High-risk Elderly Patients Research Articles

Improving early identification of the high-risk elderly trauma patient by emergency medical services

We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients. This was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score≥16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns. 33,298 injured elderly patients were transported by EMS, including 4.5% with ISS≥16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7-20.7) for ISS≥16 to 2.9% (95% CI 2.6-3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS≤14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS≥16: sensitivity (92.1% [95% CI 89.6-94.1%] vs. 75.9% [95% CI 72.3-79.2%]), specificity (41.5% [95% CI 40.6-42.4%] vs. 77.8% [95% CI 77.1-78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices. High-risk elderly trauma patients can be defined by ISS≥16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.

Clinical Outcome and Cost Analysis of Sutureless Versus Transcatheter Aortic Valve Implantation With Propensity Score Matching Analysis

Surgical sutureless and interventional transcatheter aortic valve prostheses are nowadays extensively adopted in high-risk elderly patients. An explorative analysis was carried out to compare the clinical outcome and costs associated to these approaches. Since 2010, a total of 626 patients were distributed between transcatheter aortic valve implantation (TAVI; n = 364) and sutureless (n = 262) groups. Patients of both groups were not comparable for clinical and surgical characteristics, but many patients were in a "gray zone"; therefore, a retrospective propensity score analysis was possible and performed. For the matched pair samples, postoperative, follow-up clinical data, and costs data were obtained. In-hospital death occurred in 5 patients in sutureless group and 3 patients in TAVI group (p = 0.36). Blood transfusions were higher in sutureless group (2.1 ± 2.3 vs 0.4 ± 1.0 U). TAVI group had a shorter intensive care unit and hospital stay (2.2 ± 2.7 vs 3.2 ± 3.5 days, p = 0.037; 12 ± 6 vs 14 ± 6 days, p = 0.017). No differences in postoperative neurologic (p = 0.361), renal (p = 0.106), or respiratory (p = 0.391) complications were observed between groups. At follow-up (24.5 ± 13.8 months), 1 patient in sutureless group and 7 patients in TAVI group died (p = 0.032). Paravalvular leakage occurred more frequently in patients in TAVI group (35 [34%] vs 7 [6.9%]; p <0.001) with an impact on follow-up survival rate. The costs associated to the 2 procedures are similar when the cost of the device was excluded (p = 0.217). When included, the sutureless approach resulted a cost saving (€22,451 vs €33,877, p <0.001). In conclusion, the patients in the "gray zone" record a satisfying clinical outcome after sutureless surgery and TAVI. Patients in the sutureless group endure more hospital complications, but TAVI entails a higher follow-up mortality. On the costs aspects, TAVI technologies are more expensive, and it reflects on higher overall hospital costs.

Perioperative nursing in photoselective vaporization for the high-risk elder patients with prostatic hyperplasia

Objective To discuss the perioperative nursing in the treatment of photoselective vaporization for the high-risk older patients with hyperplasia of prostate. Methods The perioperative nursing intervention were implemented in 56 high-risk elder patients with prostatic hyperplasia from January 2013 to January 2014. Results The PVP treatment was successfully performed in all the 56 patients. The mean operative time was (60.8±3.0) minutes. The mean catheterization time was 1.25 days. The mean Qmax increased from (5.6±2.5) ml/s to (16.7±3.2) ml/s. The RUV decreased from (132.5±21.3) ml to (24.6±5.6) m1. The mean IPSS and QOL decreased to (7.4±2.3) and (1.4±0.5) from (25.8±2.6) and (5.4±0.5), which showed significant improvement compared with those before operation (t=-2.046, 3.667, 3.967, 4.233, respectively; P<0.05). All patients had no severe complication. Conclusions PVP is a safe and effective minimally invasive surgery in the high-risk elder patients with prostatic hyperplasia. The comprehensive perioperative nursing intervention of corresponding psychological nursing, impeccable preoperative preparation, close postoperative observation and reasonable health guidance is a key to ensure the success of recovery. Key words: Prostatic hyperplasia; High-risk elder patients; Photoselective vaporization; Perioperative nursing

Resection of Obstructive Left-Sided Colon Cancer at a National Level: A Prospective Analysis of Short-Term Outcomes in 1,816 Patients

Background/Aims: The prematurely closed Stent-In II trial in patients with left-sided obstructive colon cancer may have influenced clinical decision making in The Netherlands. The aim of this study was to evaluate treatment of left-sided malignant colon obstruction at a population level since then. Methods: Short-term outcomes of all patients who underwent resection for left-sided obstructive colon cancer between 2009 and 2012 were assessed based on a prospective national registry. Results: In total, 1,816 evaluable patients were included; acute resection was performed in 1,485 (81.8%), and endoscopic stent or decompressing stoma followed by resection in 196 (10.8%) and 135 (7.4%), respectively. The use of endoscopic stenting significantly decreased from 18% (2009) to 6% (2012). Overall 30-day or in-hospital mortality rate was 6.9, 5.6, and 3.7%, respectively (p = 0.107). Mortality rate after acute resection was 2.9% in patients >70 years, but mortality rates up to 32.2% were observed in high-risk elderly patients. Conclusion: Acute resection as first choice treatment seems justified for patients >70 years of age given a mortality rate of 3%. For the elderly frail patients, mortality rates over 30% after acute resection stress the need for alternative treatment strategies.

Continuous spinal anesthesia versus single small dose bupivacaine–fentanyl spinal anesthesia in high risk elderly patients: A randomized controlled trial

BackgroundGreater numbers of patients are presenting for surgery with aging-related, pre-existing conditions that place them at greater risk of an adverse outcome. Hemodynamic instability due to high sympathetic block largely limits the use of conventional dose spinal anesthesia in high risk elderly patients. In this study we aim to compare the hemodynamic stability and the incidence of hypotension in continuous spinal anesthesia (CSA) versus single low dose spinal anesthesia (SD) in elderly high risk patients.MethodsThis prospective randomized blinded study was carried on 34 ASA III & IV elderly patients aged >75 years undergoing orthopedic lower limb surgery. The patients were randomly assigned to one of the study groups. Group CSA received intermittent dosing of local anesthetic solution via an intrathecal catheter using 0.5 ml of 0.5% isobaric bupivacaine increments and 0.5 ml of fentanyl (25 μg) while group SD single dose of 1.5 ml of 0.5% isobaric bupivacaine and 0.5 ml of fentanyl (25 μg). The study groups were compared regarding hemodynamic stability, incidence of hypotension and total ephedrine consumption.ResultsIncidence of severe hypotension was significant. 52.9% of patients in SD group experienced an episode of severe hypotension versus none of them in CSA group (p 0.033∗). Total dose of fluids infused was significantly more in the SD group. The use of ephedrine was significantly more in SD group.ConclusionCSA provided fewer episodes of hypotension and no severe hypotension versus SD 7.5 mg bupivacaine. CSA offers the added advantage of the ability to titrate dose of local anesthetic as needed while maintaining hemodynamic stability.

National Survey of Emergency Physicians to Define Functional Decline in Elderly Patients with Minor Trauma.

There are a number of screening tools to predict return to the emergency department (ED) in elderly trauma patients, but none exist to specifically screen for functional decline after a minor injury. The objective of this study was to identify outcome measures for a possible future clinical decision rule to be used in the ED to identify previously independent patients at high risk of functional decline at six months post minor injury. After a rigorous development process, a survey instrument was administered to a random sample of 178 emergency physicians using the Dillman's Tailored Design Method. Of 156 eligible surveys, we received 81 completed surveys (response rate 51.9%). Considering all 14 activities of daily living (ADL) items, 90% of physicians deemed a minimal clinically important difference (MCID) in function to be at least three points on the 28-point Older Americans Resources and Services (OARS) ADL Scale as clinically significant. A tool with a sensitivity of 93% to detect patients at risk of functional decline at six months post injury would meet or exceed the sensitivity deemed to be required by 90% of physicians. The majority of emergency physicians do not assess elderly injured patients for the majority of the tasks. A drop of three points on the 28-point OARS ADL Scale would be deemed clinically important by the vast majority of emergency physicians. Further, a sensitivity of 93% for a clinical decision tool would satisfy the MCID requirements of the vast majority of emergency physicians. There appears to be a gap between physician knowledge and actual practice. We intend to use these findings in the development of a clinical decision rule to identify high-risk elderly trauma patients.

Outcomes of trochanteric external fixation for geriatric inter-trochanteric hip fractures

IntroductionTrochanteric fractures are a leading cause of disability among the elderly. Internal fixation is the gold standard treatment. However, it may be challenging in the high-risk population. We present our results using external fixator in trochanteric fractures in the elderly. Patients and methodsDuring 2005-2012, twenty-three high-risk elderly patients (average age 70 years) with trochanteric fracture were managed using percutaneous external fixation (EF). ResultsAt one year follow-up, 86% returned to pre-fracture ambulatory status. Average time to fixator removal was 14 weeks. There were no cases of pin loosening, breakage, or penetration of femoral head. ConclusionAdvantages of EF include avoidance of delay, use of local/regional anesthesia, and shorter duration of surgery, blood loss and hospital stay. EF is an acceptable alternative in this patient population, given the associated co-morbidities and especially due to limited resources in developing countries.

PWE-392 Need for further surgery after delormes procedure for rectal prolapse in elderly patients

<h3>Introduction</h3> Rectal prolapse is a profoundly disabling condition, occurring mainly in elderly females. Delormes procedure is often the preferred operative option for high risk elderly patients due to its minimal invasive nature and minimal postoperative morbidity. A recent randomised control trial looking at the different operative procedure for rectal prolapse has quoted rectal prolapse recurrence after Delormes procedure as high as 46% at 5 years. Whether that high recurrence rates correlates with the need of further surgery is not known. We aimed to analyse rectal prolapse recurrence and further surgery rates for patients undergoing Delormes procedure in our institution. <h3>Method</h3> All consecutive adult patients undergoing Delormes procedure between April, 2000 – December, 2014 at the University Hospitals of Leicester NHS Trust were reviewed. This was a retrospective study. Patients were analysed for mode of surgery, 30 day post-operative mortality, post-operative length of hospital stay, clinically detected recurrence and further rectal prolapse surgery. <h3>Results</h3> 109 patients (median age = 79 years, female n = 102, male n = 7) underwent Delormes procedure over the 14 years. Ninety nine (91%) patients had planned surgery and ten (9%) patients had an urgent operation after being admitted via emergency admission route. Median follow up for all the patients was 4 years and 69 patients were alive at the time of analysis. 30 day post-operative mortality was 2.75% and median length of hospital stay after surgery was 4.5 days. 15 (13.7%) patients had a clinically detected rectal prolapse recurrence during the follow up period, 12 (11%) underwent further surgery for their rectal prolapse (redo Delormes n = 4, Altemeier–s procedure n = 5, abdominal rectopexy n = 3) and 3 patients did not undergo further surgery. <h3>Conclusion</h3> Delormes procedure remains safe and an effective procedure to treat rectal prolapse in elderly patients as clinically significant recurrence rates are low. <h3>Disclosure of interest</h3> None Declared.

First-line single-agent panitumumab in frail elderly patients with wild-type KRAS metastatic colorectal cancer and poor prognostic factors: A phase II study of the Spanish Cooperative Group for the Treatment of Digestive Tumours

BackgroundFrail elderly patients with metastatic colorectal cancer (mCRC) are not candidates for chemotherapy. Monotherapy with anti-epidermal growth factor receptor (EGFR) monoclonal antibodies may be an option for these patients with few systemic toxic effects. Patients and methodsSingle-arm, multicentre, phase II trial including patients ⩾70years with wild-type (WT) KRAS (exon 2) mCRC, Eastern Cooperative Oncology Group (ECOG) status⩽3, KPC (Köhne Prognostic Classification) – defined intermediate or high risk status, frailty and/or ineligibility for chemotherapy. Patients received panitumumab until progression or unacceptable toxicity. The primary end-point was progression free survival (PFS) rate at 6months. ResultsThe study included 33 patients (intention-to-treat (ITT) population). Median age: 81years; sex: 66.7% male; high-risk KPC status: 45.4%. Median treatment duration was 14weeks and 6-month PFS rate was 36.4% (95% confidence interval (CI): 20.0–52.8). The objective response rate: 9.1% (95% CI: 0–18.9) (all partial responses), and there were 18 stable diseases (54.5%). Median PFS was 4.3months (95% CI: 2.8–6.4) and median overall survival (OS) was 7.1months (95% CI: 5.0–12.3). There were no deaths or grade 4–5 adverse events (AEs) related to panitumumab and the most common grade 3-related AE was rash acneiform (15.2%). A significant association between clinical response and RAS status was observed (P=0.037). In the WT RAS subgroup (WT exons 2, 3, and 4 of KRAS and NRAS, N=15), 6-month PFS rate was 53.3% (95% CI: 30.1–75.2) and median PFS and OS were 7.9 and 12.3months, respectively. ConclusionsSingle-agent panitumumab is active and well tolerated and may be a therapeutic option for high-risk frail elderly patients with WT RAS tumours considered not candidates for chemotherapy (clinicaltrials.gov identifier NCT01126112).

Balloon valvuloplasty as destination therapy in elderly with severe aortic stenosis: a cardiac catheterization study.

BackgroundIn the current era of transcatheter aortic valve replacement, there is renewed interest in balloon aortic valvuloplasty (BAV) and invasive hemodynamic evaluation of aortic stenosis (AS). The current report aimed to study the invasive hemodynamics of severe AS patients treated with BAV as destination therapy and to identify factors associated with better hemodynamic outcome and prognosis.MethodsFrom 2009 to 2012, 63 high risk elderly patients were treated with BAV as destination therapy for symptomatic severe AS and were all prospectively included in the study. Their hemodynamics were invasively evaluated during catheterization, pre- and post-BAV at the same session. All Post-BAV patients were regularly followed-up.ResultsThe patients (82 ± 6 years, 52% male) had post-BAV aortic valve area index (AVAi) significantly increased and mean pressure gradient (MPG) significantly reduced. During the follow-up of 0.9 (maximum 3.3) years, those with post-BAV AVAi < 0.6 cm2/m2 compared with the AVAi ≥ 0.6 cm2/m2 group had significantly higher mortality (60% vs. 28%, log-rank P = 0.02), even after adjusting for age, gender, atrial fibrillation, chronic kidney disease, diabetes mellitus, coronary artery disease and EuroSCORE [HR: 5.58, 95% confidence interval (CI): 1.62−19.20, P = 0.006]. The only independent predictor of moderate AS post-BAV was the pre-BAV AVAi increase by 0.1cm2/m2 (OR: 3.81, 95% CI: 1.33−10.89, P = 0.01). Pre-BAV AVAi ≥ 0.39 cm2/m2 could predict with sensitivity 84% and specificity 70% the post-BAV hemodynamic outcome.ConclusionsBAV as destination therapy for severe AS offered immediate and significant hemodynamic improvement. The survival was significantly better when a moderate degree of AS was present.

IGF‐1 Deficiency Exacerbates Hypertension‐Induced Cerebral Microhemorrhages in Mice, Mimicking the Aging Phenotype

Recent studies demonstrate that age-related IGF-1 deficiency exacerbates hypertension-induced cognitive decline, but the underlying mechanisms remain elusive. Cerebral microhemorrhages (CMHs) are associated with rupture of small intracerebral vessels and are thought to impair neuronal function. To determine whether IGF-1 deficiency exacerbates hypertension-induced CMHs, mice with liver-specific knockdown of IGF-1 (Igf1f/f + TBG-iCre-AAV8) and control mice were treated with angiotensin-II plus L-NAME. We found that the same level of hypertension lead to significantly earlier onset and increased incidence of CMHs in IGF-1 deficient mice than in control mice, as shown by neurological examination, gait analysis and histological assessment of CMHs in serial brain sections. Previous studies showed that oxidative stress-mediated MMP activation importantly contribute to the pathogenesis of CMHs. Thus, it is significant that high pressure-induced oxidative stress (DHE fluorescence; control: 1±0.2 vs. IGF-1 deficient: 2.4±0.2, p<0.01) and redox-sensitive activation of MMPs (IGF-1 deficient: 5±1.9 fold increase vs. control, p<0.01) are increased in cerebral arteries isolated from IGF-1 deficient mice. Collectively, IGF-1 deficiency promotes CMHs in mice, mimicking the aging phenotype, which likely contribute to its deleterious effect on cognitive function. Therapeutic strategies that up-regulate IGF-1 signaling in the cerebral vessels and/or reduce microvascular oxidative stress and MMP activation may be useful for the prevention of CMHs, protecting neurocognitive function in high-risk elderly patients.

Off-pump Bilateral Internal Thoracic Artery Grafting

The long-term benefit of bilateral internal thoracic grafts (BITA) is well established. BITA grafting is often avoided in diabetic, female, obese, elderly and other high-risk patients because of concerns for deep sternal wound infection. The objective of this study is to analyse early results of our BITA grafting and to establish the safety of BITA use in all patients. All cases of isolated consecutive unselected CABG were included in this retrospective study. BITA were used in-situ - one was used to graft left anterior descending artery and the other was used as inflow for a composite graft with radial artery. Dual inflow using in situ BITA grafting allows easy bailout by using an additional vein graft. BITA was used in 574 patients out of 602 (95.35%). Incidence of early death was 1.33% (8/602), stroke 0.5% (3/602), reoperation for bleeding 0.17% (1/602). Deep sternal wound infection was not seen in any patient but nine patients (1.5%) had superficial wound infection which healed with dressing. We have used BITA in 95% of our unselected, consecutive off-pump CABG patients without any major wound complications. Our limited experience has shown off-pump CABG using BITA grafting can be safely adopted routinely with excellent early result.

Aging exacerbates hypertension-induced cerebral microhemorrhages in mice: role of resveratrol treatment in vasoprotection.

Recent studies demonstrate that aging exacerbates hypertension-induced cognitive decline, but the specific age-related mechanisms remain elusive. Cerebral microhemorrhages (CMHs) are associated with rupture of small intracerebral vessels and are thought to progressively impair neuronal function. To determine whether aging exacerbates hypertension-induced CMHs young (3 months) and aged (24 months) mice were treated with angiotensin II plus L-NAME. We found that the same level of hypertension leads to significantly earlier onset and increased incidence of CMHs in aged mice than in young mice, as shown by neurological examination, gait analysis, and histological assessment of CMHs in serial brain sections. Hypertension-induced cerebrovascular oxidative stress and redox-sensitive activation of matrix metalloproteinases (MMPs) were increased in aging. Treatment of aged mice with resveratrol significantly attenuated hypertension-induced oxidative stress, inhibited vascular MMP activation, significantly delayed the onset, and reduced the incidence of CMHs. Collectively, aging promotes CMHs in mice likely by exacerbating hypertension-induced oxidative stress and MMP activation. Therapeutic strategies that reduce microvascular oxidative stress and MMP activation may be useful for the prevention of CMHs, protecting neurocognitive function in high-risk elderly patients.

Transcatherter Aortic Valve Implantation (TAVI), the evolution, the 2nd. Generation, the directions & the criterias of the future generations

Transcatheter valve intervention are more advanced and also successful evolution of conventional cardiac surgery. The first step in cardiac surgery was performed on the beating hearts in the case of digital or instrumental mitral commisurotomy. Although open heart surgery stays always the “Gold Standard” procedure, because it is crucial in understanding via direct “Visus” the valve diseases. Transcatheter technologies takes advantages from the open heart technique using catheter based instruments for elderly and high risk patients. Transcatheter mitral valve commisurotomy was the first surgical therapy converted to transcatheter one in the 1980. Today with a new art of transcatheter technology, with more clinical efficacy and safety is this “The Procedure of Choice” with a faster recovery and less peri-operative pain. But although it seems the TAVI procedure is more effective at elderly high risk or non-operable patients. The German TAVR registry shows that at low risk population, the observed mortality & morbidity is higher than that population by the EUROSCORE. The key and the crucial point at the introduction a new clinical technology is the optimal “TRANSLATION” to the daily human practice. The new interventional technology have to be supported – after previous excellent results of animal and all clinical phase studies - by “Clinical Evidence!!!”. In this technology imaging is the crucial factor in the selection & in the screening process, to guide patients to the right size and art of device selection, as well as in playing a fundamental role during procedures to guide the implant safely and effectively. In the future the best imagination with a real touch will be probably holographic by an almost “REAL “ 3D or 4D anatomical peri-operative representation.

Growing Antibiotic Resistance in Fatal Cases of Staphylococcal Pneumonia in the Elderly.

Older people are often especially susceptible to pneumonia and bacteria may develop resistance to antibiotics quicker in the elderly, whose immune systems gradually diminish. This study analyses, retrospectively, resistance to antibiotics in high-risk elderly patients with fatal pneumonia. Records of all patients aged over 65 who did not survive a bout with pneumonia were gathered from the records of the Department of Pneumology of HELIOS Clinic in Wuppertal, Germany from the period of 2004-2014. Susceptibility testing was executed for the study population, whose pneumonia was triggered by various kinds of bacteria. We detected 936 pneumonia patients of the overall mean age of 68.0 ± 13.6years, with the following pneumonia types: 461 (49.3%) community-acquired, 354 (37.8%) nosocomial-acquired, and 121 (12.9%) aspiration pneumonia. There were 631 (67.4%) males and 305 (32.6%) females there. We identified 672 (71.8%) patients who had a high risk for pneumonia, especially staphylococcal pneumonia (p < 0.0001). The elderly patients had a higher risk of dying from pneumonia (2.9 odds ratio, 95% confidence interval 1.8-4.6; p < 0.0001); of the 185 pneumonia-related deaths, 163 (88.1%) were in the elderly. In those with fatal staphylococcal pneumonia, a high antibiotic resistance rate was found for piperacillin-tazobactam (p = 0.044), cefuroxime (p = 0.026), cefazolin (p = 0.043), levofloxacin (p = 0.018), erythromycin (p = 0.004), and clindamycin (p = 0.025). We conclude that elderly patients with staphylococcal pneumonia show resistance to common antibiotics. However, no significant antibiotic resistance could be ascribed for other types of pneumonia in these patients.

Effect of early surgery in high surgical risk geriatric patients with femoral neck fracture and taking antiplatelet agents

To investigate the effect of early surgical intervention on the high surgical risk elderly patients who sustained femoral neck fracture (FNF) and taking concomitant antiplatelet agents. Between 2010 and 2012, a prospective study was conducted on 49 geriatric patients, who took antiplatelet agents, sustained FNF and underwent surgery within 72 h [early surgery (ES) group], and these were compared with a retrospective consecutive case series of patients with similar characteristics (45 cases) who had delayed surgery (DS group) after 72 h during an earlier 3-year period. Postoperative outcomes were followed for one year and compared. There were non-significant differences in perioperative blood loss, blood transfusion, intensive care unit requirement and postoperative mortality (P > 0.05 all). There were 2 patients (4%) in the DS group who died after surgery (P = 0.23). However, the ES group showed a significantly better postoperative outcome in terms of postoperative complications, length of hospital stay, and functional outcome (P < 0.05 all). Early hip surgery in geriatric hip fracture patients with ongoing antiplatelet treatment was not associated with a significant increase of perioperative blood loss and postoperative mortality. Moreover, ES resulted in a better postoperative surgical outcome. In early hip surgery protocol, the antiplatelet agents are discontinued and the patient is operated on within 72 h after admission, which is safe and effective for the medically fit patients.

Change in quality of life after transcatheter aortic valve implantation and aortic valve replacement surgery in Australian patients aged ≥ 75 years: the effects of EuroSCORE and patient operability.

ObjectiveTo determine the extent to which differences in generic quality of life (QOL) between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) patients explained by EuroSCORE and heart-team operability assessment.MethodsA total of 146 high-risk patients with EuroSCORE > 6 and aged ≥ 75 years underwent TAVI (n = 80) or aortic valve replacement (n = 66) between February 2010 and July 2013. A total of 75 patients also completed preoperative and six month SF-12 QOL measures. Analyses examined incident major morbidity, compared six month QOL between groups adjusted for EuroSCORE and operability, and quantified rates of clinically significant QOL improvement and deterioration.ResultsThe AVR group required longer ventilation (> 24 h) (TAVI 5.0% vs. AVR 20.6%, P = 0.004) and more units of red blood cells [TAVI 0 (0–1) vs. AVR 2 (0–3), P = 0.01]. New renal failure was higher in TAVI (TAVI 5.0% vs. AVR 0%, P = 0.06). TAVI patients reported significantly lower vitality (P = 0.01) by comparison to AVR patients, however these findings were no longer significant after adjustment for operability. In both procedures, clinically significant QOL improvement was common [range 25.0% (general health) – 62.9% (physical role)] whereas deterioration in QOL occurred less frequently [range 9.3% (physical role) – 33.3% (mental health)].ConclusionsClinically significant improvement and deterioration in QOL was evident at six months in high risk elderly aortic valve replacement patients. Overall QOL did not differ between TAVI and AVR once operability was taken into consideration.

Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients

Objective:Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha(TNF ά), interleukin-6 and leucocyte count.Design:A prospective randomised non blind study.Setting:A clinical study in a multi specialty hospital.Participants:Eighty six patients.Material and Methods/intervention:The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: – 6, TNF ά, cortisol, Troponin – I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis.Primary Outcomes:Postoperative complications, total intensive care unit stay and hospital stay.Secondary Outcome:Stress response.Result:Study group showed decreased Interlukin – 6 at day 2, TNF ά at day 2 and 5, troponin I at day 5, and decreased total hospital stay (p < 0.05).Conclusion:Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it.

External Fixation vs. Skeletal Traction for Treatment of Intertrochanteric Fractures in the Elderly.

BackgroundHip fractures are one of the causes of disability amongst elderly patients. External fixator and skeletal traction are two modes of treatment.ObjectivesThe aim of this study is to compare two different treatment modes for intertrochanteric fractures in elderly patients.Patients and MethodsSixty elderly patients with intertrochanteric fractures were randomized for treatment with either skeletal traction (Group A) or an external fixation (Group B). In this study patients at least 60 years of age, with AO/OTA A1 or A2 type fracture and intertrochanteric fracture as a result of minor trauma, were enrolled.ResultsAcceptable reduction was achieved in eight and 26 patients of group A and B, respectively. The mean duration of hospitalization in Group A and Group B was 14.3 ± 1.1 and 2.2 ± 0.6 days, respectively. Significant differences between the two groups were observed, regarding acceptable reduction and duration of hospitalization. Less pain was observed in group B, at five days and twelve months after surgery; the average HHS was 57 and 66, in group A and B, respectively (P > 0.05).ConclusionsTreatment with an external fixator is an effective treatment modality for intertrochanteric fractures in elderly high-risk patients. The advantages include rapid and simple application, insignificant blood loss, less radiation exposure, adequate fixation, pain reduction, early discharge from the hospital, low cost and more favorable functional outcome.

Differential effectiveness of ARB plus CCB therapy and high-dose ARB therapy in high-risk elderly hypertensive patients: subanalysis of the OSCAR study.

The OSCAR study was a multicenter prospective randomized study that examined the relative benefit of combined ARB (olmesartan 20 mg per day) plus calcium channel blocker (CCB) therapy vs. high-dose ARB monotherapy (olmesartan 40 mg per day) for prevention of cardiovascular events in elderly Japanese hypertensive patients. The present subanalysis of patients enrolled in the OSCAR study (n = 1078) was performed to assess whether baseline eGFR coupled with cardiovascular disease (CVD) could predict the relative benefit of these two treatments. Patients with baseline CVD (n = 769) and patients without baseline CVD (n = 309) were divided into two groups based on baseline eGFR; (i) patients with eGFR of < 60 ml min(-1) 1.73 m(-)(2) and (ii) those with eGFR of ⩾ 60 ml min(-1) 1.73 m(-2). There was a significant treatment-subgroup interaction among these four subgroups in relation to the incidence of primary outcome events(P = 0.007 for interaction). In patients with CVD and with eGFR of <60 ml min(-1) 1.73 m(-2), ARB plus CCB therapy was associated with a lower incidence of primary events than high-dose ARB therapy and the difference of the relative risk was statistically significant (hazard ratio: 3.525, 95% confidence interval (CI): 1.676-7.412, P < 0.001). The greater benefit of ARB plus CCB therapy vs. high-dose ARB therapy in this subgroup was associated with less visit-to-visit variability of systolic BP and diastolic BP. In conclusion, baseline eGFR coupled with baseline CVD seems to be a predictor of the relative efficacy of ARB plus CCB therapy vs. high-dose ARB therapy in the elderly hypertensive patients. ARB plus CCB therapy appears to be superior to high-dose ARB therapy for preventing cardiovascular events in the patients with CVD and with eGFR of <60 ml min(-1) 1.73 m(-2).