Outcomes In Middle-aged Patients Research Articles

Clinical characteristics and outcomes in middle-aged Fontan patients

BackgroundMiddle-aged Fontan patients are underrepresented in contemporary studies. The purpose of this study was to describe the clinical characteristics and outcomes in middle-aged patients with Fontan palliation. MethodsAll adults with Fontan palliation were divided into ‘middle-aged’ group (>40 years of age at baseline encounter), and ‘young adult’ group. Clinical characteristics were assessed across multiple domains (atrial arrhythmias, heart failure, and hepatorenal function). Clinical outcomes were assessed as composite outcome of death/heart transplant. ResultsOf 455 adults (median age 26 years), 63 (14 %) were middle-aged adults while 392 (86 %) were young adults. Compared to the young adult group, the middle-aged group had a higher prevalence of atrial arrhythmias, greater neurohormonal activation, and worse hepatorenal function. Of 63 patients in the middle-aged group, 26 (41 %) patients died, and 4 (6 %) patients underwent heart transplant. The middle-aged group had a higher 5-year cumulative incidence of death/transplant (45 % versus 21 %, p < 0.001), and 10-year cumulative incidence of death/transplant (64 % versus 29 %, p < 0.001) compared to the young adult group. Higher pulmonary artery wedge pressure (hazard ratio 1.18 [1.09–1.27]), and higher model for end-stage liver disease excluding international normalized ratio score (hazard ratio 1.07, [1.03–1.14]), were associated with death/transplant. ConclusionsAbout 14 % of adults with Fontan palliation were middle-aged, and these patients had higher prevalence of cardiovascular comorbidities, hepatorenal dysfunction, and mortality. These data underscore the need for better risk stratification strategies to identify patients at risk for adverse outcomes and allow for early referral for transplant evaluation in this emerging subpopulation. Clinical summaryThe purpose of this study was to describe the clinical characteristics (comorbidities and end-organ dysfunction) and outcomes (death/transplant) in middle-aged patients with Fontan palliation. Of 455 patients (median age 26 years), 63 (14 %) were middle-aged adults while 392 (86 %) were young adults. Compared to the young adult group, the middle-aged group had a higher prevalence of atrial arrhythmias, greater neurohormonal activation, worse hepatorenal function, and higher risk of death/transplant. The correlates of death/transplant were higher pulmonary artery wedge pressure and hepatorenal dysfunction. These data underscore the need for better risk stratification in this emerging population.

Linking head and heart health: the association between psychiatric outcomes for patients with major depressive disorder and myocardial ischemia - a systematic review.

The development of depression after myocardial infarction is associated with a 2- to 2.5-fold increased risk of all-cause mortality, cardiovascular mortality, and cardiovascular events. The objective of this study was to investigate, through a broad search of the literature, whether major depression is associated with worse psychiatric outcomes in middle-aged patients with myocardial ischemia. An extensive search for studies on the association between major depression and myocardial ischemia was conducted in the PubMed, Embase, PsycINFO, and Web of Science databases. Randomized clinical trials of middle-aged patients with myocardial ischemia and concomitant depressive symptoms were included. The 14 articles included in this systematic review did not confirm an association between myocardial ischemia and depression with worse psychiatric outcomes in middle-aged patients. However, worse cardiovascular outcomes have been observed in patients with depression after myocardial infarction. The findings of this study suggest that major depression increases cardiovascular risk in patients after acute myocardial infarction, possibly because of a more pronounced increase in inflammatory markers. This systematic review was registered in the International Prospective Registry of Systematic Reviews (PROSPERO) under the number CRD: 511650.

Knee Arthroscopic Surgery in Middle-Aged Patients With Meniscal Symptoms: A 10-Year Follow-up of a Prospective, Randomized Controlled Trial

Background: Short- and midterm evaluations of arthroscopic meniscal surgery have shown little or no effect in favor of surgery, although long-term effects, including radiographic changes, are unknown. Purpose: To compare the 10-year outcomes in middle-aged patients with meniscal symptoms between a group that received an exercise program alone and a group that received knee arthroscopy in addition to the exercise program with respect to the prevalence of radiographic and symptomatic osteoarthritis (OA), patient-reported outcomes, and clinical status. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Of 179 eligible patients aged 45 to 64 years, 150 were randomized to undergo either 3 months of exercise therapy (nonsurgery group) or knee arthroscopy in addition to the exercise therapy (surgery group). Surgery usually consisted of partial meniscectomy (n = 56) or diagnostic arthroscopy (n = 8). Radiographs were assessed according to the Kellgren-Lawrence score at the baseline and 5- and 10-year follow-ups. Patient-reported outcome measures were reported at the baseline and 1-, 3-, 5-, and 10-year follow-ups. Clinical status was assessed at a 10-year follow-up. The primary outcomes were radiographic OA and changes in the Knee injury and Osteoarthritis Outcome Score Pain subscale (KOOSPAIN) from the baseline to the 10-year follow-up. The primary analysis was performed using the intention-to-treat approach. Results: At the time of the 10-year follow-up, eight patients had died, leaving 142 eligible patients. Radiographic OA was assessed for 95 patients (67%), questionnaires were answered by 110 (77%), and the clinical status was evaluated for 95 (67%). Radiographic OA was present in 67% of the patients in each group (P≥ .999); symptomatic OA was present in 47% of the nonsurgery group and 57% of the surgery group (P = .301). There were no differences between groups regarding changes from baseline to 10 years in any of the KOOS subscales. Conclusion: Knee arthroscopic surgery, in most cases consisting of partial meniscectomy or diagnostic arthroscopy, in addition to exercise therapy in middle-aged patients with meniscal symptoms, did not increase the rates of radiographic or symptomatic OA and resulted in similar patient-reported outcomes at the 10-year follow-up compared with exercise therapy alone. Considering the short-term benefit and no long-term harm from knee arthroscopic surgery, the treatment may be recommended when first-line treatment—including exercise therapy for ≥3 months—does not relieve patient’s symptoms. Registration: Clinical Trials NCT01288768 (ClinicalTrials.gov identifier).

Periacetabular osteotomy for symptomatic hip dysplasia in middle aged patients: does age alone matter?

BackgroundConflicting evidence exists regarding outcomes in middle-aged patients undergoing periacetabular osteotomy (PAO) for symptomatic developmental dysplasia of the hip (DDH).AimsTo compare patient reported outcomes (PROMs) of middle-aged PAO patients with younger patient groups.MethodsRetrospective analysis of prospectively collected data of PAO patients between 01/2015 and 06/2017 at a single orthopedic university center with a primary diagnosis of symptomatic DDH. The cohort was divided into four age groups and compared: < 20, 20–30, 30–40 and > 40 years. Joint function was assessed using iHOT-12, mHHS and SHV. Activity level was assessed using UCLA Activity score. Patient satisfaction and pain were assessed on the numerical rating scale 0–10. Conversion rates to THA were assessed.ResultsOut of 202 PAOs, 120 cases with complete data were included. Mean follow-up was 63 months (range 47–81 months). Eighteen patients were < 20 years old, 54 were 20–30 years, 37 were 30–40 years, 11 patients were older than 40. No significant differences were observed for preoperative or postoperative iHOT-12 (p = 0.898; p = 0.087), mHHS (p = 0.878; p = 0.103), SHV (p = 0.602; p = 0.352) or UCLA (p = 0.539; p = 0.978) between groups. Improvement deltas were also not significantly different for all PROMs. Postoperative patient satisfaction was similar between groups (p = 0.783).ConclusionPatients with symptomatic DDH may benefit from PAO even at middle age with similar outcomes and pre- to postoperative improvements as younger age groups. Indication should be based on biological age and preoperative joint condition rather than age.

Chronic Comorbidities in Middle Aged Patients Contribute to Ineffective Emergency Hematopoiesis in Covid-19 Fatal Outcomes

Mexico is among the countries with the highest estimated excess mortality rates due to the COVID-19 pandemic, with more than half of reported deaths occurring in adults younger than 65 years old. Although this behavior is presumably influenced by the young demographics and the high prevalence of metabolic diseases, the underlying mechanisms have not been determined. The age-stratified case fatality rate (CFR) was estimated in a prospective cohort with 245 hospitalized COVID-19 cases, followed through time, for the period October 2020-September 2021. Cellular and inflammatory parameters were exhaustively investigated in blood samples by laboratory test, multiparametric flow cytometry and multiplex immunoassays. The CFR was 35.51%, with 55.2% of deaths recorded in middle-aged adults. On admission, hematological cell differentiation, physiological stress and inflammation parameters, showed distinctive profiles of potential prognostic value in patients under 65 at 7 days follow-up. Pre-existing metabolic conditions were identified as risk factors of poor outcomes. Chronic kidney disease (CKD), as single comorbidity or in combination with diabetes, had the highest risk for COVID-19 fatality. Of note, fatal outcomes in middle-aged patients were marked from admission by an inflammatory landscape and emergency myeloid hematopoiesis at the expense of functional lymphoid innate cells for antiviral immunosurveillance, including NK and dendritic cell subsets. Comorbidities increased the development of imbalanced myeloid phenotype, rendering middle-aged individuals unable to effectively control SARS-CoV-2. A predictive signature of high-risk outcomes at day 7 of disease evolution as a tool for their early stratification in vulnerable populations is proposed.

A Systematic Review of Focal Cartilage Defect Treatments in Middle-Aged Versus Younger Patients.

Background:Focal cartilage defects are often debilitating, possess limited potential for regeneration, are associated with increased risk of osteoarthritis, and are predictive for total knee arthroplasty. Cartilage repair studies typically focus on the outcome in younger patients, but a high proportion of treated patients are 40 to 60 years of age (ie, middle-aged). The reality of current clinical practice is that the ideal patient for cartilage repair is not the typical patient. Specific attention to cartilage repair outcomes in middle-aged patients is warranted.Purpose:To systematically review available literature on knee cartilage repair in middle-aged patients and include studies comparing results across different age groups.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic search was performed in EMBASE, MEDLINE, and the Cochrane Library database. Articles were screened for relevance and appraised for quality.Results:A total of 21 articles (mean Coleman Methodology Score, 64 points) were included. Two out of 3 bone marrow stimulation (BMS) studies, including 1 using the microfracture technique, revealed inferior clinical outcomes in middle-aged patients in comparison with younger patients. Nine cell-based studies were included showing inconsistent comparisons of results across age groups for autologous chondrocyte implantation (ACI). Bone marrow aspirate concentrate showed age-independent results at up to 8 years of follow-up. A negative effect of middle age was reported in 1 study for both ACI and BMS. Four out of 5 studies on bone-based resurfacing therapies (allografting and focal knee resurfacing implants [FKRIs]) showed age-independent results up to 5 years. One study in only middle-aged patients reported better clinical outcomes for FKRIs when compared with biological repairs.Conclusion:Included studies were heterogeneous and had low methodological quality. BMS in middle-aged patients seems to only result in short-term improvements. More research is warranted to elucidate the ameliorating effects of cell-based therapies on the aging joint homeostasis. Bone-based therapies seem to be relatively insensitive to aging and may potentially result in effective joint preservation. Age subanalyses in cohort studies, randomized clinical trials, and international registries should generate more evidence for the large but underrepresented (in terms of cartilage repair) middle-aged population in the literature.

Clinical course and surgical outcomes in middle-age adults with anomalous aortic origin of a coronary artery

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with anomalous aortic origin of a coronary artery (AAOCA) present with a wide range of clinical manifestations, including ischemic symptoms (chest pain or dyspnea) and sudden cardiac death (SCD). Studies have identified coronary anatomic characteristics associated with a higher risk of SCD. However, most of the published literature consists of studies in adolescents and young adults. There is a paucity of data regarding outcomes in middle-aged patients. Current guidelines reveal gaps in evidence for identification of adults are at risk for SCD, and for whom surgery is beneficial. Purpose To study the clinical course and rate of major adverse cardiac events (MACE) in middle-aged adults with AAOCA based on presenting symptoms, coronary anatomy on coronary computed tomography angiography (CCTA), stress test results, and surgical management. Methods We included all patients from January 2013 to December 2019 age &amp;gt; 18 at our institution who were found to have AAOCA. Patients with the following were excluded to minimize confounding factors which could cause MACE: coronary artery disease (CAD) with &amp;gt;50% stenosis in any coronary vessel, CAD requiring revascularization, heart failure with ejection fraction &amp;lt;40%, history of heart transplant, and non-AAOCA congenital heart disease. All patient charts were reviewed for demographics, coronary anatomy on CCTA, presenting symptoms, rationale for pursuing stress testing and CCTA, nature of surgical interventions, post-surgical course, and MACE (cardiovascular death, myocardial infarction, and need for coronary revascularization). All patients underwent PET as well as treadmill stress testing. Results Of 19,367 patients who underwent CCTA, 47 met inclusion criteria, with median age at diagnosis of 54 and median follow-up of 48 months. No patients suffered MACE. Twenty-five patients had AAORCA and 22 had AAOLCA (Table 1). Ten patients with AAORCA and 8 patients with AAOLCA presented with ischemic symptoms and had coronary anatomy characteristics associated with higher risk of SCD, as well as ischemia corresponding to the anomalous artery on stress testing and did not undergo surgery due to personal preference. Five symptomatic patients with stress-induced ischemia corresponding to the anomalous artery underwent surgery and all achieved symptom relief over a median follow up of 5 years. Conclusion As AAOCA is a significant cause of SCD in young adults, it is compelling to observe this adult cohort in which no patients experienced MACE, including 18 symptomatic patients with high-risk anatomy and stress-induced ischemia, as well as a Class I recommendations for surgery. The results suggest that although surgery may be beneficial for symptom relief, it does not necessarily improve mortality over an intermediate follow-up period. Future studies should examine surgical outcomes in middle-aged cohorts with larger sample sizes.

Phenotypes and outcomes in middle-aged patients with diabetic foot ulcers: a retrospective cohort study

BackgroundAlthough ageing could increase the risk of delayed healing in diabetic foot ulcers (DFUs) patients, data from middle-aged patients remains greatly limited. The purpose of this study was to explore the clinical phenotypes, outcomes and predictive factors of DFU in middle-aged patients.MethodsA retrospective cohort study conducted with 422 consecutive inpatients with DFUs who visited our hospital between May 2010 and September 2017; participants were recruited and assigned according to age to either the middle-aged group or the elderly group. The Demographics, ulcer characteristics, comorbidities and diabetes complications, laboratory tests, socioeconomic data and final outcomes were collected. Moreover, predictive factors of adverse outcomes in middle-aged DFUs patients were assessed.ResultsMiddle-aged patients were more likely to have worse lifestyle and glucose control, were more likely to have microangiopathy as a complication, and tended to have larger and deeper ulcers; however, these patients also had higher rates of healing and lower rates of mortality and major amputaion than elderly patients. Severe infection,living alone,current smoking cigarettes, and having a high white blood cell count were independent risk factors for adverse outcomes in middle-aged patients.ConclusionsDFUs are relatively common in middle-aged patients with diabetes, and these patients have unique clinical phenotypes and risk profiles. Nonetheless, further investigation is needed to clarify whether intervention targeting these easily recognizable risk factors can improve healing and survival rates in middle-aged DFU patients.

The 6-m timed hop test is a prognostic factor for outcomes in patients with meniscal tears treated with exercise therapy or arthroscopic partial meniscectomy: a secondary, exploratory analysis of the Odense-Oslo meniscectomy versus exercise (OMEX) trial.

To identify the prognostic factors for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears treated with exercise therapy (ET) or arthroscopic partial meniscectomy (APM). One hundred and seven patients, with mean age 49.6 (SD 6.2) years and BMI 25.7 (SD 3.7), were included in this analysis of data from the OMEX trial ( http://www.clinicaltrials.gov NCT01002794). Linear and Poisson regression models were built to explore the associations between potential prognostic factors (patient characteristics, knee function-related and disease-related factors) and 2-year patient-reported outcomes: the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales Pain, Symptoms, ADL, Sport/Rec, QoL and 5-point Global Rating of Change scales for knee pain (GRC Pain) and function (GRC Function). Analyses were performed for the whole cohort and for the two treatment groups (n = 55 and 52) with adjustments for age, sex, BMI and baseline KOOS. For the whole cohort, a 1-s better baseline 6-m timed hop test result was associated with 3.1-7.1 points better 2-year scores for all KOOS subscales (95% CIs 1.1-5.2 to 4.1-10.1 points). A 1.61-2.80s better test was associated with scores equivalent to previously calculated clinical relevant differences for each KOOS subscale. For the groups of patients treated with ET and APM, respectively, 2.09-3.60s and 0.63-1.99s better tests were associated with clinical relevant differences. For the whole cohort, a 1-s better test was associated with 26% (95% CI 15-38%) and 22% (95% CI 11-34%) higher possibility for better or much better GRC Pain and Function scores. Patients treated with ET had 17% (95% CI 2-33%) increased possibility for better or much better GRC Pain score, and patients treated with APM had 65% (95% CI 32-108%) and 70% (95% CI 38-109%) increased possibility for better or much better GRC Pain and Function scores. The 6-m timed hop test result was a significant prognostic factor for 2-year patient-reported outcomes in middle-aged patients with degenerative meniscal tears, especially in those treated with APM. II.

Ideal Cardiovascular Health, Mortality, and Vascular Events in Elderly Subjects: The Three-City Study

BackgroundThe benefit of ideal cardiovascular health (CVH) on health-related outcomes in middle-aged patients is firmly established. In the growing elderly population, the high prevalence of comorbidities and medications for chronic diseases may offset such benefit. ObjectivesThis study analyzed the association of ideal CVH with mortality, incident coronary heart disease, and stroke events in elderly individuals from the community. MethodsBetween 1999 and 2001, 9,294 men and women, noninstitutionalized and aged 65 years and over were examined, and thereafter followed up for the occurrence of vascular events and mortality within the Three-City Study. Hazard ratios (HRs) were estimated by Cox proportional hazard model and compared subjects with 3 to 4 and subjects with 5 to 7 ideal metrics with those with 0 to 2 ideal metrics, respectively. ResultsThe mean age was 73.8 ± 5.3 years, and 36.7% were men. Only 5% of the participants had ≥5 metrics at the ideal level. After a median follow-up of 10.9 years and 8.6 years, respectively 1,987 deaths and 680 adjudicated coronary heart disease or stroke events had occurred. In multivariate analysis, the risk of mortality and of vascular events decreased across the categories of ideal metrics. In particular, in subjects with ≥5 metrics at the ideal level (compared with those with ≤2), there was a 29% (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.55 to 0.90) decreased risk of all-cause mortality and 67% (HR: 0.33; 95% CI: 0.19 to 0.57) for coronary heart disease and stroke combined (p for trend <0.001). ConclusionsEven in the elderly, higher CVH status is highly beneficial regarding mortality and vascular event risks.

Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography.

In the present prospective study, the functional outcomes of non-operative treatment were evaluated in patients aged between 30 and 45years presenting SLAP lesion in diagnostic provocative tests and magnetic resonance (MR) arthrography. Forty-six patients with a symptomatic SLAP lesion who participated in recreational level of sports were prospectively enroled. SLAP lesion was diagnosed using combinations of several clinical tests and MR arthrography findings. All patients were treated with intra-articular corticosteroid injections, followed by rotator cuff and periscapular muscle-strengthening exercises. Patients with persistent discomfort after second injection underwent arthroscopic SLAP repair. Functional outcomes were evaluated using ASES and Constant scores, and pain and satisfaction for visual analogue scale (VAS). Pain had significantly improved from 5.2±2.2 to 1.0±1.1 (p<0.001) in all patients after the first corticosteroid injection. SLAP symptoms relapsed in 12 patients at an average of 2.4months after the first injection. Symptoms were relieved in 5 of 12 patients after the second injection and strengthening exercises. The remaining seven patients underwent arthroscopic SLAP repair. Thirty-nine patients (85%) who were treated non-operatively showed improved VAS, Constant, and ASES scores at final follow-up (p<0.001). Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment. Non-operative management using combined intra-articular corticosteroid injection with rotator cuff and periscapular strengthening exercises could be applied as primary treatment for patients with symptomatic SLAP lesion who participate in recreational level of sports. IV.

Subpectoral Biceps Tenodesis For The Treatment Of Type Two And Four Slap Lesions

Objectives:Despite unsatisfactory outcomes in middle aged patients with SLAP lesions, surgical repair remains the gold standard for most Type II and Type IV SLAP lesions. Given recent data demonstrating higher SLAP repair failure rates in this subset of patients, biceps tenodesis may offer an excellent alternative. To our knowledge, only one study has investigated biceps tenodesis as an alternative to SLAP repair. This study investigates that subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle aged patients.Methods:Patients who were older than 18 years old and underwent subpectoral biceps tenodesis for isolated Type II or Type IV SLAP lesions by a single board certified shoulder surgeon from 2006-2012 were included. Exclusion criteria included those patients with Type II or Type IV SLAP lesions who underwent biceps tenodesis with rotator cuff repair, Bankart repair, or labral repair. Outcome measures included Visual Analog Pain Scale (VAS), American Shoulder and Elbow Surgeons Scores (ASES), and demographic data.Results:Between 2006-2012, 33 patients underwent 36 subpectoral biceps tenodesis for isolated Type II or Type IV SLAP lesions by a single board certified shoulder surgeon. 26 patients with 29 shoulder surgeries consented to participate in the study. Average age was 46.7 years with 16 males and 10 females participating in the study. Average follow up was 29.3 months. A statistically significant improvement in ASES and VAS scores were found with an average of 48.1 and 6.4 preoperatively and an average of 87.5 and 1.5 post-operatively (p < .001). There was no statistically significant difference noted based on SLAP lesion type, age, activity level, or gender. 26 of 29 shoulders (89.65%) were able to return to their previous activity.Conclusion:Our study is able to confirm that biceps tenodesis results in statistically significant improvement in pain and functional outcomes for Type II and IV SLAP lesions. The results of biceps tenodesis for Type II and IV SLAP lesions is comparable to historical data. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to SLAP repair in middle aged patients.

Surgery for ACL deficiency in patients over 50

To compare the outcomes of arthroscopic ACL reconstruction procedure in 20 middle-aged patients (12 men and 8 women) and 20 subjects younger than 30years (control group) at a minimum post-operative follow-up of 24months. Pre- and post-operative anterior-posterior laxity was assessed by Lachman test, pivot shift test and KT1000 arthrometer at manual maximum stress. Clinical functional evaluation was assessed according to IKDC Committee (IKDC) subjective knee form, IKDC ligament standard evaluation and Lysholm score. At 2years, all variables significantly improved in both groups compared to pre-operative values (P<0.05), with non-significant intergroup difference. When faced with ACL deficiency, physiological age, condition of the knee at the time of examination, life expectancy and activity level are probably more important than chronologic age. In the present study, arthroscopic surgery for the management of ACL tear and secondary lesions provides comparable clinical outcomes in middle-aged patients and in patients aged below 30.