain from exercise-based rehabilitation. Individualized combined exercise (ICE) may be an effective modality to achieve these goals. We compared six months of ICE to CMP in their effects on LTPA and HRQoL.Methods: Sixty patients (70 ± 9 years, 39% female) with cardiac disease and low exercise capacity (<6 MET) were randomly allocated to six months of once-weekly ICE or CMP. The patients in ICE performed moderate endurance and resistance exercise on machines, based on intensities from individual peak exercise testing. Patients in CMP performed weekly sessions of calisthenics, flexibility, coordination and relaxation activities. LTPA and HRQoL were assessed with accelerometry and questionnaires at baseline and six months.Results: Sixty patients completed the trial. ICE increased vigorous PA (ICE: Δ + 12 MET-min/d, CMP: Δ –5 MET-min/d, p = .02) and steps per day (ICE: +1586 steps/d, CMP: –838 steps/d, p < .01) compared to CMP after six months. ICE significantly improved in several components of HRQoL (vitality, emotional health, social health, positive and negative affect (all p < .05) compared to CMP.Conclusions: ICE resulted in significant improvements in physical activity levels and health related quality of life in moderate to high-risk patients compared to CMP.Implications for rehabilitationRelatively low volumes and intensities of exercise may lead to substantial improvements in both physical activity levels and health-related quality of lifeExercise modes in cardiac rehabilitation maintenance programs should not be limited to calisthenics and large group-based exerciseSupplemental resistance exercise may improve health-related quality of life and increase physical activity levels in patients with low exercise capacityModerate to high-risk elderly patients also benefit from individualized endurance-resistance exercise

Treatment of Intertrochanteric Hip Fractures in Elderly High Risk Patients with External Fixation

Treatment of Intertrochanteric Hip Fractures in Elderly High Risk Patients with External Fixation

Percutaneous cholecystostomy for acute cholecystitis in high-risk elderly patients

Emergency cholecystectomy for acute cholecystitis (AC) is associated with high morbidity and mortality rates in elderly patients with significant comorbidities. The aim of this study was to evaluate percutaneous cholecystostomy for AC in elderly patients with various coexisting diseases. We retrospectively reviewed the records of 4311 patients with AC treated in Mackay Memorial Hospital between the years 2000 and 2015. The clinical course of AC was compared between nonelderly (age ≤70 years) and elderly patients (age>70 years). In total, 67 elderly patients and 32 nonelderly patients received percutaneous cholecystostomy. The rate of percutaneous cholecystostomy increased between the years 2011 and 2015 (from 2.5% to 12.2%) and this procedure was more common in the elderly group (p=0.009). In addition, the comorbidities of ischemic heart disease and chronic kidney disease were higher in elderly than in nonelderly patients (p=0.014 and p=0.015, respectively). The American Society of Anesthesiologists' classification was higher in the elderly patients (p=0.001). The overall survival-free rate of recurrent cholecystitis in patients who did not receive cholecystectomy was not significantly different in the two groups. When compared with emergent cholecystectomy in high-risk elderly patients, percutaneous cholecystostomy resulted in reduced hospital stay and morbidity (p=0.002 and p=0.013, respectively). Our results demonstrate that percutaneous cholecystostomy has become a common and early treatment for AC in high-risk elderly patients with ischemic heart disease or chronic kidney disease. Identifying such patients will possibly improve clinical outcomes, reduce hospital stay and morbidity, and facilitate delayed laparoscopic cholecystectomy.

How could we identify the ‘old’ patient in gastric cancer surgery? A single centre cohort study

PurposeTo analyze the population submitted to gastric cancer surgery in our Institution in order to find those characteristics which could help in the identification of the elderly high-risk patient. MethodsIn a cohort of 263 patients (>65 y) we selectively investigated the risk factors for medical and surgical complications and postoperative mortality, focusing on the variable “age”. All the significant variables were used to find predictors of complications with Clavien-Dindo>2. ResultsAge>75 (AUC 0.61; 95% 0.55–0.67, p = 0.003) and ASA score >2 (AUC 0.60; 95% CI 0.54–0.67, p = 0.01) were significantly associated with an increased risk of medical complications. Operative time >330 min (OR 1.00; 95% CI 1.00–1.01; p = 0.0001- AUC 0.62, 95% CI 0.56–0.68, p = 0.01) was the only significant predictor of surgical complications. In-hospital mortality (6/263 patients) was significantly associated with preoperative albumin ≤2.95 g/dl (OR 0.15; 95% CI 0.04–0.93, p = 0.041 – AUC 0.74 95% CI 0.68–0.80; p = 0.003) and additional procedures (OR 7.05; 1.23–40.32, p = 0.03). Stepwise multivariate analysis showed that albumin ≤2.95 g/dl (OR 3.43; 95% CI 1.06–11.13 p = 0.033), ASA>2 (OR 9.51; 95% CI 1.23–72.97; p = 0.042) and additional resections (OR 3.39; 95% CI 1.36–8.45; p = 0.045) were independent risk factors for complications Clavien Dindo >2. ConclusionsOur work demonstrated that, in our institution, 75 years of age could identify the elderly in gastric surgery as those patients were at higher risk of medical complications. ASA >2, preoperative serum albumin ≤2.95 g/dl and the need of additional procedures could increase the risk of severe postoperative adverse events.

Aortic valve stenosis: treatments options in elderly high-risk patients.

In the last decades, a trend towards a worldwide aging has been reported and diseases which are common in the elderly people would have important implications in clinical practice. Aortic stenosis (AS) is perhaps the most common and most often cause of sudden death among valvular heart diseases.[1] Its prevalence is low among adults aged 2.1), extra-cardiac arteriopathy and peripheral neurological dysfunction.[6] Moreover, there are increasing evidences regarding the potential benefits of minimally invasive surgical procedures (MIS) in AS. Apart better aesthetic results, MIS could indeed offer several advantages over conventional full sternotomy (FS) AVR, aiming to reduce trauma and to achieve decreased postoperative pain and ventilation time, less blood loss and faster recovery. Current evidence suggests that MIS is associated with excellent early and late outcomes that are at least comparable to FS. Progressive technical improvements (facilitated by the development of sutureless or rapid deployment prostheses)[7],[8] may further reduce operative times durations and continue to increase its clinical application[9],[10] Whether strongest long-term follow-up, randomized studies and registry data are still required to assess the durability and long-term outcomes, perspective of MIS-AVR in elderly patients should be carefully evaluated. Transcatheter aortic valve replacement (TAVR) has also expanded the proportion of patients with AS who are candidates for valve replacement. Indeed, it has been shown to be a viable alternative treatment modality for patients previously deemed in-operable.[11] Being patient selection for TAVR still now one of the most challenging issues in clinical practice, geriatricians should be part of Heart Team and overall frailty (combination of ageing, disease and risk factors making people vulnerable) carefully evaluated.[12] In this new era with expanded treatment options, symptomatic patients who remain untreated after referral for TAVR experience a mortality rate of 39% at one year.[13] Recently reported data, suggested good outcomes even in selected population of very older patients (> 85 years)[14] The results of the Pegaso Registry have showed that octogenarians (84.2 ± 3.5 years) symptomatic for severe AS are frequently managed conservatively. Older age, logistic EuroSCORE, Katz index A, maximum gradient, pulmonary artery pressure, and reduced left ventricle ejection fraction were predictive factors for the absence of surgery (TAVI or conservative management). The planned conservative management was associated with a poor prognosis [TAVI, HR = 0.68 (95% CI: 0.49−0.93; P = 0.016) and AVR, HR = 0.56 (95% CI: 0.39−0.8; P = 0.002)].[15] In high-risk patients with “temporary” contraindication to AVR or TAVR, percutaneous balloon aortic valvuloplasty could be safely used as a bridging intervention procedure (bridge-to-decision) and the short-term procedural and clinic outcomes are satisfactory.[16],[17] Along with a provision of a detailed overview of the current literature regarding the improved understanding on pathophysiology of AS and its clinical implications, this special issue will address specific consideration of treatment options especially in elderly high-risk patients.

Special nutrition intervention is required for muscle protective efficacy of physical exercise in elderly people at highest risk of sarcopenia.

Progressive loss of muscle mass and strength is a physiological consequence of aging, and without interventions, it usually deteriorates into sarcopenia. In this study, the hypothesis that combined special nutritional-physiotherapeutical intervention to prevent or reverse this biological deterioration in elderly people was tested. The effects of the regular resistance muscle training (PT, n = 17) alone and the combined exercise + special nutrition therapy containing whey protein and vitamin D (PT + NT, n = 17) were monitored for 3 months in 34 elderly patients (12 men and 22 women; mean age: 66.47 years) randomly distributed into two groups at a long-term care facility. Physical exercise alone did not result in significant improvement in skeletal muscle mass or strength, whereas combined intervention significantly increased the muscle strength (22.51 ± 2.35 vs. 24.54 ± 2.65, [Formula: see text] ± SEM, kg, p = 0.027). When therapeutic responses to the intervention were compared, a significant advantage of PT + NT over PT was found. The same trend was found when the non-significant post-therapeutic alterations (χ2 test) of the distribution of normal vs. pre-sarcopenic + sarcopenic conditions within the two groups were compared. Combined intervention (PT + NT) is necessary for the efficient protection of the musculature in the high-risk elderly patients.