Does the Multidimensional Prognostic Index (MPI), based on a Comprehensive Geriatric Assessment (CGA), predict mortality in cancer patients? Results of a prospective observational trial.

OBJECTIVE: Despite the lack of definitive data on the impact of Comprehensive Geriatric Assessment (CGA) in the geriatric oncology setting, the broad use of any form of CGA is strongly recommended before any treatment decision in elderly cancer patients (ECP); currently there is no consensus about the best format for this geriatric assessment. The aim of this study was to firstly test the Multidimensional Prognostic Index (MPI) in ECP with locally advanced or metastatic disease. MATERIALS AND METHODS: Patients aged ≥70years with inoperable or metastatic solid cancer consecutively admitted to our Program of Geriatric Oncology were assessed by a multidisciplinary team and received a basal CGA to calculate the MPI score. RESULTS: A hundred and sixty patients entered the study. In the Cox's regression model, MPI, CIRS-SI, BSA, GDS, MMSE, chemotherapy and a diagnosis of primary lung cancer were associated with mortality at 6 and 12months. The ROC curves confirmed the prognostic value of MPI, with the best discriminatory power for mortality at both 6 and 12months. CONCLUSION: The present study is the first to indicate that the MPI retains its prognostic value even in elderly cancer patients with advanced stage of disease. The CIRS-SI and the GDS may potentiate the prognostic value of MPI.

Maximizing the general success of cecal intubation during propofol sedation in a multi-endoscopist academic centre.

BACKGROUND: Achieving the target of 95% colonoscopy completion rate at centres conducting colorectal screening programs is an important issue. Large centres and teaching hospitals employing endoscopists with different levels of training and expertise risk achieving worse results. Deep sedation with propofol in routine colonoscopy could maximize the results of cecal intubation. METHODS: The present study on the experience of a single centre focused on estimating the overall completion rate of colonoscopies performed under routine propofol sedation at a large teaching hospital with many operators involved, and on assessing the factors that influence the success rate of the procedure and how to improve this performance, analyzing the aspects relating to using of deep sedation. Twenty-one endoscopists, classified by their level of specialization in colonoscopic practice, performed 1381 colonoscopies under deep sedation. All actions needed for the anaesthesiologist to restore adequate oxygenation or hemodynamics, even for transient changes, were recorded. RESULTS: The "crude" overall completion rate was 93.3%. This finding shows that with routine deep sedation, the colonoscopy completion rate nears, but still does not reach, the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs.Factors interfering with cecal intubation were: inadequate colon cleansing, endoscopists' expertise in colonoscopic practice, patients' body weight under 60 kg or age over 71 years, and the need for active intervention by the anaesthesiologist. The most favourable situation--a patient less than 71 years old with a body weight over 60 kg, an adequate bowel preparation, a "highly experienced specialist" performing the test, and no need for active anaesthesiological intervention during the procedure--coincided with a 98.8% probability of the colonoscopy being completed. CONCLUSIONS: With routine deep sedation, the colonoscopy completion rate nears the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs. Organizing the daily workload to prevent negative factors affecting the success rate from occurring in combination may enable up to 85% of incomplete procedures to be converted into successful colonoscopies.

Pautas para reducir el número de prescripciones inadecuadas en pacientes con dispepsia / Guidelines to cut the number of inappropriate prescriptions in dyspepsia patients

Se considera demostrado que diferentes métodos de implementación dan como resultado un mayor o menor grado de aceptación de las pautas en atención primaria. Este estudio analiza el efecto sobre los gastos estimados en medicamentos a partir de tres métodos distintos de implementar las mismas pautas, utilizados en tres grupos diferentes de médicos generalistas. La investigación estuvo basada en: un método de implementación negociado, de nueve meses de duración (con incentivos económicos para completar el programa) (proyecto A); una sesión de un día de entrenamiento basado en la evidencia llevada adelante por colegas en pequeños grupos de trabajo (proyecto B); una reunión de aplicación conducida por un experto (proyecto C). Para cada proyecto comparamos los gastos estimados mensuales en inhibidores de la bomba de protones (IBP) y antagonistas de los receptores de histamina (ARH2) por cada mil pacientes registrados de los médicos generalistas (MG) que participaron con los de un grupo de MG de control, antes y después de implementar las pautas. Los 58 MG involucrados en el proyecto A redujeron las prescripciones en IBP alrededor del 26% (4 564 euros vs. 6 201 euros para 222 controles, p = 0.057) y de ARH2 alrededor de 30% (954 vs. 1 365 euros; p = 0.026). Los 101 MG que participaron del proyecto B prescribieron 5 535 euros en IBP y 556 euros en bloqueantes H2, mientras que los 61 MG controles hiceron prescripciones por 5 732 y 706 euros, respectivamente (lo que significó un ahorro del 3% en IBP y 21% en ARH2; p = ns). Los 15 MG que estuvieron en el proyecto C prescribieron 2 479 euros en IBP y 1 258 euros en ARH2, lo que implica un gasto 12% superior en IBP y una reducción del 17% en ARH2 cuando se los compara con los 2 215 euros empleados en IBP y 1 524 euros en bloqueantes H2 por los 270 MG del grupo control (p = ns)...

Infrapopliteal arterial reconstructions for limb salvage in patients aged > or =80 years according to preoperative ambulatory function and residential status.

BACKGROUND: Although numerous studies have addressed peripheral revascularizations for critical limb ischemia (CLI) in patients aged > or =80 years, few have focused exclusively on infrapopliteal arterial reconstructions. This study aimed to analyze early and long-term outcomes in very elderly patients who underwent surgical infrapopliteal revascularization for CLI according to their pre-operative ambulatory function and residential status. METHODS: Over an 18-year period, all consecutive patients aged > or =80 years referred to our institution for CLI requiring primary infrapopliteal or inframalleolar arterial reconstruction were enrolled in the study. All procedures were completed by the same surgeon with patients under regional anesthesia. Patency, limb salvage, amputation-free survival, and cumulative survival rates were assessed by Kaplan-Meier analysis. The patient's pre- and postoperative ambulatory function and residential status (at home vs in a nursing home) were also analyzed. The mean follow-up was 6.2 years (range, 0.1-11.5) and was obtained for 98% of patients. RESULTS: In all, 197 patients (134 men; mean +/- SD age, 82.8 +/- 1.7 years) with 201 critically ischemic limbs were enrolled in the study. No deaths or fatal major complications occurred in the peri-operative period (first 30 days); the local complication rate was 6%. After 1 and 7 years, the primary patency rates were 88% and 68%, the limb salvage rates were 96% and 87%, the amputation-free survival rates were 88% and 39%, and the survival rates were 91% and 44%, respectively. At last follow-up or death, 80% of the patients were ambulatory and 20% were not; 80% lived at home and were independent, another 9% lived at home with assistance, and 76% of the sample lived at home and were ambulatory. CONCLUSION: Infrapopliteal arterial revascularization in the very elderly with CLI proved safe, effective, and durable, confirming that age per se and concomitant comorbidities do not necessarily affect technical and clinical outcomes. Ambulatory function and independent living status are well preserved because, despite a relatively short life expectancy, the majority of very elderly revascularized CLI patients can be expected to spend their remaining years ambulatory and at home. In contrast, patients with poor ambulatory function or who required assistance pre-operatively were less likely to improve their status after limb revascularization despite a successful technical result.

Constipation in the acutely hospitalized older patients.

The aim of this work was to establish the factors that determine the onset of constipation in acutely hospitalized older patients with a view to contributing towards an evidence-based identification of which patients warrant early, specific preventive measures. To evade the problem posed by the definition of constipation, we have considered parameters that are part of the daily routine in the hospital ward, such as the prescription of laxatives, also paying attention to how the co-operative older person subjectively interpret this condition. One thirds of the 192 hospitalized older patients needed a laxative at least once every 3 days. Multivariate analysis identified the use of laxatives at home as the only risk factor for objective constipation while in hospital (odds ratio (OR)=3.0). A significant risk of being dissatisfied with their bowel emptying emerged among patients who were bedridden for more than 2 weeks (OR=6.0), and in those who experienced cerebrovascular events (OR=3.1). The use of laxatives at home and awareness that satisfaction with bowel movements drops in patients obliged to stay in bed for lengthy periods of time and in those who have suffered cerebrovascular damage, should provide the grounds for a screening program to establish rational guidelines on bowel movement therapy.

Ischemic colitis in the elderly: predictors of the disease and prognostic factors to negative outcome.

OBJECTIVE: Ischemic colitis (IC) poses a challenge for physicians, especially in elderly patients. The aim of this study was to identify predictors of the disease and to assess the factors predicting its evolution in elderly people. MATERIAL AND METHODS: A retrospective study was undertaken in patients with IC admitted to Padua General Hospital between 2003 and 2008. Only patients with biopsy-proven IC were considered. Fifty control subjects were randomly selected from those seen at our units for acute geriatric disease during the same interval. Patients with IC were classified as having either a positive or negative outcome. RESULTS: A total of 46 patients were considered. The risk factors for IC identified from univariate analysis were analyzed in a multivariate logistic regression model and constipation [adjusted odds ratio (OR) 4.8; 95% confidence interval (CI) 1.1-20.1], vasculopathy (OR 4.9; 95% CI 1.4-16.6), hepatitis C virus (HCV) (OR 9.9; 95% CI 1.1-92.9) and cancer (OR 7.5; 95% CI 2.1-26.9) confirmed their independent significance as risk factors. Hematochezia was predictive of a positive outcome (OR 0.07; 95% CI 0.02-0.40), while cancer (OR 3.2; 95% CI 1.2-11.9), HCV positivity (OR 9.6; 95% CI 1.6-56.5), signs of peritonism (OR 4.7; 95% CI 1.2-18.4), localization in the right colon (OR 5.75; 95% CI 1.5-21.9) and increased levels of lactate dehydrogenase (LDH) and urea were independently predictive of a negative outcome. CONCLUSIONS: Elderly patients with IC are characterized by significant comorbidities. The absence of hematochezia and the presence of a concomitant malignancy, HCV, a marked increase in urea and LDH and disease involving only the right colon are factors that may predict a negative outcome in elderly patients.

Implementation of a guideline versus use of individual prognostic factors to prioritize waiting lists for upper gastrointestinal endoscopy.

BACKGROUND: Studying factors associated with positive gastroscopies in dyspeptic patients can help limit and rationalize waiting lists for endoscopies. Dyspepsia guidelines have a controversial role because their main purpose is to provide specifications on efficient global management of primary care patients. AIM: To assess and weigh the risk of major endoscopic diagnoses against different age groups, gender, Helicobacter pylori infection, compliance with European Society of Primary Care Gastroenterology (ESPCG) guideline statements, and participation of prescribing general practitioners in a quality improvement programme for dyspepsia management, based on these guidelines. METHODS: We consecutively studied the outcomes of 752 gastroscopies with respect to two sets of useful results: the first considered diagnoses of carcinoma, gastric and duodenal ulcer; the second excluded duodenal ulcer. RESULTS: A diagnosis of cancer or gastric/duodenal ulcer was associated with male sex (odds ratio (OR)=1.81, P=0.016), age above 41 years (OR=3.24, P=0.009) and particularly with positivity to H. pylori (OR=4.49, P<0.001), while the risk increased by two and a half times in gastroscopies conforming with ESPCG guidelines (OR=2.47, P=0.003). In the second set of analysis, we noted a statistically significant correlation between cancer or gastric ulcer and compliance with ESPCG guidelines (OR=4.69, P=0.013), but not with H. pylori positivity (OR=1.83, P=0.11); a linear relationship was observed across age groups, with a 60% increase in the risk of disease with every 5-year increase in age (OR=1.59, P=0.002). CONCLUSION: Participation of general practitioners in the Dyspepsia Management Programme (DMP) was not significantly associated with a positive gastroscopy.

Major elective surgery for vascular disease in patients aged 80 or more: perioperative (30-day) outcomes.

Although major vascular surgery is performed with increasing frequency in elderly people, the impact of age on outcomes is uncertain. We evaluated the perioperative (30-day) outcomes for patients who underwent major elective vascular operations under general or peripheral anesthesia in their eighties and nineties in a 14-year period. Data for all consecutive 3,060 patients (456 of them > or years old) who underwent 3,314 elective vascular surgery procedures were prospectively entered into a computerized vascular registry. Detailed information was collected on patients' preoperative status, type of procedure and anesthesia, perioperative outcomes, and predictors of perioperative outcomes. The end points of the study were perioperative death and main surgical complications. Perioperative all-cause mortality rates varied across operations and were higher in elderly than in younger patients (1.4% vs. 0.2%, P = 0.014) after abdominal surgery (2.4% vs. 0.1%, P = 0.006) and especially after abdominal aortic aneurysm repair (2.8% vs. 0%, P = 0.035). In the elderly cohort, the mortality rate was <1% for almost 60% of all operations. In logistic regression analysis, only preoperative hypertension (odds ratio [OR] = 72.5, 95% confidence interval [CI] 9.4-557.6), congestive heart failure (OR = 16.5, 95% CI 2.3-115.9), and perioperative cardiac (OR = 20.7, 95% CI 1.6-273.8) and pulmonary (OR = 41.7, 95% CI 7.9-218.9) complications were associated with a higher 30-day death risk. In this series, perioperative outcomes were not influenced by the type of elective surgical procedure. Though overall mortality after major vascular surgery was higher in patients > or 80 years old, age per se was not an independent factor of a higher perioperative mortality risk or fatal and nonfatal complications.

Esophagitis in frail elderly people.

INTRODUCTION: We studied the clinical course of elderly patients acutely hospitalized for various diseases, assessing any differences between patients with and without esophagitis. STUDY: A case-control study on the presence of esophagitis was conducted on the clinical records of all in-patients undergoing gastroduodenoscopy at Padova Geriatric Hospital from 1997 to 2001. Data were examined on 338 sex-matched patients: 169 with a diagnosis of esophagitis and 169 with a negative endoscopy. RESULTS: Admissions for acute respiratory disorders [odds ratios (OR) 2.68; 95% confidence interval (CI) 0.89-8.01], a remote diagnosis of esophagitis (OR 11.34; 95%CI 2.68-48.07), obesity (OR 3.36; 95%CI 0.91-12.48), and being bedridden (OR 6.84; 95%CI 3.27-14.29) were found to be independent risk factors for the presence of esophagitis. The symptoms prompting the endoscopic diagnoses included: gastrointestinal bleeding (OR 7.61; 95%CI 2.76-21.0), heartburn (OR 4.58; 95%CI 1.86-11.28), and cough (OR 3.59; 95%CI 1.34-9.62). Steroids (OR 2.68; 95%CI 1.11-6.44) and calcium antagonists (OR 1.50; 95%CI 0.79-2.87) were associated with esophagitis as risk factors, whereas proton pump inhibitors (OR 0.46; 95%CI 0.25-0.87), nitrates (OR 0.14; 95%CI 0.02-0.78), and sucralfate in males (OR 0.09; 95%CI 0.01-0.92) were associated as protective factors. Patients with esophagitis were discharged with an endocrinologic/metabolic-type diagnosis. Deaths were significantly higher among patients with esophagitis (25 vs. 9); more severe esophagitis was characterized by a higher Charlson comorbidity index and a greater presence of anorexia and nausea. CONCLUSIONS: These findings seem to substantiate the theory that esophagitis is a characteristic which exacerbates frailty in hospitalized elderly people and its identification may be helpful in these patients.

Clinical and prognostic aspects of gastric carcinoma in the elderly.

The aim of the present study was to analyze the influence of various factors on the prognosis for elderly patients with gastric carcinoma. Forty-eight patients aged > or =65 years admitted to Padova General Hospital were divided into two groups by age (<75 or >75 years). They all had a histologically confirmed diagnosis of gastric adenocarcinoma. Information on their clinicopathological characteristics was collected from the Padova Hospital medical records. On univariate analysis, significant prognostic factors in the two age groups were gender, stage, histotype (Lauren's intestinal type), Charlson index, and type of surgery (curative resection, palliative resection, and no surgery). On multivariate analysis, independent prognostic factors were the Charlson index, tumor stage, and age group. The 52-month survival rate was 72.7% for females and 12.5% for males for patients > or =75 years (P = 0.01), while for the whole series of patients it was 67.5% for females and 29.9% for males (P = 0.003). The 17-month survival rate was 55.6% for surgically treated patients and 0% for the untreated cases in stage 4 (P = 0.03). Gastric cancer should be treated with conventional surgery even in the very elderly, since the survival rate for this age group does not differ significantly from the figures for younger patients.

Effects of aging on abdominal wall healing in rats.

PURPOSE: The aim of this study was to assess abdominal wall healing in old and young adult rats. METHODS: On average, young animals were 110 days old and old animals were 762 days old. A 4.0 cm median laparotomy was performed under anesthesia, followed by laparorrhaphy on two synthesis planes, i.e. peritoneum-muscle-aponeurosis and skin, using continuous 5.0 nylon sutures. The animals were evaluated on the 3rd, 7th, 14th and 21st postoperative days. The resistance of the two planes was studied separately and a histopathologic analysis was performed on sections stained with hematoxylineosin and Sirius Red. Immunohistochemical analysis was also carried out using PCNA, LCA and CD34. RESULTS: The skin scars gained resistance in a similar manner at the initial time points, but those of young rats were more resistant on the 21st day (p=0.0029). Total and type III collagen content was similar in the two groups and type I collagen content was higher in young animals on the 14th day. Inflammatory cell infiltration was more marked in the skin wounds of young animals on the 3rd day (p=0.0190). Reepithelialization was similar and angiogenesis was more intense in the skin wounds of young animals on the 14th day (p=0.0062). The peritoneum-muscle-aponeurosis wounds gained similar resistance during the early phases, but were more resistant on the 14th day (p=0.0005) and on the 21st day (p=0.0023) in old rats Collagen concentration was higher in the wounds of old animals on the 3rd day (p=0.0112) and in the wounds of young animals on the 21st day (p=0.0348). The inflammatory reaction was more intense in the wounds of old animals on the 3rd day (p=0.0060) and angiogenesis was more intense on the 14th day (0.0432). CONCLUSION: Although there are some differences in the healing course between young and old animals, age, of itself, does not impair the healing of abdominal wall wounds in rats.

Effects of aging on abdominal wall healing in rats

OBJETIVO: Estudar a cicatrização da parede abdominal em ratos adultos jovens e velhos. MÉTODOS: Os ratos adultos jovens tinham em média 110 dias de idade e os velhos 762 dias. Uma laparotomia mediana de 4,0 cm foi feita sob anestesia, seguida de laparorrafia com 2 planos de síntese, isto é, peritônio-músculo-aponevrose e pele, com síntese contínua de fio de náilon 5.0. Os animais foram avaliados com 3, 7, 14 e 21 dias de pós-operatório. A resistência dos dois planos foi avaliada separadamente e a análise histológica feita em cortes preparados pela Hematoxilina-eosina e Sirius red. Análise imunohistoquímica foi realizada empregando PCNA, LCA and CD34. RESULTADOS: A cicatriz da pele ganhou resistência de modo similar nos tempos iniciais, mas as dos animais jovens foram mais resistentes no 21º dia (p=0.0029). A densidade de colágeno total e tipo III foi similar nos dois grupos, porém o colágeno tipo I mostrou-se mais denso nas cicatrizes dos animais jovens no 14.º dia. O infiltrado de células inflamatórias foi maior nas cicatrizes dos animais jovens no 3.º dia (p=0.0190). A reepitelização foi similar e a angiogênese foi mais intensa na pele dos animais jovens, no 14.º dia (p=0.0062). O plano peritônio-músculo-aponevrótico ganhou similar resistência durante as fases iniciais, porém foi mais resistente no 14.º dia (p=0.0005) e no 21.º dia (p=0.0023) nos animais velhos. A densidade de colágeno foi maior nas paredes dos animais velhos no 3.º dia (p=0.0112) e nos animais jovens no 21.º dia (p=0.0348). A reação inflamatória foi mais intensa nas paredes dos animais velhos no 3.º dia (p=0.0060) e a angiogênese mais intensa no 14.º dia (0.0432). CONCLUSÃO: Embora existam diferenças na evolução do processo de cicatrização de jovens e velhos, a idade por si só, não prejudica a cicatrização da parede abdominal, em ratos.

Prospective randomized study on reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus superficial femoral or popliteal and tibial arteries as inflow.

PURPOSE: Use of inflow sources distal to the common femoral artery (CFA) for bypass to infrapopliteal arteries is a compromise measure when the length of the vein is not adequate. The purpose of this study was to compare the clinical outcome of vein infrapopliteal bypass arising from the CFA and from the distal superficial femoral or popliteal and tibial arteries in patients with limb-threatening ischemia. METHODS: Over 13 years, 160 vein infrapopliteal vein bypass procedures (160 patients) were randomized into 2 groups, 80 with inflow arising from the CFA (group 1) and 80 with inflow from below the CFA (group 2). Patency and limb salvage rates were assessed with the Kaplan-Meier method. All patients underwent graft surveillance at discharge and at 30 days and 6 months after surgery, then every 6 months thereafter. Follow-up ranged from 30 days to 127 months (mean, 49 months). RESULTS: Groups were similar with regard to age, sex, and most atherosclerotic risk factors. Gangrene as an indication for surgery was statistically more frequent in group 1 (73.7% vs 48.7%; P = .002), whereas nonhealing ulcer and rest pain were statistically more frequent in group 2 (respectively, 51.2% vs 25%; P = .001 and 46.2% vs 28.7%; P = .03). No patients died during the perioperative (30 days) period. At 1, 3, and 5 years patency and limb salvage rates were comparable between groups, tending toward significance for the 5-year primary patency rate (73% vs 57%; P = .08). CONCLUSIONS: In the absence of significant proximal disease, infrapopliteal revascularization arising distal to the CFA can ensure patency and limb salvage rates statistically similar to those with use of the CFA. Moreover, procedures arising distal to the CFA required fewer graft revisions to maintain patency of failing grafts.

Octogenarians with contralateral carotid artery occlusion: a cohort at higher risk for carotid endarterectomy?

PURPOSE: Carotid angioplasty and stenting has been proposed as a treatment option for carotid occlusive disease in patients at high risk, including those 80 years of age or older or with contralateral carotid occlusion. We analyzed 30-day mortality and stroke risk rates of carotid endarterectomy (CEA) in patients aged 80 years or older with concurrent carotid occlusive disease. METHODS: From a retrospective review of 1000 patients undergoing 1150 CEA procedures to treat symptomatic and asymptomatic carotid lesions over 13 years, we identified 54 patients (5.4%) aged 80 years or older with concurrent contralateral carotid occlusion. These patients were compared with 38 patients (3.8%) aged 80 years or older with normal or diseased patent contralateral carotid artery and 81 patients (8.1%) younger than 80 years with contralateral carotid occlusion. All CEA procedures involved either standard CEA with patching or eversion CEA, and were performed by the same surgeon, with the patients under deep general anesthesia and cerebral protection involving continuous perioperative electroencephalographic monitoring for selective shunting. Shunting criteria were based exclusively on electroencephalographic abnormalities consistent with cerebral ischemia. RESULTS: The 30-day mortality and stroke rate in patients aged 80 years or older with concurrent contralateral carotid occlusion was zero. CONCLUSIONS: The concept of high-risk CEA needs to be revisited. Patients with two of the criteria considered high risk in the medical literature, that is, age 80 years or older and contralateral carotid occlusion, can undergo CEA with no greater risks or complications. Until prospective randomized trials designed to evaluate the role of carotid angioplasty and stenting have been completed, CEA should remain the standard treatment in such patients.

Pathophysiology of giant incisional hernias with loss of abdominal wall substance.

Incisional hernia represents the most common wound complication after abdominal surgery. The repair of large incisional hernias requires an accurate knowledge of the interactions between the tissues of the abdominal wall, the prosthetic materials and the bowel. At the same time a careful attention must be placed on the physiopathology of abdominal hypertension. Repair of giant incisional hernias with heavy loss of substance may take to a sudden increase of intra-abdominal pressure and, sometimes, to Abdominal Compartment Syndrome (ACS). The aim of preventing recurrences very often requires the use of a prosthesis, which must be placed on a low-tension environment to avoid early failures and excessive increase of intra-abdominal pressure. It is also necessary to employ as much parietal tissues as possible to prevent visceral adhesions and lesions and to pay attention to an appropriate employment of prosthesis. Utilization of composite materials, absorbable prosthesis or of combinations of mesh and flaps looks promising in preventing endoabdominal hypertension without increasing the rate of recurrences, infections and adhesive complications.