Patients Of Higher Age Research Articles

Molecular microarray analysis reveals allergen‐ and exotoxin‐specific IgE repertoires in children with atopic dermatitis

Children suffering from atopic dermatitis frequently show allergen-specific sensitization. However, the corresponding IgE-recognition patterns have not yet been extensively characterized using multiallergen microarrays. To provide comprehensive, molecular IgE repertoires in paediatric patients with atopic dermatitis using microarray technology. Sera of 140 affected children were screened with a protein microarray containing a panel of 95 inhalant, food and staphylococcal antigen components. In addition, total serum IgE levels and further clinical parameters were recorded. At a mean total IgE level of 1528 kU/L, the number of sensitizations varied from 0 to 32 per patient, and regression analysis revealed a significant association between total IgE and the quantity of recognized antigens. A total of 78 single allergen and microbial components elicited at least one IgE response, while 11 plant and 13 non-plant molecules were recognized by more than 10% of patients. Specific IgE against Staphylococcus aureus could be detected in 14% of children. Sensitization rates against the studied allergen molecules differed significantly when stratified by age. Whereas reactivity against inhalant allergens and SEC was lowest in the youngest group (<24 months) reaching highest values in children ≥ 72 months, IgE responses against food allergen components peaked in younger age groups (0-48 months) and clearly declined in patients of higher age. The large amount of microarray data could be aggregated by centroid cluster analysis revealing valid allergen clusters possibly linked with higher disease severity as determined by multivariate analysis of covariance. Allergenic molecule microarray analysis can be regarded as a suitable research tool for large-scale IgE screening in infants and children with atopic dermatitis (AD). Still, further studies in well-defined populations are needed to exactly identify its tangible benefits in the diagnostic and therapeutic management of affected patients in daily clinical practice.

The epidemiological characteristics of zygomatic complex fractures: A comparison between the surgically and non-surgically treated patients

Introduction:This retrospective study is aimed at the documentation of a more complete view of epidemiological data with particular focus on the characteristics of the surgically and non-surgically treated patients with zygomatic complex fractures.Materials and Methods:A total of 133 surgically and 150 non-surgically patients were treated with zygomatic complex fractures in VU University medical center Amsterdam from January 2007 to January 2012 were analyzed. These patient groups were further subdivided into displaced or non-displaced fractures and compared with each other according to age, gender and trauma etiology.Results:The mean age of all 286 patients was 42.8 years (standard deviation [SD: ±19.8]). Surgically and non-surgically treated patients differed in presentation with a significantly overall higher age of females, especially within the non-surgically treated patient group with displaced fractures (mean age of 59.5 years, SD: ±27.4). The mean ages of males from the different subgroups were more consistent with the overall mean age. The main causes were traffic accidents, whereas the contribution of falls and assaults depended on age group, gender, treatment management and even fracture displacement.Conclusions:This report provides us important epidemiological data of all patients with zygomatic complex fractures. The non-surgically treated patient group contained patients of higher age, more females and a fall-related cause, compared to the surgically treated patient group. The surgically treated patient group showed the same epidemiological characteristics as were demonstrated in previous studies.

Predicting the risk of chemotherapy toxicity in older patients: The Chemotherapy Risk Assessment Scale for High‐Age Patients (CRASH) score

Tools are lacking to assess the individual risk of severe toxicity from chemotherapy. Such tools would be especially useful for older patients, who vary considerably in terms of health status and functional reserve. The authors conducted a prospective, multicentric study of patients aged ≥70 years who were starting chemotherapy. Grade 4 hematologic (H) or grade 3/4 nonhematologic (NH) toxicity according to version 3.0 of the Common Terminology Criteria for Adverse Events was defined as severe. Twenty-four parameters were assessed. Toxicity of the regimen (Chemotox) was adjusted using an index to estimate the average per-patient risk of chemotherapy toxicity (the MAX2 index). In total, 562 patients were accrued, and 518 patients were evaluable and were split randomly (2:1 ratio) into a derivation cohort and a validation cohort. Severe toxicity was observed in 64% of patients. The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score was constructed along 2 subscores: H toxicity and NH toxicity. Predictors of H toxicity were lymphocytes, aspartate aminotransferase level, Instrumental Activities of Daily Living score, lactate dehydrogenase level, diastolic blood pressure, and Chemotox. The best model included the 4 latter predictors (risk categories: low, 7%; medium-low, 23%; medium-high, 54%; and high, 100%, respectively; P(trend) < .001). Predictors of NH toxicity were hemoglobin, creatinine clearance, albumin, self-rated health, Eastern Cooperative Oncology Group performance, Mini-Mental Status score, Mini-Nutritional Assessment score, and Chemotox. The 4 latter predictors provided the best model (risk categories: 33%, 46%, 67%, and 93%, respectively; P(trend) < .001). The combined risk categories were 50%, 58%, 77%, and 79%, respectively; P(trend) < .001). Bootstrap internal validation and independent sample validation demonstrated stable risk categorization and P(trend) < .001. The CRASH score distinguished several risk levels of severe toxicity. The split score discriminated better than the combined score. To the authors' knowledge, this is the first score systematically integrating both chemotherapy and patient risk for older patients and has a potential for future clinical application.

Is Age of 80 Years a Threshold for Carotid Revascularization?

Background and purpose:Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available literature.Methods:Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate (disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.Results:After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA. A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9% (range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA.A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 – 8.8%)Conclusions:MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the treatment of significant carotid artery stenoses, even in the very elderly.

Current state of cardiac rehabilitation in Germany: patient characteristics, risk factor management and control status, by education level

BackgroundAfter the acute hospital stay, most cardiac patients in Germany are transferred for a 3–4-week period of inpatient cardiac rehabilitation. We aim to describe patient characteristics and risk factor management of cardiac rehabilitation patients with a focus on drug treatment and control status, differentiated by education level (low level, elementary school; intermediate level, secondary modern school; high level, grammar school/university).MethodsData covering a time period between 2003 and 2008 from 68,191 hospitalized patients in cardiac rehabilitation from a large-scale registry (Transparency Registry to Objectify Guideline- Oriented Risk Factor Management) were analyzed descriptively. Further, a multivariate model was applied to assess factors associated with good control of risk factors.ResultsIn the total cohort, patients with a manifestation of coronary artery disease (mean age 63.7 years, males 71.7%) were referred to cardiac rehabilitation after having received percutaneous coronary intervention (51.6%) or coronary bypass surgery (39.5%). Statin therapy increased from 76.3% at entry to 88.9% at discharge, and low density lipoprotein cholesterol < 100 mg/dL rates increased from 31.1% to 69.6%. Mean fasting blood glucose decreased from 108 mg/dL to 104 mg/dL, and mean exercise capacity increased from 78 W to 95 W. Age and gender did not differ by education. In contrast with patients having high education, those with low education had more diabetes, hypertension, and peripheral arterial disease, had lower exercise capacity, and received less treatment with statins and guideline-orientated therapy in general. In the multivariate model, good control was significantly more likely in men (odds ratio 1.38; 95% confidence interval 1.30–1.46), less likely in patients of higher age (0.99; 0.99–0.99), with diabetes (0.90; 0.85–0.95), or peripheral arterial disease (0.88; 0.82–0.95). Compared with a low level education, a mid level education was associated with poor control (0.94; 0.89–0.99), while high education did not have a significant effect (1.08; 0.99–1.17).ConclusionPatients with different levels of education treated in cardiac rehabilitation did not differ relevantly in terms of demographics, but did differ in some clinical aspects. With respect to the ultimate goal of cardiac rehabilitation, ie, optimal control of risk factors, education level does not play an important role.

Long-term Survival After Surgical Intensive Care Unit Admission

Treatment of surgical patients in intensive care unit (ICU) comes along with major disadvantages, which have to be justified by some acceptable short- and long-term outcomes. Short-term effects of treatment in ICU have been well-documented. The aims of this study were to quantify the long-term survival of more than 10 years' follow-up of a large cohort of patients admitted to a surgical ICU and to investigate the effects of age, gender, and underlying disease on this long-term survival. Of all surgical patients admitted to the ICU of the St Elisabeth Hospital between 1995 and 2000, patient characteristics, disease category, APACHE II score, and survival were prospectively registered. A follow-up with a mean of 8 years after discharge was achieved. The independent association of multiple covariates was done using cox proportional hazard analysis. Of the 1822 patients included, 936 (51%) had died within 11 years and 52 patients were lost to follow-up. Overall ICU and in-hospital mortality were 11% and 16%, respectively. Age, gender, APACHE II score, the need for dialysis, and surgical classification were independently associated with long-term survival. Mortality increased with age of admittance to the ICU (hazard ratio, 1.058), whereas female patients had a lower chance to die (hazard ratio, 0.793). However, the preadmission disease did not influence long-term outcome. Long-term mortality rates in various surgical classification groups varied between 29% for trauma and 80% for gastrointestinal patients. In gastrointestinal, oncological, general surgical, and/or high-aged patients, a negative effect on mortality persisted beyond 5 years. The mortality ratio was increased twofold in comparison to the general population (51% vs 27%). Ten years after ICU discharge, survival was only 50%. After ICU treatment, survival follows distinct patterns in which age, gender, surgical classification, the need of dialysis, and APACHE II score are independent determinants, and long lasting.

Study on the relationship between sclerosis rim and bone morphogenetic proteins of osteonecrosis of the femoral head

To analyze retrospectively the formation and histological changes of sclerosis rim in patients with osteonecrosis of the femoral head (ONFH), and to study the relationship between bone morphogenetic proteins (BMP4) and sclerosis rim, so as to acquire experimental and theoretical basis on individualized treatment for ONFH patients. From November 2005 to November 2007, 184 hips of steroid-induced ONFH inpatients were collected. The mean age was (47 ± 7) years, the patients were divided into high (more than 54 years old), middle (40 - 54 years old) and low (less than 40 years old) age groups. Their clinical data were analyzed retrospectively according to gender and age. Parts of the femoral heads were selected for the study, including 18 hips in high age group, 11 hips in low age group and 20 hips in middle age group. Each 10 hips were selected with or without sclerosis rim. The femoral heads were cut along middle coronal plane, their weight-bearing and non-weight-bearing areas were used for the study. The specimens were processed by routine HE staining and picric acid-Sirius red staining and electron microscopy preparation and immunohistochemistry stain. The average optical density of BMP4 protein was calculated by image analysis software. The trabecular of sclerosis rim was thickening and disorder. But its osteocytes were normal and with high secretion. The ratio of sclerosis rim was 71.4% (105/147) in middle age ONFH patients, which was significantly higher than the low age group patients (45.5%, 5/11) and high age group patients (38.5%, 10/26) (P < 0.01). The optical density of BMP4 in middle age ONFH patients was 0.32 ± 0.14, which was significantly higher than the low age group 0.20 ± 0.17 and high age patients 0.19 ± 0.27 (P < 0.05). The optical density was 0.16 ± 0.11 in ONFH patients without sclerosis rim, which was significantly lower than with sclerosis rim (0.28 ± 0.13) (P < 0.01). The time from hip pain to joint replacement in patients with sclerosis rim was (49 ± 11) months, and (15 ± 2) months without sclerosis rim. There was significant difference between the two groups (P < 0.01). The formation of sclerosis rim is positively related to the expression of BMP4, and high expression of BMP maybe promote the formation of sclerosis rim.

The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score: Design and validation.

9000 Background: We do not have a good tool to assess the individual risk of severe toxicity from chemotherapy in clinic. Such a tool would be especially useful for older patients, who are very diverse in health status and functional reserve. Methods: Patients were from 7 academic and community centers in Florida. They were 70 and older, initiating chemotherapy. Toxicity was per Common Toxicity Criteria v. 3.0. Grade 4 hematologic (H) or grade 3-4 non-hematologic (NH) toxicity was defined as severe. Age, sex, BMI, diastolic BP (DBP), cancer stage, comorbidity (CIRS-G), polymedication, CBC, liver tests, LDH, creatinine clearance (CrCl), albumin, self-rated health, ECOG PS, Instrumental Activities of Daily Living (IADL), geriatric depression scale, Mini-Mental Status (MMS), mini-nutritional assessment (MNA), marrow invasion, previous chemotherapy, and tumor response were analyzed as variables. The toxicity of the chemotherapy regimen (chemotox) was adjusted using MAX2 (Extermann et al., Eur J Cancer 2004). Results: We accrued 562 patients, 518 evaluable. 113 chemotherapy regimens/schedules were used. Cases were randomly split 2/3-1/3 into a derivation and a validation cohort. No common strong predictor was found for H and NH toxicity, except chemotox. So we designed the CRASH score along two subscores: H and NH. Predictors of H were albumin, IADL, LDH, DBP, and chemotox, with the 4 latter giving the best model. Predictors of NH were hemoglobin, CrCl, albumin, self-rated health, CIRS-G Severity Index, ECOG PS, MMS, MNA, and chemotox, with the 4 latter providing the best model. Numbers are below (max. 2 points/variable). Conclusions: The CRASH score offers a validated, clinically applicable mean of predicting significant differences in the risk of severe toxicity in older cancer patients starting a new chemotherapy. This provides a useful tool to individualize treatment choices on an objective basis. CRASH score (points/% with severe toxicity) Sample H subscore NH subscore Combined score Derivation (n = 347) 0-1: 7% 0-2: 33% 0-3: 50% 2-3: 23% 3-4: 46% 4-6: 58% 4-5: 54% 5-6: 67% 7-9: 77% >5: 100% >6: 93% >9: 79% Validation (n = 171) 0-1: 12% 0-2: 42% 0-3: 61% 2-3: 35% 3-4: 59% 4-6: 72% 4-5: 45% 5-6: 66% 7-9: 77% >5: 50% >6: 100% >9: 100% Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Amgen, Pfizer, Roche, sanofi-aventis, Schering-Plough Amgen

P01-377 - Separated wards for the elderly in psychiatric hospitals: the patient view

BackgroundAt least at the larger hospitals specialised gero-psychiatric units have been introduced, usually taking care of those at age 65y and higher. The advantages of this approach have been discussed and examined. The patients’ view has only rarely been investigated and mostly only from a single perspective (e.g. patient satisfaction on gero-psychiatric wards).MethodsWe performed semistructured qualitative interviews in our hospital in a balanced sample of (n=14) patients at 18-40y, (n=10) patients at 41-60y, (n=16) patients at 61-75y, (n=8) patients over 75y. There were (n=) 24 male and (n=) 24 female patients. 12 patients hat been treated exclusively in old age psychiatry, and 10 patients had been treated in old age psychiatry after their 65th birthday.ResultsThe majorities of the patients saw advantages in mixed sex and age care for the younger and for the older patients. Disadvantages where not seen for younger patients, however for the elderly the view was ambivalent (26 yes versus 22 no). Female and higher age patients and those with multiple hospitalisations tended to expect more disadvantages. While a mixed ward would be regarded as more (stimulating), disadvantages could be the combination of aggressive young and frail elderly patients as well as the overburdening of the staff.ConclusionThis is the first investigation on patient view on the segregation of old age psychiatric patients. Further studies should lead to a consumer guided care provision allowing specialisation as well as defending ageism.

Dynamic changes in traditional Chinese medicine syndromes in patients with ischemic stroke treated by acupuncture

To explore the dynamic state of traditional Chinese medicine (TCM) syndromes in acute ischemic stroke patients within 30 days of onset when treated with acupuncture, and to analyze the discrimination effects of the functions based on "decision trees" in identification of TCM syndromes of ischemic stroke. A total of 264 cases with acute ischemic stroke regularly treated by acupuncture were included. Unified syndrome questionnaire was made by document retrieval and expert advice. The syndrome elements of the patients with acute ischemic stroke were surveyed on any day of three time periods (days 0-3, 4-10 and 11-30). The study was performed on multi time dynamic state results and correlated factors of basic TCM syndromes of the 264 patients. Bayes discriminant function of four syndromes of acute ischemic stroke on the basis of "decision trees" was used for computing the rate of miscarriage justice by original test and cross-validation, and the discrimination effects of "decision trees" were evaluated too. Wind, phlegm, fire-heat, qi deficiency, blood stasis, and hyperactivity of yang due to yin deficiency syndromes were found in the patients with acute ischemic stroke treated by acupuncture on the first 30 days of onset, and the incidence rates were 80.7%, 68.9%, 52.7%, 50.8%, 29.2% and 25.0% respectively. The mean scores and incidence rates of the six syndromes decreased gradually on three-time-point, especially of blood stasis syndrome. The main combined-syndromes were two-syndrome, three-syndrome and four-syndrome, and three-syndrome was the most frequently encountered type. Single syndrome was not found in the patients with acute ischemic stroke on the first three days of onset. Two-syndrome combination types were wind-phlegm, wind-heat, wind combined with qi deficiency or phlegm stagnation due to qi deficiency, phlegm-heat and blood stasis combined with hyperactivity of yang due to yin deficiency, and the incidence rates were 54.5%, 42.8%, 40.9%, 39.4%, 35.6% and 3.8% respectively. The mean scores of phlegm and qi deficiency in high-age patients were higher than those in low-age patients. The mean score and incidence rate of qi deficiency in female patients were higher than those in male patients. The mean score of phlegm in female patients was higher than that in male patients. To simplify the "decision trees" composed of 21 items, the group of Bayes discriminant function including eight most significant items out of the original 21 items was set up. The discrimination effect of the eight items including reddish face, constipation, yellow tongue fur, short breath, bright-white or gray complexion, tinnitus, feverish palms and soles and scanty tongue fur was similar to that of the 21 items, and there was no significant difference between the two functions. Wind syndrome and phlegm syndrome are the major single syndromes occurring in acute ischemic stroke patients within 30 days of onset, and three-syndrome combination is the most frequent multiple syndrome type. After acupuncture treatment, some syndrome elements including wind, phlegm, fire-heat, qi deficiency, blood stasis, and hyperactivity of yang due to yin deficiency are gradually reduced, and combined syndrome type is gradually become simple. Eight syndrome element items including reddish face, constipation, yellow tongue fur, short breath, bright-white or gray complexion, tinnitus, feverish palms and soles and scanty tongue fur have important means in discriminating yin syndrome from yang syndrome and sthenia syndrome from asthenia syndrome.

Influence of age on symptoms and laboratory findings at presentation in patients with influenza-associated pneumonia

Influenza virus infection is a major respiratory infectious disease that generally induces pneumonia. The clinical manifestations of influenza virus infection and community-acquired pneumonia (CAP) differ between elderly persons and younger adults. To determine the clinical features of influenza-associated pneumonia, we studied 21 adult patients with influenza-associated pneumonia, as indicated by positive test results for influenza virus antigen. At presentation, the higher-age patients (≥75 years; n=12) with influenza-associated pneumonia had lower body temperature than did the lower-age (<75 years) patients (n=9). Conversely, the laboratory data indicated significantly higher C-reactive protein (CRP) concentration in higher-age patients than that in lower-age patients. None of the 18 patients undergoing neuraminidase inhibitor therapy died, but two of three patients who did not receive this therapy died from complications of advanced pneumonia. In this study, vaccination did not appear to be an important factor for prevention of pneumonia. High-age patients with CAP have lower body temperature, raising the possibility that diagnosis and treatment may be delayed in these patients. Increased CRP levels in these patients at presentation, however, could contribute to early detection of this serious pulmonary complication.

Indications and complications of surgical treatment of orthopedic diseases in patients over 80

Due to increasing life expectation the number of elder patients, who need medical care, increases, too. Orthopedic surgery of elder patients especially deals with degenerative changes of locomotor and supporting apparatus, as well as with traumatic lesions. Because of the polymorbidity the rate of complications and risks of operative treatment raises. Representation of a casuistry of 173 operative intervention in patients undergoing operative treatment between 1965 and 1984 (20 years), who where 80 years and older. Most of the cases were operations of choice without any vital indication. Concerning emergency operations traumatological cases were well to the fore. All operative interventions are classified in localisation and intra- and postoperative complications. There was rather a high mortality in these patients compared to the average mortality in our clinic. The indication for operative treatment in high aged patients needs a careful and critical examination of risks and the attainable results. Aesthetic aspects are lesser important. The interdisciplinary collaboration of internal specialists, surgeons, haemostasiologists a.o. is very important to prepare the patients for surgical treatment and to reduce the postoperative complication rate.

超高齢者（90歳以上）の大腿骨近位部骨折手術例の検討

超高齢者（90歳以上）の大腿骨近位部骨折手術例の検討

高齢冠動脈疾患患者におけるメタボリックシンドロームの検討

Recently, metabolic syndrome is increasing in Japan and it is thought to be the cause of coronary heart disease. In this study, we evaluated the metabolic syndrome and insulin resistance that is thought to be located in the upstream of metabolic syndrome in high age patients of coronary heart disease. Coronary risk factors were examined and OGTT with measurement of plasma glucose and serum insulin was done to evaluate metabolic syndrome and insulin resistance in 214 patients who underwent coronary angiography; 102 patients were over 65 years old (high age group) and another 112 were young age group. We compared the two groups. The rate of hypertension was significantly high and that of obesity, LDL-cholesterol level and triglyceride level were significantly low in high age group compared with the young age group. There was no difference in the ratio of metabolic syndrome between the two groups. The frequency of insulin resistance confirmed by HOMA-R was significantly high in the young age group, however there was no difference confirmed by 2 hour serum insulin level after OGTT. The influence of glucose metabolism and insulin resistance was equal between the two groups. The frequency of metabolic syndrome was the same, but the coronary risk factors were different between the two groups. Abnormal glucose metabolism and insulin resistance were common to both groups. To diagnose insulin resistance, 2 hour serum insulin level was more effective than HOMA-R.

Muscle weakness is a significant problem in older patients receiving chemotherapy

8545 Background: Accurate prediction of toxicities from chemotherapy in the elderly could lead to improved decision making and supportive care. Methods: A large prospective multicentric cohort study of older cancer patients undergoing chemotherapy is underway to document the occurrence of chemotherapy toxicity and to develop a predictive score: the CRASH score (Chemotherapy Risk Assessment Score for High Age patients). Toxicity, including muscle weakness, is assessed using the Common Toxicity Criteria v.3.0. Results: An analysis of the first 200 patients entered in the study revealed an infrequently highlighted side effect: muscle weakness. Twenty patients were not evaluable for this analysis. Muscle weakness was reported by 22 patients. This represented 12.2% of the patients, of whom 13 (7.2%) had grade 3 muscle weakness. There was no grade 4 muscle weakness. This side effect appears to be independent from fatigue: only 4/22 patients reported concomitant severe (grade 3–4) fatigue, and among the 24 patients with severe fatigue, only 4 reported any muscle weakness. Muscle weakness occurred fairly early during the treatment: median 30 days (range 6–126 days). The muscle weakness was predominantly of two types: a generalized muscle weakness, or a weakness affecting the lower extremities. It was accompanied by falls in two patients. That weakness was present across tumor types, chemotherapy types, individual physicians, and oncology centers. Like the rest of the study population, the majority of these patients had advanced disease. Other frequent severe side effects were: grade 4 neutropenia 31.7%; grade 3–4: hypokalemia 8.8%, hyperglycemia 8.3%, hyponatremia 7.2%, febrile neutropenia 7.2%, diarrhea 7.2%, infection with neutropenia 6.7%. Conclusion: Muscle weakness is a frequent and clinically significant side effect of chemotherapy in the elderly, distinguishable from fatigue. This could be targeted by a preventive physical therapy intervention to prevent muscle deconditioning. [Table: see text]

Dramatic Increases in Pregnancy Rates by Low-dose Metformin Therapy for IVF Repeaters Without Polycystic Ovary Syndrome: A Novel Method to Rescue Poor Responders and High-aged Patients

Insulin resistance is associated with advancing age, stress, and negative mood, and these factors exist commonly in patients who repeatedly failed to conceive in IVF therapy (IVF repeaters). Thus, this study has examined whether administration of low-dose metformin improves IVF outcomes in IVF repeaters without polycystic ovary syndrome (PCOS), and what the mechanism and indication of the low-dose metformin therapy are.

Results of radiation monotherapy for primary central nervous system lymphoma in the 1990s

Results of radiation therapy for primary central nervous system lymphoma (PCNSL) were poor in the 1970-1980s, with most reported 5-year survival rates being less than 10%. To investigate whether the prognosis of PCNSL patients treated by radiation alone remains still poor, we investigated the results of radiation monotherapy in the 1990s. We collected data on 132 patients with histologically proven PCNSL treated by radiation alone in the 1990s from three nationwide or regional multiinstitutional studies conducted by the Japanese Society for Therapeutic Radiology and Oncology (JASTRO) Lymphoma Study Group or the Chubu Radiation Oncology Group. Follow-up data were updated as far as possible. Eleven patients who did not complete planned radiotherapy were included. The data were analyzed in relation to patient and tumor characteristics. The median patient age was 63 years, and the World Health Organization performance status (PS) was 3 or 4 in 40% of the patients. Multiple tumors were seen in 34%. Whole-brain irradiation with or without focal boost was used in 92%. The median radiation dose to the tumor site was 50 Gy (range, 8-74 Gy). For all 132 patients, the median survival time was 18 months and the 5-year survival rate was 18.0%. For 62 patients with PS 0-3 and aged 16-65 years (i.e., those eligible for the European Organization for Research and Treatment of Cancer 20962 study), the median survival was 26 months and 5-year survival was 24%. The 5-year survival was 25% for patients 63 years old or younger, and 9.8% for those older than 63 years (p = 0.0005). The 5-year survival was 22% for patients with PS 0-2 and 13% for those with PS 3 or 4 (p = 0.0040). Multivariate analysis confirmed the negative influence of higher age on patient prognosis. The results of radiation monotherapy for PCNSL appear to have improved as compared with those reported previously. The results of new treatment should be evaluated in light of this finding. Since most prospective studies on the combined treatment exclude poor PS and high-age patients, the 5-year survival rate of 30% may not be regarded as a marked improvement over radiation alone.

Early Treatment for Ruptured Cerebral Aneurysms

The purpose of this study was to evaluate the effect of endovascular treatment with Guglielmi detachable coils (GDC) on the outcomes of subarachnoid haemorrhage (SAH) patients of poor grades and high ages for each location of aneurysms. Between 1990 and 2003, 529 SAH cases underwent angiograghy as candidates of early aggressive treatment in our hospital. For the 299 cases in 1990-96 (Group 1), treatment options were early and intensively delayed craniotomy surgery and conservative management, while for the 230 cases in 1997-2003 (Group 2), GDG embolization at acute stage was added to these three treatment options. We compared clinical courses and outcomes of the poor grade (Hunt & Kosnik Grade 4-5) patients and high age (>=70 years old) patients between two groups for each location of aneurysms. Introduction of GDC embolization expanded the indication for early treatment in the poor grade patients with anterior communicating artery aneurysm (A-Comm An), the high age patients with internal carotid artery aneurysm (IC An) and all patients with Basilar bifurcation aneurysm (BA-Top An), and has contributed to improvement of their outcomes. To the poor grade patients with middle cerebral artery aneurysm (MCA An), GDC embolization was hardly indicated, because haematoma evacuation concomitantly performed with aneurysm occlusion would be necessary for those patients. In conclusion, results of treatment with GDC embolization at an acute stage are desirable for poor grade patients with A-Comm An, aged patients with IC An and all patients with BA-Top An. The indication of GDC embolization for the patients with MCA An is limited.

頚部頚動脈病変の治療 Ｈｉｇｈ−ｒｉｓｋ症例に対する頚動脈内膜剥離術（ＣＥＡ）の要点

Carotid endarterectomy (CEA) is becoming a standard treatment of the internal carotid artery (ICA) stenosis in Japan. But frequency of high-risk patients for CEA and management of high-risk patients to reduce operative complications have not been well established. The purpose of this study is to determine frequency of high-risk patients for CEA and to discuss management of high-risk patients. Between 1984 and 2002, 230 CEAs under general anesthesia were performed in our institute. High-risk patients for CEA were defined according to the following criteria: (1) patients older than 71 years, (2) patients with stenosis positioned higher than the second cervical vertebra, (3) patients vulnerable to ischemia during cross-clamping of the ICA, (4) patients at risk of hyperperfusion, and (5) patients with ischemic heart disease. Fifty-one high-aged patients (22%) were operated without any complications due to high age. Twenty-one patients (14%) had high-positioned stenosis. There were no complications due to high position. Cerebral ischemia after cross-clamping of the ICA occurred in 24% of the patients according to the intraoperative monitorings of ICA stump pressure, somatosensory evoked potential, and oxygenation of the cerebral cortex. Hyperperfusion, diagnosed by the ICA flow, velocity of the middle cerebral artery by TCD, and postoperative measurement of cerebral blood flow, occurred in about 5% of the patients. To avoid ischemic complications, we have routinely used a T-shaped internal shunt and maintained the systemic blood pressure during CEA. Management of hyperperfusion comprised strict control of the systemic blood pressure and barbiturate therapy. Ischemic heart disease was associated in 24% of the patients. Coronary artery revascularization such as coronary artery bypass grafting (CABG), coronary angioplasty, or stenting were performed in 4 patients before CEA. We have not done combined CABG and CEA. There was no myocardiac infarction in the perioperative time. In this series, perioperative mortality and morbidity were 0% and 1.7%, respectively. Although there were fewer perioperative complications, proper management for high-risk patients is essential.

Head and neck cancer surgery in the elderly

The literature on management of advanced head and neck cancer in the elderly is limited. Diagnostic and treatment decisions may be implicated by advanced age itself. Treatment outcomes of head and neck cancer in elderly patients were reviewed in the literature. The results should serve as a basis for an individualized treatment strategy. A comparison of data shows that chronologic age alone should not be a contraindication to adequate oncologic surgery. An aggressive approach to head and neck cancer management with curative intention can be also considered in high aged patients with advanced cancer. Surgical therapy of head and neck cancer can be as effective in elderly patients as in younger patients without a significant increase in mortality and complications. Head and neck cancer patients of all age groups should have a treatment of equal quality regardless of whether the expected outcome is cure or palliation.