Elderly Patients Research Articles

Valacyclovir induced neurotoxicity, with therapeutic drug monitoring, in a hospital-based setting in the Netherlands

Background: Valacyclovir-induced neurotoxicity is a rare side effect. The aim of this study was to perform a retrospective analysis of patients with valacyclovir-induced neurotoxicity and establish valacyclovir plasma concentrations in a tertiary hospital between January 2018 and November 2022. Case descriptions: In total 208 patients were identified with measured acyclovir concentrations, and the electronic health records of these patients were analysed. Based on the in- and exclusion criteria, 4 patents were identified in whom high plasma concentrations were linked to neurotoxicity. The first patient experienced balance and coordination problems, visual hallucinations, speaking difficulties and headaches. The second patient experienced a progressive decline of consciousness, resulting in coma. The third patient also experienced reduced consciousness and was found unconscious on the floor during the night. The fourth patient experienced vertigo after administration of acyclovir. Conclusion: Based on this study, neurotoxicity appears to be an underreported adverse effect of valacyclovir therapy in a hospital setting. This side effect may have a high impact on individuals as well as on the duration of hospitalization. In order to exclude valacyclovir as the cause, clinicians should consider requesting an acyclovir plasma concentration as standard hospital-based intervention whenever a patient experiences neurotoxic symptoms. Moreover, pharmacists and clinicians should be made better aware of the interaction between valacyclovir and cyclosporine and/or mycophenolic acid, in particular in elderly patients with impaired kidney function.

Neuronal Intranuclear Inclusion Disease Presenting with Acute-Onset Dementia and Cortical Edema: A Case Report

BackgroundNeuronal Intranuclear Inclusion Disease (NIID) is a neurodegenerative disorder characterized by the formation of eosinophilic inclusions in the neurons, visceral and skin cells. The cause is associated with the GGC nucleotide repeat expansion in the NOTCH2NLC gene. The imaging hallmark of NIID is hyperintensities on diffusion-weighted imaging (DWI) at the corticomedullary junction. Clinical manifestations of NIID are highly heterogeneous. Here, we report a case of NIID presenting with acute-onset dementia and cortical edema.Case presentationWe describe an elderly male patient who presented with sudden dementia within a day. Considering the abrupt onset and the stroke history, we initially diagnosed vascular disease. However, further imaging revealed cortical edema in the temporo-parieto-occipital lobes. Blood and cerebrospinal fluid tests ruled out immunological, metabolic, infectious, or neoplastic etiologies. Genetic testing ultimately confirmed the diagnosis of NIID. Intravenous immunoglobulin (IVIG) therapy did not improve the patient’s symptoms; However, about 1 month after treatment, spontaneous improvement was observed. It is noteworthy that 22 months before the onset of cognitive impairment, the patient’s MRI for headaches already exhibited the typical imaging lesions of this disease in the cerebellum paravermal region.ConclusionPatients with encephalopathy syndrome exhibiting imaging features resembling mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome or Creutzfeldt-Jakob disease should consider the NIID as differential diagnosis. Chronic headaches and symmetric lesions in the cerebellar paravermal region on MRI may be noteworthy indicators of NIID during non-episodic phases.

Atrial functional and ventricular functional mitral regurgitation: definitions, epidemiology, and prognostic implications

Abstract Background Severe functional mitral regurgitation (fMR) can be divided into two subgroups: fMR of atrial (AfMR) and fMR of ventricular origin (VfMR). Studies on AfMR are scarce and inconsistent, lacking a uniform definition of AfMR. Hence, little is known about its epidemiology, morphological features, associated risk profiles, and prognostic implications. Purpose The objective of this study was to develop and test a uniform definition of fMR based on the morphological correlate and to describe demographic characteristics, detail entity-specific morphological features and to investigate the associated prognostic impact. Methods 13052 patients with severe fMR and those at risk of severe fMR (comprising mild and moderate fMR)were included. Based on the ratio of left atrial volume (LA) to left ventricular end-diastolic volume (LVEDV), those with severe fMR (n=1163) were divided into AfMR and VfMR. The median of this ratio was used for allocation. Therefore, a LA/LVEDV ratio ≤ 0.56 indicated predominantly ventricular eccentric remodelling, whereas a ratio > 0.56 indicated predominantly atrial remodelling. Results AfMR was more frequently observed in female patients and peak age was a decade later, compared to VfMR. AfMR was the predominant fMR subtype in patients with heart failure with preserved (76%) and mildly reduced ejection fraction (61%), but a significant proportion could be observed even in patients with heart failure with reduced ejection fraction (32%). Severe fMR was associated with excess mortality for both entities: VfMR HR 1.31 [95% CI: 1.14-1.50], p<0.001, with a more pronounced impact in patients with AfMR HR 1.68 [95% CI: 1.47-1.91], p<0.001; AfMR vs. VfMR: HR 1.27 [95% CI: 1.06-1.54], p=0.011. The association between fMR and excess mortality persisted even after multivariate adjustment. In both entities, ischaemic heart disease was common and resulted in a significant increase of mortality (VfMR: HR 1.67 [95% CI: 1.40-1.98], p for interaction<0.001; AfMR: HR 2.10 [95% CI: 1.75-2.52], p for interaction=0.006). Conclusion Based on the entity-specific morphological correlate, severe fMR can be classified into AfMR and VfMR. AfMR occurs across the entire HF spectrum, is more frequently observed in elderly and female patients, and exhibits a worse prognosis than VfMR. The presence of ischaemic heart disease is associated with a near doubling of mortality in both subgroups of severe fMR.Prevalence of fMRKaplan-Meier analysis

Assessment of poor cardiovascular health metrics and related disparities among cancer patients in the United States: a nationwide analysis of over 1.5 million individuals

Abstract Background Cancer, a major health challenge and a leading cause of mortality in the United States, significantly impacts cardiovascular health (CVH). The American Heart Association (AHA) emphasizes several CVH metrics to improve health outcomes, yet disparities in CVH persist nationwide. The specific impact of these disparities on the CVH of individuals with cancer, however, has yet to be fully explored. Purpose This study aims to utilize a detailed and nationally representative dataset from the U.S. to assess the prevalence of poor CVH among adults with a cancer diagnosis, focusing on uncovering sociodemographic disparities. Methods We utilized self-reported data from the Behavioral Risk Factor Surveillance System (2011 to 2019). This system, a state-based telephone survey, gathering data on cancer diagnoses, CVH metrics, and sociodemographic characteristics. We measured CVH through a composite score (0-7) based on the AHA’s seven CVH indicators: hypertension, high cholesterol, smoking, body mass index, diabetes, physical activity, and fruits and vegetables consumption. Individuals scoring between 0 and 2 were defined as having poor CVH. Multivariable generalized linear models within a binomial framework was applied to estimate adjusted prevalence ratios (aPRs) for poor CVH among cancer patients. Results Of 1,575,187 U.S. adults (representing an estimated 154.5 million; 50.7% female, 10.9% non-Hispanic black), 7.8% reported a cancer diagnosis between 2011 and 2019. Adjusted* findings show that having cancer (vs without) associated with a 16% higher prevalence of poor CVH (aPR=1.16; 95% CI [1.12-1.19]). Age-specific analysis revealed increased prevalence of poor CVH in middle-aged (45-64; aPR=3.55) and elderly (≥65; aPR=3.58) cancer patients, indicating a 255% and 358% rise, respectively, with p_interaction <0.001. Female cancer patients experienced a 22% lower prevalence of poor CVH than males (aPR=0.78; p_interaction <0.001). Non-Hispanic black cancer patients faced a 42% higher prevalence of poor CVH than their non-Hispanic white counterparts (aPR=1.42; p_interaction=0.001). Higher-income and education levels associated with 52% and 53% reduced prevalence of poor CVH, respectively (p_interaction <0.001; Table). Conclusions Our research identifies a strong correlation between cancer and deteriorating CVH metrics across U.S. adults, with pronounced variations based on sociodemographic factors. Specifically, the prevalence of poor CVH is substantially higher among cancer patients who are middle-aged, elderly, or identify as non-Hispanic Black, compared to other groups. Conversely, female cancer patients and those with a higher socioeconomic status appear to have a reduced risk of poor CVH. These outcomes stress the critical need for targeted, equitable public health initiatives that address both the cardiovascular and broader health needs of cancer patients, particularly among those most vulnerable.Table1

Optimizing elderly care: a data-driven AI model for predicting polypharmacy risk using SHARE data

Abstract Background Polypharmacy (PP), which rises with age, is a growing public health challenge, affecting health outcomes and escalating healthcare expenditure. Leveraging the comprehensive European coverage and longitudinality of the Survey of Health, Ageing, and Retirement in Europe (SHARE) study, we aim to assess PP prevalence patterns and identify the most effective machine learning (ML) model for predicting long-term PP risk, as a foundation for a scalable predictive tool. Methods We used data from participants aged above 50 who were present in wave 6 and at least one of the subsequent three waves of the SHARE study, aiming to predict PP risk at 2, 4, and 6-year intervals. PP was defined as the concurrent use of five or more medications. We analyzed PP prevalence trends and selected the predictor variables from wave 6 using LASSO regression analysis. We evaluated eight ML models, namely, ANN, SVM, DT, RF, GB, XGBoost, LightGBM, and CatBoost, using a rigorous cross-validation strategy to ensure robustness and reliability. Results Our analysis reveals an upward trend in PP prevalence across the surveyed countries, with aggregate figures rising from 34.03% (95% CI 33.1-34.9) in wave 7 to 36.75% (95% CI 35.6-37.9) in wave 8, reaching 39.91 (95% CI 38.9-40.9) in wave 9. Additionally, using the Categorical Boosting ML model to predict PP resulted in overall accuracies of 75.08%, 73.7%, and 71.65% and recall rates of 72.83%, 70.48%, and 67.96% for the 2, 4, and 6-year intervals, respectively. Conclusions This study reveals a rising trend of PP across European countries and demonstrates the potential of using longitudinal data and ML to enhance PP prediction. The tool developed represents a step forward in risk stratification, which would be particularly beneficial in practical settings where family physicians or pharmacists could employ the tool to monitor elderly patients, predict and thus prevent PP, and reduce the negative health and economic impact associated with it. Key messages • The integration of machine learning with longitudinal data presents a significant advance in polypharmacy risk prediction. • The tool we developed highlights the potential translational impact of our findings.

Risk factors for procedure-related complications in very elderly patients undergoing atrial fibrillation ablation: analysis from the Japan Ablation Registry

Abstract Background As atrial fibrillation (AF) ablation procedures become increasingly prevalent, understanding the risks of procedure-related complications is crucial, particularly in the very elderly population, defined in this context as patients aged 80 years and above. This study aimed to identify risk factors for complications in this demographic. Methods We conducted a prospective analysis of 170,017 AF ablation procedures from the Japan Ablation Registry, covering 482 facilities between 2017 and 2020. The analysis focused on patients aged 80 or older (very elderly group, n=14,389). Multivariate analysis was employed to identify risk factors for procedure-related complications in the very elderly, incorporating factors that showed a p-value of less than 0.1 in univariate analysis. Results Procedure-related complications were observed in 3.62% of the very elderly group. The multivariate analysis (Model 1) identified significant risk factors were the initial procedure (OR 1.30, 95% CI 1.01-1.67, p=0.041), type of AF (OR 1.34, 95% CI 1.03-1.74), and body weight (OR 0.99, 95% CI 0.98-1.00, p=0.082). For further analysis, the type of AF was categorized into paroxysmal AF (PAF), persistent AF (PeAF) and long-standing PeAF. We included these categories, along with the initial procedure and body weight, into further multivariate analysis (Model 2), which revealed that long-standing PeAF (OR 1.34, 95% CI 1.03-1.74, p=0.032), initial ablation (OR 1.30, 95% CI 1.01-1.67, p=0.042) and body weight (OR 0.99, 95% CI 0.98-0.99, p=0.001) were independently and significantly associated with complications. Conclusion This study identifies initial procedures, low body weight, and long-standing PeAF as significant risk factors for procedure-related complications in very elderly patients undergoing AF ablation. These findings highlight the importance of careful patient selection and tailored procedure planning for these subgroups in the very elderly population.

Age-related and age-independent complications in atrial fibrillation ablation: insights from the Japan ablation registry

Abstract Background The growing prevalence of atrial fibrillation (AF) has intensified the focus on managing this condition in the elderly. Catheter ablation, a popular treatment option, requires more detailed examination due to limited data on its efficacy and risks in this age group. Aim To identify the types of complications of AF ablation correlated with advanced age and to differentiate them from age-independent complications. Method We conducted a prospective analysis of 170,017 AF ablation procedures from the Japan ablation registry, conducted across 482 facilities between 2017 and 2020. Complications in patients aged 80 and above (elderly group, n=14,389) were compared with those under 80 (control group, n=155,628). The overall complication rate was 2.77%, with a higher occurrence in the elderly group (elderly group vs. control group, 3.62% vs. 2.69%, p<0.001). Notably, the elderly experienced more cardiac tamponade/pericardial effusion (0.95% vs. 0.6%, p<0.001), symptomatic cerebral infarction or transient ischemic attacks (0.27% vs. 0.15%, p=0.001), and sick sinus syndrome (0.31% vs. 0.05%, p<0.001). While in-hospital mortality in the elderly group was relatively low (0.16%), it was significantly higher compared to the control group (0.06%, p<0.001). However, incidences of other complications like puncture-site complications (0.49% vs. 0.42%, p=0.28), non-puncture-site bleeding, esophagus-related complications (0.22% vs. 0.22%, p=0.72), and phrenic nerve palsy (0.44% vs. 0.43%, p=0.69) showed no significant age-related differences. Conclusion Elderly patients undergoing AF ablation are at a higher risk of overall complications, with particular susceptibility to cardiac tamponade/pericardial effusion, symptomatic cerebral infarction/transient ischemic attacks, and sick sinus syndrome. This highlights the need for careful monitoring of these specific complications in the elderly. Additionally, it is noteworthy that the risk of certain complications appears to be independent of age.

"I don't want hear about that": Treatment wishes/preferences of elderly patients regarding possible treatment goals in acute life-threatening illness or acute organ failure

Abstract Background In many people with acutely life-threatening illnesses, the will to undergo treatment is not known with sufficient precision. It is often unclear whether the person concerned would have consented to life-sustaining measures or would have preferred to die with palliative care. This applies in particular to the vulnerable group of elderly, chronically ill/fragile people. It is not uncommon for people to reject the risks/burdens of medical treatment, even if there is a chance of success. On the other hand, there are many people who fight to continue living, even if this can be associated with great burdens and the outcome is rather uncertain. Aim of the study is to determine the characteristics of cardiologic patients who refuse to discuss treatment wishes/preferences in case of acute emergencies, temporary (e.g. in the context of intensive care unit (ICU) treatment), or permanent (vegetative state) inability to consent. Methods Prospective, questionnaire-based cross-sectional study including Hospital Anxiety and Depression Scale (HADS) and assessment of quality of life using the 12-item Short Form Health Survey (SF-12) on normal cardiology wards. Results 455 cardiologic patients were interviewed (mean age 71.2 ± 12.9 years, 39.6% female), 76.1% had moderate-severe concomitant diseases according to the Carlsson Comorbidity Index (4.3 ± 2.4 points) (see Table I). 23.5 % of respondents did not wish to address the above-mentioned question, they were significantly older (74.6 ± 13.1 vs. 69.9 ± 12.8 years; p=0.0009), had more comorbidities, were less likely to have a high level of education (university degree: 13.0 % vs. 30.6 %; p=0.0021) and were less likely to be employed (11.7 % vs. 25.8 %; p=0.0026). Furthermore, these patients live alone more frequently (45.8% vs. 30.6%; p=0.0048) and are less likely to live in a partnership (52.0% vs. 68.0%; p=0.0043). Refusal of an advance directive was also more common (22.5% vs. 10.7%; p=0.05), quality of life was impaired (42.4 ± 9.8 vs. 45.9 ± 10.5 points; p=0.0022), and the HADS-score levels were higher (15.6 ± 7.3 vs. 12.7 ± 7.8 points; p=0.0007). Conclusions A relevant proportion of our patients refuse to discuss treatment wishes/preferences in case of acute emergencies, temporary or permanent inability to consent. Paradoxically, these were patients for whom it would make particular sense (older, sicker, and more socially isolated patients). Those patients are also prone to anxiety and depression, and have a reduced quality of life.

4.C. Scientific session: Navigating through complex challenges of responding to outbreaks of multidrug-resistant organisms

Abstract Antimicrobial resistance is one of the top ten global public health threats according to the WHO, contributing to millions of deaths each year. While outbreaks of multidrug-resistant organisms (MDROs) are well studied in hospital and nursing home settings, knowledge gaps exist concerning the complex challenges of outbreaks of MDROs among vulnerable patient populations, such as patients with intellectual disabilities or elderly patients living longer at home with multiple comorbidities. The coordination of such outbreaks requires a multidisciplinary approach as these patients often receive care throughout different healthcare settings, including long-term care and home-based nursing care. We delve into the complexities of coordinating an MDRO outbreak response involving healthcare professionals from various healthcare settings. The challenges inherent to the coordination of multidisciplinary involvement and the use of innovative strategies for outbreak preparedness and surveillance, will be thoroughly examined based on scientific evidence and practice based experiences. Workshop objectives • To exchange experiences on managing cross-institutional outbreaks of MDROs • To foster deeper understanding of the complexities of multidisciplinary involvement during MDRO outbreaks among vulnerable patient populations The workshop structure: - A brief introduction will be provided on the generic challenges in providing long-term care to vulnerable patient populations carrying MDROs. We will subsequently illustrate potential challenges faced during a cross-institutional MDRO outbreak among these patients through a realistic scenario (5 min): A patient with severe intellectual and physical disabilities living in both a long-term care facility as well as with family at home, unexpectedly turns out to be carrying an MDRO after recent hospital admission. As the patient receives nursing care from both from family members and nursing staff in different healthcare settings, a cross-institutional MDRO outbreak has occurred requiring a coordinated response. - Hereafter, individual presenters will address evidence- and experience-based challenges faced in MDRO outbreak responses within the specific healthcare settings covered in the previously presented scenario. We will navigate through the scenario together with the participants, discussing practical and ethical dilemmas, and explore ways for containing the MDRO outbreak while maintaining effective and compassionate healthcare delivery. In addition, we will discuss the use of public health innovations, such as social network analysis as a basis for the development of a stress test exercise to improve preparedness for MDRO outbreaks, and the role of wastewater surveillance in MDRO outbreaks. Discussions will be facilitated by (online) voting tools to invite participants to exchange experiences (40 min). We conclude with an exciting quiz to summarize the key messages of this workshop (10 min). Key messages • Healthcare setting, knowledge, proportionality and well-being of vulnerable patients populations are important to acknowledge during cross-institutional MDRO outbreaks. • Novel stress test exercise and wastewater surveillance are potential methods to improve preparedness and surveillance, respectively, during cross-institutional MDRO outbreak responses.

Long-term outcomes in patients with dual pathology aortic stenosis and cardiac amyloidosis referred for valve intervention

Abstract Background The coexistence of aortic stenosis (AS) and cardiac amyloidosis (CA) is common. If treated with transcatheter aortic valve implantation (TAVI), patients with the combined phenotype (AS-CA) have a comparable short term survival to those with lone AS, whereas data on longer term outcomes is currently lacking. Purpose This study aimed to evaluate the clinical outcomes of AS-CA compared to lone AS over a 5-year follow-up. Methods Using a prospective, multicentre, observational, case-control design, we screened consecutive patients with severe AS referred for TAVI for co-existing CA. CA screening included blinded 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1-3 increasingly positive) with additional SPECT/CT and light chain assessment prior to intervention. Transthyretin CA (ATTR) was diagnosed by bone scintigraphy and unremarkable light chain assessment, light-chain CA (AL) by endomyocardial biopsy. Mortality (all-cause and cardiovascular [CV]) and hospitalisation for heart failure (HHF) were captured as clinical endpoints. Results 376 patients (83±7 years, 52% female, EuroSCORE-II 4.9±2.9) were recruited, of which 43 (11.4%) had AS-CA (42 ATTR, 1 AL). Compared to lone AS, patients with AS-CA were older with higher cardiac biomarkers (NT-proBNP, high-sensitive Troponin-T) and a higher prevalence of atrial fibrillation. Heart team decision yielded valve replacement in 320 (85%) and conservative management in 56 (15%) patients, without differences between AS-CA and lone AS. Over a median follow-up of 5.4 (Q1: 4.9; Q3: 5.7) years, 230 (61.1%) patients died and 67 (17.8%) experienced HHF (with a total HHF number of 91). AS-CA was associated with higher all-cause mortality (crude HR 1.64, 95%CI 1.15-2.35; log-rank, p=0.006), which remained significant after multivariate adjustment for clinical confounders (EuroSCORE-II, valve replacement; adjusted HR 1.63, 95%CI 1.15-2.32; p=0.006). AS-CA was not associated with CV mortality (log-rank, p=0.18) or time to first HHF (log-rank, p=0.43), but the rate of HHF was significantly higher in AS-CA compared to lone AS (5.7 versus 3.5 per 1,000 patient years, p=0.022). Conclusions Among elderly patients referred for TAVI, long-term outcomes of AS-CA are characterized by higher mortality and a higher rate of heart failure hospitalisations compared to patients with lone AS. Studies evaluating the role of CA-specific treatments are warranted in this population.

Building bridges: mobile mental health care units in four European countries

Abstract Background Individuals living in rural and remote areas may have limited access to mental healthcare due to lack of facilities, socioeconomic reasons, stigma and lack of mental health literacy. To meet the needs and provide needs-based care care mobile mental health care clinics were established in some countries in Europe, including in Belgium, Germany, Greece and in Moldowa. A mobile clinic is a customized motor vehicle that travels to communities to provide mental health care. The mobile clinics are an integral part of the health care system and help ensure access to mental care. Aims To describe mobile care clinics in two countries in Europe using a case study design. Results Mobile clinics deliver a wide variety of mental health services, are heterogeneous and consist of multidisciplinary teams, including physicians, social workers, and other health professionals. The organization and financing of the Mobile mental health clinics is different in the four countries (e.g. part of the mental health care system in Belgium, and Moldova, part of initiatives in Germany and Greece). Due to data protection no detailed data on patients can be provided at the moment. The structures on mental health care mobile clinics in the four countries will be described in detail in the talk. Discussion Mobile clinics often serve as a bridge between communities and the mental health care system. Another important issue in rural areas is the ongoing aging of the population. The number of Elderly patients is expected to rise in the future. The care of those patients is challenging for the mental health and the primary care system. There is a necessity for establishing bridges between mobile clinics and hospital care.

Young patients in the cardiac intensive care unit: insights from the critical care cardiology trials network registry

Abstract Background Elderly patients treated in the cardiac intensive care unit (CICU) have engendered much warranted investigation. However, little is known about young patients as another distinct population. Purpose: To describe the demographics, clinical profiles, and outcomes of young CICU patients in order to understand any distinct needs and challenges of this population. Methods: We analyzed consecutive admissions to adult CICUs from 2018 to 2023 in the Critical Care Cardiology Trials Network (CCCTN), a multicenter prospective registry of advanced CICUs in North America coordinated by the TIMI Study Group. Patients aged <40 years were classified as "young patients" and compared to patients ≥ 40 years of age. Results: Among 29,035 CICU admissions during the study period, the median age was 67 years (25th, 75th %iles: 56, 70). Admissions 18 to 40 years of age comprised 6.7% (n=1959) of total admissions. The young cohort was more likely to be female (40.0% vs 36.4%, p=0.0015) and non-Caucasian (55.3% vs. 43.0%, p<0.0001). Traditional cardiovascular risk factors were less common among the young, as were prior cardiovascular diagnoses other than congenital heart disease and pulmonary hypertension. Initial SOFA scores and serum lactate levels were similar in the 2 groups (Table). The most common CICU admission diagnoses in the young were heart failure (HF), arrhythmia, and acute coronary syndrome (ACS) (Panel A). Of these, HF was more common in the young (26.4% vs 19.5%, p<0.0001), while arrhythmia (16.8% vs 18.9%, p=0.03) and ACS (10.9% vs 29.4%, p<0.0001) were less common compared to the older group (Panel B). Tamponade, hypertensive emergency, and congenital disease were more common in the young (Panel B). Respiratory insufficiency was the most common indication for admission to CICU in the young (24.6%) followed by cardiogenic shock (22.4%), unstable arrythmia (15.7%), and cardiac arrest (12.7%, Panel C). Critical care resources, other than coronary angiography/PCI, were utilized significantly more often in the young group (Panel D). Overall utilization of mechanical circulatory support (MCS) was modestly higher among the young cohort (13.1% vs. 11.4%, p=0.03, Panel D); however, among those managed with MCS, the % of MCS that was ECMO was higher among the young (29.3% vs 9.9%, p<0.0001). Young admissions had longer CICU stays (2.7 [1.2-5.9] vs 2.3 [1.2-4.9], p<0.0001). CICU mortality (6.5% vs 10.5%, p<0.0001) and hospital mortality (9.5% vs 14.4%, p<0.0001) were significantly lower in the young. Conclusion: Patients under the age of 40 admitted to CICUs presented with similar disease severity to older patients but more often had shock or cardiac arrest, had longer ICU stays, and more use of advanced ICU therapies but with lower in-hospital mortality. This important patient cohort merits continued clinical and research focus.

Obesity paradox exists in super elderly patients with heart failure

Abstract Background Aging and obesity are two global concerns in public health. As obesity is associated with several metabolic disorders, it is a well-known risk factor of heart failure (HF). However, several studies have suggested that obesity may have paradoxical survival benefits in patients with HF. Therefore, the aim of this study was to investigate whether the obesity paradox exists in super elderly patients with HF in Japan. Methods A total of 4,292 patients from our hospital HF registry were divided into four age subgroups: (A) less than 65, (B) elderly 65-74, (C) high elderly 75-84, (D) super elderly ≥85. The primary endpoint was the all-cause death within 1-year after discharge. Results At baseline, the proportion of men in each group was 42-76%, the mean left ventricular ejection fraction was 49-61%, the average of N-terminal pro-B-type natriuretic peptide was 1972-2944 pg/ml, and the mean body mass index (BMI) ranged 21-25 kg/m2. Patients with higher BMI were more common in the younger age group, while those with lower BMI were more common in the older age group. Cubic spline curves of Cox proportional hazard regression models demonstrated an inverse relationship between BMI and mortality (Fig. 1). Lower BMI was associated with higher all-cause mortality in all ages, although this association was attenuated at the young age, and pre-obesity (25–29.9 kg/m2) was associated with the greatest survival benefit. Meanwhile, the impact of underweight (<18.5 kg/m2) was stronger super elderly subjects, a one-unit increase in BMI was associated with a 10.3% decrease in the hazard ratio of death (P=0.021). Kaplan-Meier curves for all-cause mortality also showed that lower BMI was associated with higher all-cause mortality in all groups, and the differences were statistically significant in Groups B, C, and D (Fig. 2). Conclusion Our study suggested the existence of the obesity paradox among HF patients in super elderly. Mildly overweight may be beneficial at old age with HF.

Weaning Failure in Elderly Patients: A Systematic Review and Meta-Analysis

Background/Objectives: Weaning failure in elderly patients undergoing mechanical ventilation presents a complex clinical challenge due to age-related physiological changes and comorbidities. Understanding the dynamics of this phenomenon through systematic analysis can provide valuable insights for clinical management. This meta-analysis aims to investigate the factors contributing to weaning failure in elderly patients and to assess the efficacy of different strategies in mitigating this challenge. Design: The design of this study is a systematic review and meta-analysis. Methods: A systematic search of electronic databases was conducted to identify relevant studies focusing on weaning failure in elderly patients. Studies reporting outcomes related to mechanical ventilation weaning failure were included. Data extraction, quality assessment, and statistical analysis were performed following established guidelines. Results: A total of 15 studies met the inclusion criteria and were included in the meta-analysis. The average age of participants throughout the studies was 66.24 ± 10.21 years. This suggests that the study population largely consisted of older adults and displayed a moderate range of ages centered around the mean. The rate of weaning failure across these studies was slightly above 31.56%, indicating a significant occurrence of this complication in the patient cohorts. The analysis revealed age-related physiological changes, such as decreased respiratory muscle strength and increased chest wall stiffness, as significant contributors to weaning failure in elderly patients. Comorbidities, including chronic pulmonary diseases and cardiovascular conditions, further exacerbated the challenge. Various interventions, including tailored weaning protocols and respiratory therapies, showed promising results in improving weaning outcomes in this population. Conclusions: Weaning failure in elderly patients undergoing mechanical ventilation is influenced by a combination of age-related physiological changes and comorbidities. Tailored interventions addressing these factors are essential for optimizing weaning success rates in this vulnerable population. Further research is warranted to refine the strategies and enhance outcomes in elderly patients requiring mechanical ventilation.

Atrioventricular block as a common problem in elderly patients with coronary artery disease: clinical observation

Complete atrioventricular block is a dangerous complication in elderly patients with coronary artery disease that requires surgical treatment. Treatment of elderly patients with coronary artery disease and atrioventricular block is a debatable problem, and at the moment, there are no clear recommendations regarding the sequence of surgical interventions in this age group. In our opinion, in some cases it is advisable to perform epicardial lead placement during revascularization, because the risk of complications during the implantation procedure increases on the background of dual antiplatelet therapy, which is required after coronary artery bypass grafting. In addition, this approach provides a significant socio-economic effect, saving a patient from re-hospitalization and intervention for conduction disorders. This article presents a clinical observation with a step-by-step algorithm of actions in multivessel coronary artery disease with complete symptomatic atrioventricular block.

Association between weight-adjusted waist index with incident stroke in the elderly with hypertension: a cohort study

The objective of this study was to ascertain the relationship between the weight-adjusted waist index (WWI) and the risk of stroke in an elderly hypertensive population, a relationship that has not been previously elucidated. The Cox regression model was employed to assess the correlation between baseline WWI measurements and the incidence of stroke. To further elucidate the shape of the association between baseline WWI and stroke, restricted cubic splines were employed. Furthermore, subgroup analyses and interaction tests were carried out to investigate potential heterogeneities. Our study cohort comprised 4962 hypertensive individuals aged 60 years or older with no prior history of stroke. Over a median follow-up of 3.2 years, we found 547 new-onset stroke cases. After adjusting for confounding variables, the Cox regression analysis revealed a positive association between baseline WWI and the risk of stroke, with hazard ratios (HRs) escalating progressively as WWI values increased. When compared to the lowest quartile of WWI, the highest quartile demonstrated an HR of 1.87 (95% CI, 1.44–2.42) for stroke. Subgroup analyses confirmed the consistency of this relationship across different demographic and clinical strata. The study findings indicate that an elevated WWI is significantly related with a higher risk of new-onset stroke among elderly patients with hypertension. These results underscore the importance of WWI as a potential risk stratification tool. To confirm these results and explore the causal mechanisms behind the observed correlation, more study is necessary.

A Symptomatic Calcified Chronic Subdural Hematoma in an Elderly Patient: A Case Report

Calcified chronic subdural hematomas are rare forms of chronic subdural hematoma, accounting for 0.3-2.7%. Surgery is adequate for most chronic subdural hematomas, but its effectiveness is uncertain for calcified chronic subdural hematomas. In this case report, we illustrate a case of a 70-year-old male presenting with a motor function deficit in his left limbs over two months and neurological deterioration. A substantial calcified subdural collection was seen on computed tomography in the right parietal hemisphere. This was surgically removed with success and completeness. A chronic subdural hematoma has minimal possibility of becoming calcified. Because of the patient's condition's severity, surgery was the only remaining choice. J Shaheed Suhrawardy Med Coll 2023; 15(1): 83-86

Facial Merkel cell carcinoma in a 92-year-old man: A case report.

Merkel cell carcinoma (MCC) is a rare and aggressive skin cancer that can be easily misdiagnosed in its early stages. Clinicians should maintain a high index of suspicion for rapidly growing skin lesions in elderly patients and promptly investigate with histopathology and immunohistochemistry. Treatment for MCC should be individualized, considering the patient's age, overall health, and quality of life. Close follow-up is essential to detect recurrence or metastasis early.

Injury of the musculoskeletal system in civilian casualties as a result of hostilities. Report 1. Age structure

The integration of the military medical supply system into the unified medical space of Ukraine involves the functional combination of forces and means of medical services and the civilian health care system in order to maximize their capabilities for effective medical supply of the troops while preserving organizational independence. The purpose of our study was to determine the clinical and epidemiological characteristics of civilian patients with trauma due to modern hostilities. Materials and methods. To carry out our work, we analyzed skeletal traumas in 137 civilian patients who were injured during modern hostilities in Ukraine and were treated in health care facilities of the frontline zone in 2014–2023. Results. Comparing epidemiological data in two different periods of the war in Ukraine, we concluded that there is some difference in the age structure of victims with traumatic injuries sustained during modern hostilities. Thus, during the high-intensity conflict, the number of children’s injuries increased dramatically. The share of victims under the age of 15 during the full-scale invasion increased 4.5 times. In this period, the percentage of young and middle-aged wounded civilians decreased. If in the period of Anti-Terrorist Operation/Joint Forces Operation the number of people aged 16–60 was 67.6 %, then with the beginning of hostilities their share decreased to 42.0 %. This trend indicates the strengthening of internal and external migration starting from February 2022. Unlike the young and middle-aged, the share of elderly and senile people increased dramatically during the full-scale war. During the period of low-intensity military operations, the number of patients aged 61–91 was 29.4 %, while during high-intensity conflict, it was already 44.8 %. A sharp increase in traumatic injuries among elderly and senile patients is another feature of this conflict. Conclusions. Publicizing the experience of providing medical care to patients with injuries sustained due to military actions in Ukraine is only at the beginning of its existence. That is why, based on the above, we planned to continue scientific research on this problem.

Drug-gene interactions in older patients with coronary artery disease

BackgroundOlder patients with coronary artery disease (CAD) are particularly vulnerable to the efficacy and adverse drug reactions, and may therefore particularly benefit from personalized medication. Drug–gene interactions (DGIs) occur when an individual’s genotype affects the pharmacokinetics and/or pharmacodynamics of a victim drug.ObjectivesThis study aimed to investigate the impact of cardiovascular-related DGIs on the clinical efficacy and safety outcomes in older patients with CAD.MethodsHospitalized older patients (≥ 65 years old) with CAD were consecutively recruited from August 2018 to May 2022. Eligible patients were genotyped for the actionable pharmacogenetic variants of CYP2C9, CYP2C19, CYP2D6, CYP3A5, and SLCO1B1, which had clinical annotations or implementation guidelines for cardiovascular drugs. Allele frequencies and DGIs were determined in the cohort for the 5 actionable PGx genes and the prescribed cardiovascular drugs. All patients were followed up for at least 1 year. The influence of DGIs on the cardiovascular drug-related efficacy outcomes (all-cause mortality and/or major cardiovascular events, MACEs) and drug response phenotypes of “drug-stop” and “dose-decrease” were evaluated.ResultsA total of 1,017 eligible older patients with CAD were included, among whom 63.2% were male, with an average age of 80.8 years old, and 87.6% were administrated with polypharmacy (≥ 5 medications). After genotyping, we found that 96.0% of the older patients with CAD patients had at least one allele of the 5 pharmacogenes associated with a therapeutic change, indicating a need for a therapeutic change in a mean of 1.32 drugs of the 19 cardiovascular-related drugs. We also identified that 79.5% of the patients had at least one DGI (range 0–6). The median follow-up interval was 39 months. Independent of age, negative association could be found between the number of DGIs and all-cause mortality (adjusted HR: 0.84, 95% CI: 0.73–0.96, P = 0.008), and MACEs (adjusted HR: 0.84, 95% CI: 0.72–0.98, P = 0.023), but positive association could be found between the number of DGIs and drug response phenotypes (adjusted OR: 1.24, 95% CI: 1.05–1.45, P = 0.011) in the elderly patients with CAD.ConclusionsThe association between cardiovascular DGIs and the clinical outcomes emphasized the necessity for the integration of genetic and clinical data to enhance the optimization of cardiovascular polypharmacy in older patients with CAD. The causal relationship between DGIs and the clinical outcomes should be established in the large scale prospectively designed cohort study.