Blood pressure management in older people: balancing the risks.

Guidelines of arterial hypertension treatment based on individualised expected outcomes are not available for frail older persons. In this paper, we review the evidence, concerning management of arterial blood pressure (BP) in frail older patients. We focused on the best affordable methods for BP measurement; the age-related optimum BP; specific BP goals in agreement with the patients' general heath, frailty status, orthostatic and postprandial hypotension; balancing the benefits against risks of antihypertensive treatment. Lenient BP goals are generally recommended for older persons with moderate or severe frailty, multimorbidity and limited life expectancy. To this aim, there may be a need for deintensification of antihypertensive treatment.

Comparison of Covid-19 antibody status after vaccination between residents in long-term geriatric care and residents assisted-living facilities.

OBJECTIVE: To compare 2 CoV-SARS-2 ('anti-s') antibody levels after vaccination between residents in long-term geriatric care (LTGC) and residents in assisted-living facilities who had received two doses of the BNT162b2 vaccine. SARS-CoV-2 serology was tested with Quant II IgG CoV-SARS-2. Blood samples were collected 3-4 months after administration of the second vaccine dose. RESULTS: Anti-s ≥ 50 AU/ml was found in 85.4% of 90 residents in LTGC (median 498 AU/ml) and 94.9% of 214 residents in assisted living (median 728 AU/ml). p = .006. Factors associated with anti-s < 300 AU/ml were multi-morbidity, diabetes mellitus and cancer.

Cancer-Associated Atherothrombosis: The Challenge.

The association between venous thrombosis and malignancy, having typical features of a paraneoplastic syndrome, has been established for a century. Currently, it is recognized that arterial thromboembolism (ATE) may also behave as a paraneoplastic syndrome. Recent matched cohort studies, systematic reviews, and observational studies concur in showing an increased incidence of acute coronary events, ischemic stroke, accelerated peripheral arterial disease, and in-stent thrombosis during the 6-month period before cancer diagnosis, peaking for 30 days immediately before cancer diagnosis. Cancer patients with ATE are at higher risk of in-hospital and long-term mortality as compared with noncancer patients. In the present review, we focus on the epidemiology, clinical variants and presentation, morbidity, mortality, primary and secondary prevention, and treatment of cancer-associated ATE. The awareness that cancer can be a risk factor for ATE and that cancer therapy can initiate cardiovascular complications make it mandatory to identify high-risk patients, modify preexistent cardiovascular risk factors, and adopt effective antithrombotic prophylaxis. For ATE prophylaxis, modifiable patient-related risk factors and oncology treatment-related factors are levers for intervention. Statins and platelet antiaggregants have been studied, but their efficacy for prevention of cancer-associated ATE remains to be demonstrated. Results of revascularization procedures for cancer-associated ATE are worse than for ATE in noncancer patients. It is important that a multidisciplinary approach is adopted for making informed decisions, by involving the vascular surgeon, interventional radiologist, oncologist, and palliative medicine, as well as the patients and their family.

An Unusual Tracing.

This case report presents the electrocardiogram findings of a patient in their 90s with end-stage dementia, pressure ulcers, extrapyramidal syndrome, paroxysmal atrial fibrillation, and hypothyroidism who experienced a massive aspiration of gastric content.

Orthostatic hypotension: framework of the syndrome.

According to the 1996 consensus definition, orthostatic hypotension (OH) is diagnosed when a fall in systolic blood pressure of at least 20 mm Hg and/or diastolic blood pressure of at least 10 mm Hg within 3 min of standing is recorded. The elements of orthostatic blood pressure drop that are relevant to the definition of OH include magnitude of the drop, time to reach the blood pressure difference defined as OH, and reproducibility of the orthostatic blood pressure drop. In each of these elements, there exist issues that argue for modification of the presently accepted criteria of OH. Additional questions need to be addressed. Should one standard orthostatic test be applied to different patient populations or should tests be tailored to the patients' clinical circumstances? Are different OH thresholds relevant to various clinical settings, aetiologies of OH and comorbidity? Which test has the best predictive power of morbidity and mortality?

Isolated periaortitis: clinical and imaging characteristics.

Chronic periaortitis includes a variety of conditions that have similar clinical and histopathological findings, and thus probably represents different manifestations of the same disease: idiopathic retroperitoneal fibrosis, perianeurysmal retroperitoneal fibrosis, and inflammatory abdominal aortic aneurysms. We describe the clinical and imaging characteristics of the nonaneurysmal form of chronic periaortitis, recognized as isolated periaortitis, in an adult male patient presented with low back pain.

Predicting outcomes on head-up tilt based on orthostatic hypotension patterns.

OBJECTIVE: To assess the frequency of different orthostatic hypotension (OH) patterns in patients having supine hypertension with OH ('SHOH') versus patients with OH and normal supine blood pressure ('OH alone'); and to relate OH patterns with outcomes on head-up tilt. METHODS: Consecutive patients with nonspecific dizziness were studied with a 10-min supine, 30-min head-up tilt test. Supine hypertension was diagnosed when supine systolic blood pressure (SBP) was at least 140 mmHg and/or supine diastolic blood pressure was at least 90 mmHg. OH was defined as SBP reduction of at least 20 mmHg within 3 min of tilt. OH patterns were identified corresponding to SBP time-curves during the initial 5 min of tilt: progressive, sustained and transient patterns. RESULTS: Among 400 patients tested, 31 had 'SHOH' and 39 had 'OH alone'. Frequencies of OH patterns were similar in both groups. The progressive OH pattern predicted symptomatic hypotension, leading to early tilt termination in all 'SHOH' and 88% of 'OH alone' patients. In comparison, tilt was early terminated in 33-48% of patients with sustained OH, transient OH and without OH. Early tilt termination was unrelated to age, gender, magnitude of supine SBP, pulse pressure and nadir SBP within 5 min tilt. CONCLUSIONS: Five minutes of postural challenge permitted assessing OH patterns. Outcome on protracted tilt was related to OH patterns, the worse outcome being likened to progressive OH, both in patients with 'SHOH' and in patients with 'OH alone'. Future studies will show whether OH patterns may serve as guidance for blood pressure therapy in selected patients.

Patterns of hypocapnia on tilt in patients with fibromyalgia, chronic fatigue syndrome, nonspecific dizziness, and neurally mediated syncope.

OBJECTIVES: To assess whether head-up tilt-induced hyperventilation is seen more often in patients with chronic fatigue syndrome (CFS), fibromyalgia, dizziness, or neurally mediated syncope (NMS) as compared to healthy subjects or those with familial Mediterranean fever (FMF). PATIENTS AND METHODS: A total of 585 patients were assessed with a 10-minute supine, 30-minute head-up tilt test combined with capnography. Experimental groups included CFS (n = 90), non-CFS fatigue (n = 50), fibromyalgia (n = 70), nonspecific dizziness (n = 75), and NMS (n =160); control groups were FMF (n = 90) and healthy (n = 50). Hypocapnia, the objective measure of hyperventilation, was diagnosed when end-tidal pressure of CO2 (PETCO2) less than 30 mm Hg was recorded consecutively for 10 minutes or longer. When tilting was discontinued because of syncope, one PETCO2 measurement of 25 or less was accepted as hyperventilation. RESULTS: Hypocapnia was diagnosed on tilt test in 9% to 27% of patients with fibromyalgia, CFS, dizziness, and NMS versus 0% to 2% of control subjects. Three patterns of hypocapnia were recognized: supine hypocapnia (n = 14), sustained hypocapnia on tilt (n = 76), and mixed hypotensive-hypocapnic events (n = 80). Hypocapnia associated with postural tachycardia syndrome (POTS) occurred in 8 of 41 patients. CONCLUSIONS: Hyperventilation appears to be the major abnormal response to postural challenge in sustained hypocapnia but possibly merely an epiphenomenon in hypotensive-hypocapnic events. Our study does not support an essential role for hypocapnia in NMS or in postural symptoms associated with POTS. Because unrecognized hypocapnia is common in CFS, fibromyalgia, and nonspecific dizziness, capnography should be a part of the evaluation of patients with such conditions.

The case for hepatitis C arthritis.

OBJECTIVE: To present the data available supporting the existence of an arthropathy associated with hepatitis C infection. METHODS: The MEDLINE database was searched for "arthritis" intersecting with "hepatitis C" in addition to the authors' investigations and experience on this subject. RESULTS: Arthritis, not otherwise explained, has been noted in 2% to 20% of hepatitis C virus (HCV) patients. This arthritis is rheumatoid-like in two thirds of the cases and a waxing/waning oligoarthritis in the rest. Cryoglobulinemia alone does not explain the arthritis, and there is difficulty in differentiating it from rheumatoid arthritis. The arthropathy is nonerosive/nondeforming. Whereas nonsteroidal anti-inflammatory drugs, low-dose corticosteroids, and hydroxychloroquine may be helpful, conventional treatment of arthritis may be problematic in the context of viral hepatitic arthropathy. Antiviral therapy is most effective, even without viral clearance, but rheumatic complications may ensue. CONCLUSIONS: HCV arthropathy should be considered in the differential diagnosis of new-onset arthritis.

Hemodynamics instability score in chronic fatigue syndrome and in non-chronic fatigue syndrome.

OBJECTIVE: In studying patients with chronic fatigue syndrome (CFS) we developed a method that confers numerical expression to the degree of blood pressure and heart rate lability, ie, the 'hemodynamic instability score' (HIS). The HIS in CFS patients differed significantly from healthy subjects. The present investigation compares the HIS in CFS, non-CFS chronic fatigue and patients with recurrent syncope. METHODS: Patients with CFS (n = 21), non-CFS chronic fatigue (n = 24), syncope of unknown cause (n = 44), and their age and sex-matched healthy controls (n = 21) were evaluated with a standardized head-up tilt test (HUTT). Abnormal reactions (endpoints) on HUTT were classified 'clinical outcomes' (cardioinhibitory or vasodepressor reaction, orthostatic hypotension, postural tachycardia syndrome) and 'HIS endpoint', i.e. HIS >-0.98. RESULTS: The highest incidence of endpoints was noted in patients with CFS (79%), followed by patients with syncope of unknown cause (46%), non-CFS chronic fatigue (35%), and healthy subjects (14%). Presyncope or syncope during tilt occurred in 38% of CFS patients, 21% of patients with non-CFS chronic fatigue, and 43% of patients with recurrent syncope. The average HIS values were: CFS = +2.02 (SD 4.07), non-CFS chronic fatigue = -2.89 (SD 3.64), syncope = -3.2 (SD 3.0), healthy = -2.48 (4.07). The odds ratios for CFS patients to have HIS >-0.98 was 8.8 compared with non-CFS chronic fatigue patients, 14.6 compared with recurrent syncope patients, and 34.8 compared with healthy subjects. CONCLUSION: The cardiovascular reactivity in patients with CFS has certain features in common with the reactivity in patients with recurrent syncope or non-CFS chronic fatigue, such as the frequent occurrence of vasodepressor reaction, cardioinhibitory reaction, and postural tachycardia syndrome. Apart from to these shared responses, the large majority of CFS patients exhibit a particular abnormality which is characterized by HIS values >-0.98. Thus, HIS >-0.98 lends objective criteria to the assessment of CFS.

Dysautonomia in chronic fatigue syndrome: facts, hypotheses, implications.

The diagnosis of chronic fatigue syndrome (CFS) is based on patient history and treatment on cognitive behavior therapy and graded exercise. There is increasing evidence that dysautonomia occurs in CFS manifest primarily as disordered regulation of cardiovascular responses to stress. We impart our experience relating to diagnosis, monitoring, and treatment of CFS based on identification and management of dysautonomia. Recently proposed methods for assessment of the cardiovascular reactivity, the 'hemodynamic instability score' (HIS) and the 'Fractal and Recurrence Analysis-based Score' (FRAS), served for this purpose. On HUTT, a particular dysautonomia is revealed in CFS patients that differ from dysautonomia in several other disorders. This distinct abnormality in CFS can be identified by HIS >-0.98 (sensitivity 84.5% and specificity 85.1%) and FRAS > +0.22 (sensitivity 70% and specificity 88%). Therefore, the HIS and FRAS may be used, in the appropriate clinical context, to support the diagnosis of CFS, which until now, could only be subjectively inferred. A pilot study suggested that midodrine treatment, directed at the autonomic nervous system in CFS, results first in correction of dysautonomia followed by improvement of fatigue. This finding implies that dysautonomia is pivotal in the pathophysiology CFS, at least in a large part of the patients, and that manipulating the autonomic nervous system may be effective in the treatment of CFS.

Vascular disorders preceding diagnosis of cancer: distinguishing the causal relationship based on Bradford-Hill guidelines.

The literature investigating the association between vascular disorders and malignant neoplasms does not comprehensively review the full spectrum of vascular disorders associated with cancer, or provide proof that cancer is an etiologic factor in the development of these disorders. This paper investigates the causal role of cancer in the pathogenesis of vascular disorders, based on the Bradford-Hill criteria of causation. The Medline database was searched for articles on vascular disorders preceding the diagnosis of cancer (VDPCD). Included in the analysis were vascular disorders caused either by direct tumoral involvement of vessels or by paraneoplastic mechanisms. Vascular disorders caused by adverse reactions to anticancer therapy were excluded from analysis. Seven categories of VDPCDs were recognized: venous thromboembolism, arterial thrombosis and embolism, nonbacterial thrombotic endocarditis, migratory superficial thrombophlebitis, vasculitis, thrombotic microangiopathy, and leukothrombosis. To establish causality of the association between VDPCDs and malignancy, the degree of fulfillment of the Bradford-Hill criteria was assessed. A strong association was found in the literature between venous thromboembolism and cancer (OR 2.3-14.9 and SIR 1.3-4.4). Consistency and temporality of the association were confirmed in all VDPCD variants. Seven Bradford-Hill criteria were fulfilled for cancer associated with venous thromboembolism, six criteria for superficial phlebitis and cancer, and five criteria for each of the other VDPCDs. In conclusion, these data support the causal role of cancer in the pathogenesis of all seven categories of VDPCDs. Recognition of such a causal link between cancer and various vascular disorders may promote an earlier cancer diagnosis.

Unilateral necrobiosis lipoidica of the ischemic limb--a case report.

A 63-year-old diabetic woman presented with new-onset intermittent claudication of the right calf accompanied by ipsilateral necrobiosis lipoidica (NL). The latter presented the typical appearance of oval, indurated plaques, with brownish-red margins and central atrophy, scattered over the right thigh and calf. Arteriography demonstrated severe obstructive lesions on the right femoral artery. NL and claudication spared the left leg. A possible ischemic pathogenesis of NL emerges from this observation and is supported by recent studies in the literature.

The feeling of fatigue--fatigue severity by unidimensional versus composite questionnaires.

The authors' purpose in this study was to compare the perception of fatigue severity as measured by different fatigue questionnaires. The authors evaluated 3 groups of patients in a cross-sectional study: chronic fatigue syndrome (CFS, n = 20), non-CFS fatigue (n = 20), and familial Mediterranean fever (FMF n = 25). In addition, the authors tracked 7 patients with CFS longitudinally for severity of fatigue. The severity of fatigue-related symptoms was assessed with 2 questionnaires: the unidimensional Chalder's Fatigue Severity Scale (CH) and the composite Fatigue Impact Scale (FI) which has 3 subscales--cognitive, physical, and social--and a total score. In the cross-sectional study, correlations between CH and FI cognitive scores were r = .78 (p < .0001), CH versus FI physical scores r = .603 (p < .0001), CH versus FI social scores r = .66 (p < .0001), and CH versus FI total scores r = .74 (p < .0001). In the longitudinal survey of CFS patients, the authors compared 30 questionnaires revealing correlations of CH versus FI cognitive scores r = .64 (p = .0004), CH versus FI physical r = .68 (p = .0001), CH versus FI social r = .87 (p < .0001), and CH versus FI total r = .90 (p < .0001). Fatigue severity as assessed by the unidimensional CH scale and the composite FI scale is comparable. The simple CH scale may be adequate for the assessment of the feeling of fatigue, in general, and for monitoring the severity of fatigue in CFS, in particular.

[Primary well-differentiated papillary mesothelioma of the peritoneum--a rare but important differential diagnosis].

The primary well-differentiated papillary mesothelioma of the peritoneum is a rare neoplasm, characterized by an indolent course and good prognosis. We report the case of a 55-year-old male, who presented progressive abdominal swelling due to ascites. On computerized tomography, the peritoneum was diffusely thickened and irregular. Cytologic examination showed a lymphocyte rich ascitic fluid. Malignant cells could not be identified. On laparoscopy, numerous nodular lesions were observed on the peritoneal surface. A biopsy of the latter showed an unusual malignant growth. Using immunohisto-chemistry and electron microscopy, typical features of a well-differentiated papillary mesothelioma were recognized. The patient underwent tumor debulking. Two years later he is symptom free. This case study, much similar to another 38 reported cases in the MEDLINE database, illustrates the characteristic features of this rare malignancy that should be recognized and distinguished from other, common, more aggressive neoplasms involving the peritoneum.