Triglyceride glucose index predicts all-cause mortality in oldest-old patients with acute coronary syndrome and diabetes mellitus.

BACKGROUND: Acute coronary syndrome (ACS) and diabetes mellitus (DM) are the leading health risks for the elderly. Triglyceride-glucose (TyG) index is a novel and reliable indicator of insulin resistance (IR). This study aims to explore the relationship between the TyG index and all-cause mortality in oldest-old patients with ACS and DM. METHODS: Seven hundred twenty hospitalized patients with ACS aged ≥ 80 years were enrolled, and 699 patients signed informed consent for the study. During the follow-up period, 37 were lost to follow-up, and the follow-up rate was 94.7%. 231 ACS patients with DM were selected for the study's analyses. Kaplan-Meier curve, Cox regression model and receiver operating characteristic (ROC) curve were used to analyze the association between the TyG index and all-cause mortality. RESULTS: The mean age of participants was 81.58 ± 1.93 years, and 32.47% were women. Compared to TyG tertile 1, the Hazard Ratio (HR) [95% confidence interval (CI)] of all-cause mortality was 2.04 (1.09, 3.81) for TyG tertile 3 in the fully adjusted model. For the TyG index per standard deviation (SD) increment, the HR (95% CI) of all-cause mortality was 1.44 (1.13, 1.83). Further, the association between the TyG index and all-cause mortality was dose-response (P for trend = 0.026). ROC curve analyses indicated that the TyG index outperformed FBG and TG in the prediction of mortality risk and improved the prognostic value of the Gensini score combined with LVEF. CONCLUSION: The TyG index predicts the risk of all-cause mortality in the oldest-old ACS patients with DM.

The prognostic value of the Charlson comorbidity index in aged patients with intracerebral hemorrhage.

BACKGROUND: Comorbidities are common in aged intracerebral hemorrhage patients. The purpose of this study was to assess whether the Charlson Comorbidity Index (CCI) was associated with in-hospital death and short-term functional outcome in elderly patients (age ≥ 70) with intracerebral hemorrhage (ICH). METHODS: This was a retrospective cohort of aged ICH patients (≥70 years old) admitted within 24 hours of ICH onset. The CCI was derived using hospital discharge ICD-9 CM codes and patient history obtained from standardized case report forms. Multivariable logistic regression was used to determine the independent effect of the CCI score on clinical outcomes. RESULTS: In this cohort of 248 aged ICH patients, comorbid conditions were common, with CCI scores ranging from 2 to 12. Logistic regression showed that the CCI score was independently predictive of 1-month functional outcome (OR = 1.642, P < 0.001) and in-hospital death (OR = 1.480, P = 0.003). Neither ICH volume nor the presence of IVH was an independent predictive factor for 1-month functional outcome or in-hospital mortality (P < 0.05). CONCLUSION: Comorbid medical conditions as assessed by the CCI independently influence short-term outcomes in aged ICH patients. The characteristics of the hematoma itself, such as ICH volume and the presence of IVH, seem to have a reduced effect on it.

Short-term mortality of patients ≥80 years old admitted to European intensive care units: an international observational study.

BACKGROUND: Limited evidence suggests variation in mortality of older critically ill adults across Europe. We aimed to investigate regional differences in mortality among very old ICU patients. METHODS: Multilevel analysis of two international prospective cohort studies. We included patients ≥80 yr old from 322 ICUs located in 16 European countries. The primary outcome was mortality within 30 days from admission to the ICU. Results are presented as n (%) with 95% confidence intervals and odds ratios (ORs). RESULTS: Of 8457 patients, 2944 (36.9% [35.9-38.0%]) died within 30 days. Crude mortality rates varied widely between participating countries (from 10.1% [6.4-15.6%] to 45.1% [41.1-49.2%] in the ICU and from 21.3% [16.3-28.9%] to 55.3% [51.1-59.5%] within 30 days). After adjustment for confounding variables, the variation in 30-day mortality between countries was substantially smaller than between ICUs (median OR 1.14 vs 1.58). Healthcare expenditure per capita (OR=0.84 per $1000 [0.75-0.94]) and social health insurance framework (OR=1.43 [1.01-2.01]) were associated with ICU mortality, but the direction and magnitude of these relationships was uncertain in 30-day follow-up. Volume of admissions was associated with lower mortality both in the ICU (OR=0.81 per 1000 annual ICU admissions [0.71-0.94]) and in 30-day follow-up (OR=0.86 [0.76-0.97]). CONCLUSION: The apparent variation in short-term mortality rates of older adults hospitalised in ICUs across Europe can be largely attributed to differences in the clinical profile of patients admitted. The volume-outcome relationship identified in this population requires further investigation.

Direct oral anticoagulants for secondary stroke prevention in patients over 80 years of age: the role of geriatric functional status.

Prescribing anticoagulation therapy in very old (≥ 80-years) patients with atrial fibrillation (AF) is an emerging clinical issue, but current knowledge and recommendations are insufficient. We aimed to determine the efficacy and safety of direct oral anticoagulants (DOACs) in secondary stroke prevention in very old patients and to explore the related geriatric functional status of these patients. Three hundred fifty-three consecutive ≥ 80-year-old patients treated for transient ischemic attack (TIA) or ischemic stroke (IS) at the neurological clinic at UMC Ljubljana, who were prescribed DOACs for AF between December 2012 and May 2020, were included. Data regarding recurrent TIA/IS, major bleeds, intracranial hemorrhage (ICH) and death were collected. Data were descriptively compared with data from RCTs- including younger patients. Patients prescribed DOACs between January 2018 and May 2020 were contacted in December 2020, and their functional status was assessed using the Barthel index (BI). The efficacy of secondary stroke prevention with DOACs was comparable to RCTs for significantly younger patients. Major bleeds occurred more often, but most incidences were gastrointestinal, and the rate of ICH was comparable. Importantly, most patients were highly independent determined by BI. Overall, our real world results suggest that DOACs are as effective at preventing IS in secondary prevention in very old patients than in younger patients and that geriatric functional assessment could be a useful tool in the decision-making process.

Efficacy and safety of sodium-glucose co-transporter 2 inhibitors in the elderly versus non-elderly patients with type 2 diabetes mellitus: a meta-analysis.

This meta-analysis was performed to compare the influence of sodium-glucose co-transporter 2 inhibitors (SGLT2i) on the efficacy and safety of elderly patients with type 2 diabetes with the young ones. PubMed, Medline, Web of Science, EMbase, and Cochrane Library were searched for literature published before March 2020 to identify studies comparing efficacy and safety of SGLT2i in elderly diabetes patients (≥65 years) and young controls (<65 years). A fixed or random-effect model was used to calculate the summary standard means difference and odds ratios. A total of 13 articles with data for 86,433 participants were included. Old patients receiving SGLT2i had a smaller reduction in hemoglobin A1c (SMD = -0.07, 95% CI -0.14 to -0.00, p = 0.044) than young ones. They had higher incidence of serious adverse events (SAEs) (OR 1.78, 95% CI 1.25-2.55, p = 0.001), AE leading to discontinuation (OR 2.34, 95%CI 1.53-3.59, p = 0.000), volume depletion (OR 2.80, 95% CI 1.82-4.32, p = 0.000) , and urinary tract infections (OR 1.37, 95% CI 1.18-1.60, p = 0.000), and renal function impairment (OR 2.61, 95% CI 1.78-3.81, p = 0.000) than young patients, and there was a opposite result in genital mycotic infections (OR 0.69, 95% CI 0.55-0.87, p = 0.002). No significant differences were recorded in the reduction of fasting blood glucose, blood pressure, body weight, and in incidence of overall AEs and fracture. In summary, relatively satisfying efficacy was observed in the elderly patients receiving SGLT2i. Although some AEs were more prevalent among older patients, the majority of them were generally mild.

Incidence, predictors and health outcomes of delirium in very old hospitalized patients: a prospective cohort study.

BACKGROUND: Delirium is a common complication that leads to poor health outcomes in older patients undergoing treatment. Due to severe consequences, early recognition of high-risk patients and risk factors for delirium are crucial in the prompt initiation of prevention measures. However, research in medically hospitalized patients aged ≥80 years remains limited. This study aimed to determine the incidence, predictors and health outcomes of delirium in very old (aged ≥80 years) hospitalized patients in China. METHODS: A prospective study was conducted in individuals aged ≥80 years admitted to geriatric departments. Potential risk factors were assessed within 24 h after hospital admission. Screening for delirium was performed on admission and every 48 h thereafter for 14 days and assessed if acute mental status changes were observed. During hospitalization, health outcomes were recorded daily. RESULTS: Incident delirium occurred in 109 of 637 very old hospitalized patients (17.1%). The independent predictors of delirium in hospitalized patients aged 80 and over were cognitive function impairment [OR 17.42, 95% CI:(7.47-40.64)], depression [OR 9.30, 95% CI: (4.59-18.84)], CCI ≥ 5 [OR 4.21, 95% CI: (1.48-12.01)], sleep deprivation [OR 3.89, 95% CI: (1.71-8.82)], infection [OR 3.33, 95% CI: (1.70-6.54)], polypharmacy (≥5 medications) [OR 2.85, 95% CI: (1.51-5.39)], constipation [OR 2.58, 95% CI: (1.33-5.02)], and emergency admission [OR 2.13, 95% CI: (1.02-4.45)]. Patients with delirium had significantly longer hospital stays(P < 0.001) and higher percentages of physical restraint use(P < 0.001) and falls (P = 0.001) than those without delirium,. CONCLUSION: The incidence of delirium was high in hospitalized patients aged ≥80 years admitted to the geriatric department and was associated with prolonged hospital stay and higher rates of physical restraint use and falls. In this population, the most important independent risk factors for incident delirium were cognitive function impairment and depression. Health care professionals should recognize and initiate interventions for delirium early in geriatric patients.

Short- and mid-term outcomes of laparoscopic colorectal surgery in patients ≥ 85 years old: a multicenter study using a propensity score-matched analysis.

PURPOSE: The number of laparoscopic surgeries for colorectal cancer (CRC) in elderly patients has been increasing. We examined the short- and mid-term outcomes of laparoscopic surgery for CRC in oldest-old patients (≥ 85 years old) compared with the outcomes in younger patients (< 85 years old). METHODS: We retrospectively reviewed primary tumor resection for CRC from April 2015 to December 2020 at six hospitals. Short- and mid-term outcomes were compared after propensity score matching. RESULTS: From the 1374 patients, 126 matched pairs were selected. In the matched cohort, the duration of postoperative hospital stay was longer in the oldest-old patients than in the younger patients (15 days vs. 12 days, p = 0.001). There were no significant differences between the groups in the rate of Clavien-Dindo grade ≥ 2 postoperative complications (21.4% vs. 15.1%, p = 0.254). The oldest-old patients showed a poorer overall survival (OS) than the younger patients (3-year OS, 79.9% vs. 93.5%, p = 0.005) but comparable recurrence-free survival (RFS) (3-year RFS, 72.2% vs. 81.6%, p = 0.530) and cancer-specific survival rates (CSS) (3-year CSS, 90.1% vs. 99.0%, p = 0.124). CONCLUSION: Laparoscopic surgery for CRC in oldest-old patients was performed safely with comparable short-term outcomes to those in younger patients. Although the OS was poorer in the oldest-old patients than in the younger patients, the oncological mid-term outcomes were comparable. Laparoscopic surgery for CRC can be considered acceptable as a treatment in oldest-old patients.

Factors associated with impaired physical function in elderly rheumatoid arthritis patients who had achieved low disease activity.

OBJECTIVE: We aimed to investigate factors associated with impaired physical function (defined as HAQ Disability Index [HAQ-DI] >0.5) of old-old (aged 75-84) patients with rheumatoid arthritis (RA). METHODS: Data from 15,185 RA patients in the National Database of Rheumatic Disease in Japan were extracted from 2017 to 2018. We enrolled 3,708 patients aged 55-84 in simplified disease activity index (SDAI) ≤11 and Steinbrocker stage I/II. Factors associated with HAQ-DI >0.5 were analyzed by multivariable logistic regression. RESULTS: About half of the old-old patients received methotrexate, which was lower than middle-aged (55-64) and young-old patients (65-74). The proportion of glucocorticoids in the old-old patients was highest among the three groups, and biological disease-modifying anti-rheumatic drugs were similarly used. The prevalence of HAQ-DI >0.5 was significantly higher in old-old patients with low disease activity than in those with remission. The same was true in the middle-aged and young-old patients. Multivariable analysis showed age, higher SDAI, glucocorticoid use, and methotrexate non-use were significantly associated with HAQ-DI >0.5 in the old-old patients. CONCLUSIONS: SDAI remission was an ideal goal for old-old patients in terms of physical function. Glucocorticoids and a low proportion of methotrexate use may influence the physical function of old-old patients.

Long-term quality of life and sexual function of elderly people with endometrial or ovarian cancer.

BACKGROUND: With the growing number of older endometrial cancer (EC) and ovarian cancer (OC) survivors, data on long-term health-related quality of life (HRQoL) became an important issue in the management of older patients. So, the aim of this study was to describe and compare according to age long-term HRQoL, sexual function, and social deprivation of adults with either EC or OC. METHODS: A cross-sectional study was set up using data from the Côte d'Or gynecological cancer registry. A series of questionnaires assessing HRQoL (SF-12), sexual function (FSFI), anxiety/depression (HADS), social support (SSQ6) and deprivation (EPICES) were offered to women with EC or OC diagnosed between 2006 and 2013. HRQoL, sexual function, anxiety/depression, social support and deprivation scores were generated and compared according to age (< 70 years and ≥ 70 years). RESULTS: A total of 145 women with EC (N = 103) and OC (N = 42) participated in this study. Fifty-six percent and 38% of EC and OC survivors respectively were aged 70 and over. Treatment did not differ according to age either in OC or EC. The deprivation level did not differ between older and younger survivors with OC while older survivors with EC were more precarious. The physical HRQoL was more altered in older EC survivors. This deterioration concerned only physical functioning (MD = 24, p = 0.012) for OC survivors while it concerned physical functioning (MD = 30, p < 0.0001), role physical (MD = 22, p = 0.001) and bodily pain (MD = 21, p = 0.001) for EC survivors. Global health (MD = 11, p = 0.011) and role emotional (MD = 12, p = 0.018) were also deteriorated in elderly EC survivors. Sexual function was deteriorated regardless of age and cancer location with a more pronounced deterioration in elderly EC survivors for desire (p = 0.005), arousal (p = 0.015) and orgasm (p = 0.007). Social support, anxiety and depression were not affected by age regardless of location. CONCLUSION: An average 6 years after diagnosis, the impact of cancer on HRQoL is greatest in elderly survivors with either EC or OC.

Real-world long-term outcomes based on three therapeutic strategies in very old patients with three-vessel disease.

BACKGROUND: There are relatively limited data regarding real-world outcomes in very old patients with three-vessel disease (3VD) receiving different therapeutic strategies. This study aimed to perform analysis of long-term clinical outcomes of medical therapy (MT), coronary artery bypass grafting (CABG), and percutaneous coronary intervention (PCI) in this population. METHODS: We included 711 patients aged ≥ 75 years from a prospective cohort of patients with 3VD. Consecutive enrollment of these patients began from April 2004 to February 2011 at Fu Wai Hospital. Patients were categorized into three groups (MT, n = 296; CABG, n = 129; PCI, n = 286) on the basis of different treatment strategies. RESULTS: During a median follow-up of 7.25 years, 262 deaths and 354 major adverse cardiac and cerebrovascular events (MACCE) occurred. Multivariate Cox analysis showed that the risk of cardiac death was significantly lower for CABG compared with PCI (adjusted hazard ratio [HR] = 0.475, 95% confidence interval [CI] 0.232-0.974, P = 0.042). Additionally, MACCE appeared to show a trend towards a better outcome for CABG (adjusted HR = 0.759, 95% CI 0.536-1.074, P = 0.119). Furthermore, CABG was significantly superior in terms of unplanned revascularization (adjusted HR = 0.279, 95% CI 0.079-0.982, P = 0.047) and myocardial infarction (adjusted HR = 0.196, 95% CI 0.043-0.892, P = 0.035). No significant difference in all-cause death between CABG and PCI was observed. MT had a higher risk of cardiac death than PCI (adjusted HR = 1.636, 95% CI 1.092-2.449, P = 0.017). Subgroup analysis showed that there was a significant interaction between treatment strategy (PCI vs. CABG) and sex for MACCE (P = 0.026), with a lower risk in men for CABG compared with that of PCI, but not in women. CONCLUSIONS: CABG can be performed with reasonable results in very old patients with 3VD. Sex should be taken into consideration in therapeutic decision-making in this population.

Management of pertrochanteric fractures in patients over 90 years: In-hospital mortality rate, complications and associated risk factors.

PURPOSE: This study aims primarily to investigate the outcome following surgical management of pertrochanteric fractures of patients over 90 years compared to the outcome of a control group below 90 years under special consideration of the timing of surgery. The second aim was to analyze potential risk factors for early deaths in very old patients. This study allows us to draw conclusions to minimize complications linked to this particular age segment. METHODS: The study group consisted of very old patients aged 90 years and older. Geriatric patients aged between 60 and 89 years of age were part of the control group. Type A1 pertrochanteric fractures were typically treated by dynamic hip crews, type A2 and A3 fractures by femoral nails. Full weight bearing physiotherapy was initiated on the day after surgery to improve mobility and muscle strength. RESULTS: A total of 71 patients belonged to the study group (mean age: 92.5 years ±2.3 years), whereas 223 patients formed the control group (mean age: 79.9 ± 7.4 years). The mortality rate and the number of detected and documented complications were significantly higher in the study group (p = 0.001; p = 0.009, respectively). Despite the significantly higher complication rate in the > 90-year-old patients, there was no significant difference in the mean length of in-hospital-stay between the both groups (> 90 yrs.: 12.1d; < 90 yrs.: 13.1 d) and the timing of surgery. CONCLUSION: The number of co-morbidities, number of daily-administered medications and the time between admission and surgery have no impact on the outcome. We noticed a longer period between admission and surgery in very old patients who survived. Patients with pertrochanteric fractures should be screened for multimorbidity and cognitive disorders in a standardized manner.

Oral Cancer in Young vs Old Individuals: A Systematic Review.

AIM: To compare various parameters associated with oral cancer in young and old patients and systematically compile the data on prognosis or outcome of oral cancer in young and old patients that include case series, matched-pair analyses, institutional series, and database reviews. BACKGROUND: Though oral cancer is considered a disease of old age, a recent clinical scenario witnesses its increasing incidence among young persons. When compared to old patients, young patients with oral cancer are exposed to the carcinogens for a very petite period of time suggesting underlying pathogenesis to be distinct from that in older individuals. Literature reports several studies about the occurrence of oral cancer in young patients; however, no unanimous opinion exists about its prognosis and treatment outcomes when compared to older patients. Keeping this in mind, we have extensively studied all the possible aspects (location, local and regional recurrence, nodal and distant metastasis, overall survival, etc.) from the English literature and systematically compiled the available data on prognosis or outcomes of oral cancer. REVIEW RESULTS: The overall outcome of the case series shows poorer prognosis in young patients, matched-pair analyses, and institutional series suggesting no significant differences whereas the databases favored a better prognosis in young patients. The mean overall survival rate was found to be better for young patients in the database and institutional review whereas worse in the matched-pair analyses. The mean 5-year survival rate was found to be more in young individuals in matched-pair analyses, database reviews, and institutional series as compared to older oral cancer patients. CONCLUSION: Though data extracted from various study designs are heterogeneous, the present review gives a scoping view of the papers published on oral cancer in young vs old patients. More prospective studies are suggested with a larger sample size in the future. CLINICAL SIGNIFICANCE: The present review will help to better understand the nature, course, and biologic behavior of oral cancer in young patients leading to the development of specific treatment strategies to manage the patients based on their age-groups.

Severe Acute Respiratory Infections (SARI) surveillance in over-65-years-old patients: the experience of a University hospital (seasons 2017-2018 and 2018-2019).

Background: Influenza is a relevant public health problem, also due to the risk of complications. The most effective measure to prevent influenza is vaccination; therefore, at present, there is consensus among European countries, regarding the need for routine seasonal influenza vaccination of elderly and individuals at increased risk of severe influenza. At the same time, influenza surveillance is necessary to understand the viruses circulating and effectiveness of vaccination strategies. The present study reports the results of two seasons influenza surveillance (2017/2018 and 2018/2019) conduced in an University Hospital in Rome among hospitalized patients aged ≥65 years. Study design: A prospective cohort study. Methods: The study consisted of systematic daily screening of all admissions among patients aged ≥65 years meeting a syndromic SARI case definition during two consecutive influenza seasons: 2017/2018 and 2018/2019. Characteristics of patients and their risk factors were collected by a standardized questionnaire and nose-pharyngeal swabs were performed to each patient. Influenza vaccine effectiveness (IVE), rates of vaccinated subjects and case fatality rate were also evaluated. Results: Influenza was laboratory confirmed in 11 (9.9%) of the 111 and 11 (9.6%) of the 115 enrolled patients in seasons 2017/18 and 2018/19, respectively. Adjusted IVE against all influenza type, calculated for each season, was 88.5% (95% CI: 38.9 to 97.8) and 61.7% (95% CI: -59.9 to 90.9) for 2017/2018 and 2018/2019 seasons, respectively. Our analysis shows a Case Fatality Rate of 2.7% and 4.3% for the 2017/18 and 2018/19 seasons, respectively. Conclusions: The surveillance of SARI conduced in one hospital in Rome confirmed that influenza is an important cause of hospital admissions. Routine monitoring of infectious diseases and related aetiology associated with SARI, also at the local-level, is useful for targeting the right preventive measures.

Comparison of clinical and polysomnographic characteristics in young and old patients with obstructive sleep apnea syndrome.

AIM: This study aimed to determine the differences in the clinical, demographic and polysomnographic characteristics of OSAS between patients older than and younger than 65 years of age. METHODS: Two groups of OSAS patients under 65 years of age and older who underwent PAP treatment in our sleep center were included in the study. Demographic, clinical, and polysomnographic variables of patients were compared as well as the PAP device usage compliance. RESULTS: The study was conducted with 183 patients (81 females and 102 males) having the diagnosis of OSAS. The ages of the patients ranged from 37 to 85 years (mean: 58.77 ± 12.59). The incidence of apnea, chest pain, arrhythmia, headache, non-concentration, forgetfulness, psychiatric disorders, motor activity, enuresis, libido and impotence complaints as well as the sedative usage rates and incidence of additional diseases were higher in elderly patients. Apnea hypopnea index, inspiratory positive airway pressure, and expiratory positive airway pressure measurements were significantly higher in the elderly group. The rates of NREM2 (%) and NREM3 (%) were lower in elderly patients. CONCLUSION: Many comorbid medical conditions, concomitant drug use, and age-related physiological changes in sleep architecture and circadian rhythm and their effects on sleep should be considered in the elderly sleep.

Differential leukocyte counts and cardiovascular mortality in very old patients with acute myocardial infarction: a Chinese cohort study.

BACKGROUND: Total leukocyte and differential Leukocyte counts are prognostic indictors in patients with coronary artery disease (CAD). However, there is no data available regarding their prognostic utility in very old patients with acute myocardial infarction (AMI). The aim of this study is to investigate the potential role of different leukocyte parameters in predicting the mortality among very old patients with AMI. METHODS: A total of 523 patients aged over 80 years with AMI were consecutively enrolled into this study. Leukocyte and its subtypes were obtained at admission in each patient. The primary study endpoint was cardiovascular mortality. Patients were followed up for an average of 2.2 years and 153 patients died. The associations of leukocyte parameters with mortality were assessed using Cox regression analyses. The concordance index was calculated to test the model efficiency. RESULTS: In multivariable regression analysis, neutrophils-plus-monocytes-to-lymphocytes ratio (NMLR) and neutrophils-to-lymphocytes ratio (NLR) were two most significant predictors of mortality among all the leukocyte parameters (HR = 3.21, 95% CI 1.75-5.35; HR = 2.79, 95% CI 1.59-4.88, respectively, all p < 0.001, adjusted for age, male gender, body mass index, family history of CAD, smoking, hypertension, diabetes mellitus, high-density lipoprotein cholesterol (HDL-C), non-HDL-C, high sensitivity C-reactive protein, creatinine, left ventricular ejection fraction, troponin I, use of statin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and percutaneous coronary intervention). Furthermore, adding NMLR and NLR into the Cox model increased the C-statistic by 0.038 and 0.037 respectively, which were more significant than that of other leukocyte parameters. Besides, addition of NMLR and NLR to the Canada Acute Coronary Syndrome Risk Score model also increased the C-statistic by 0.079 and 0.077 respectively. CONCLUSION: Our data firstly indicated that most leukocyte subtypes were independent markers for the mortality in very old patients with AMI, while NMLR and NLR appeared to be more effective.

Analysis of outcome for elderly patients after microvascular flap surgery: a monocentric retrospective cohort study.

OBJECTIVES: Increasingly, aging societies pose a challenge, particularly in the most developed countries. This trend leads to an increasing group of old and very old patients presenting unique requirements and challenges. One of these challenges consists in reassessment and adaption of established treatment strategies for the elderly patients. There is an ongoing discussion taking place among cranio-maxillo-facial surgeons about the appropriate extent of reconstructive flap surgery for old patients. MATERIALS AND METHODS: This monocentric retrospective cohort study investigated 281 reconstructions with microvascular flaps by comparing the risk for a negative outcome, which was defined as revision, flap loss, and patient death, between three subgroups of elderly patients and younger patients. The three subgroups of elderly patients were defined as-1: young old (65-74 years), 2: old (75-84 years), and 3: oldest old (≥ 85 years). The group of the younger patients was defined by age between 50 and 64 years. Data were obtained within a defined period of 42 months. RESULTS: Significant correlations with a negative outcome were found for the variables stay on IMC/ICU, multiple flaps, and radiotherapy prior surgery. Our data showed no significant correlation between age and a higher risk for a negative outcome. CONCLUSION: Defect reconstruction with microvascular flaps in old patients is not related with a higher risk for a negative outcome. CLINICAL RELEVANCE: Independently of age, treatment with microvascular flaps is an option for all operable patients, with an indication for oncologic surgery. For optimal therapy planning, individual patient resources and preferences should be considered instead of chronologic age.

Toxicity and risk factors after combined high-dose-rate brachytherapy and external beam radiation therapy in men ≥75 years with localized prostate cancer.

PURPOSE: Combined high-dose-rate brachytherapy (HDR-BT) and external beam radiation therapy (EBRT) is a favorable treatment option in non-metastatic prostate cancer. However, reports on toxicity and outcome have mainly focused on younger patients. We aimed to determine toxicity and biochemical control rates after combined HDR-BT and EBRT in men ≥75 years. METHODS: From 1999 to 2015, 134 patients aged ≥75 years (median 76 years; 75-82 years) were identified. Patients received 18 Gy of HDR-BT (9 Gy/fraction on days 1 and 8) with an iridium-192 source. After 1 week, supplemental EBRT with a target dose of 50.4 Gy was started (delivered in 1.8 Gy fractions). RESULTS: Median follow-up time was 25 months (0-127 months). No severe (grade 4) gastrointestinal (GIT) or genitourinary (GUT) toxicities were observed. In 76 patients (56.7%), 3D conformal radiation therapy (CRT) and in 34.3% intensity-modulated radiotherapy (IMRT) was applied. CRT-treated patients were at a 2.17-times higher risk (hazard ratio [HR]: 2.17, 95% confidence interval [CI]: 1.31-3.57, p = 0.002) of experiencing GUT. GIT risks could be reduced by 78% using IMRT (HR: 0.22, 95% CI: 0.07-0.75, p = 0.015). Patients with a higher T stage (T2c-3a/b) were less likely to experience GIT or GUT (HR: 0.49, 95% CI: 0.29-0.85, p = 0.011 and HR: 0.5, 95% CI: 0.3-0.81, p = 0.005, respectively). CONCLUSION: HDR-BT/EBRT is a well-tolerated treatment option for elderly men ≥75 years with a limited number of comorbidities and localized intermediate- or high-risk prostate cancer. IMRT should be favored since side effects were significantly reduced in IMRT-treated patients.

Long-term survival and clinical forms in the acute phase of Chikungunya virus infection in older Caribbeans.

OBJECTIVE: To investigate whether the long-term survival in elderly patients with prior Chikungunya virus infection (CVI) is associated with the clinical form presented in the acute phase, as defined by the WHO classification. METHODS: Retrospective cohort study performed in Martinique University Hospitals. Patients who attended the emergency department for suspected CVI, and who had a positive biological diagnosis of CVI by reverse transcription-polymerase chain reaction on a plasma sample between 10 January and 31 December 2014 were eligible for inclusion. Time-to-death was the primary outcome. The independent relationship between clinical forms and time-to-death was analysed using a Cox model. RESULTS: In total, 268 patients were included. Mean age was 80 ± 8 years, 53% were women. Median length of follow-up was 28 months (range: 0-39). During follow-up, 53 (19.8%) patients died. Median survival time was 13.2 months (range: 0-33.6). At the end of follow-up, death rates were 4.6% for acute clinical cases, 19.0% for atypical cases, 19.2% for severe acute cases and 23.5% for unclassifiable cases. By multivariable analysis, the clinical form of CVI at admission was found to be independently associated with long-term survival (atypical form: HR = 2.38; 95% CI = 2.15-2.62; severe acute form: HR = 2.40; 95% CI = 2.17-2.64; unclassifiable form: HR = 2.28; 95% CI = 2.06-2.51). CONCLUSION: The clinical form at presentation with CVI has a significant impact on long-term survival. Management of CVI patients should be tailored according to their clinical form at admission.

OBJECTIF: Etudier si la survie à long terme chez les patients âgés avec une infection antérieure par le virus du chikungunya (IVC) est associée à la forme clinique présente dans la phase aiguë, telle que définie par la classification de l'OMS. MÉTHODES: Etude de cohorte rétrospective réalisée dans les hôpitaux universitaires de la Martinique. Les patients qui se présentaient au service des urgences en cas de suspicion d'IVC et qui avaient un diagnostic biologique positif d'ICV par la PCR à transcription inverse sur un échantillon plasmatique entre le 10 janvier et le 31 décembre 2014 étaient éligibles à l'inclusion. Le temps jusqu'au décès était le résultat principal. La relation indépendante entre les formes cliniques et le temps jusqu'au décès a été analysée à l'aide d'un modèle de Cox. RÉSULTATS: Au total, 268 patients ont été inclus. L'âge moyen était de 80 ± 8 ans, 53% étaient des femmes. La durée médiane du suivi était de 28 mois (intervalle: 0 à 39 ans). Au cours du suivi, 53 patients (19,8%) sont décédés. La durée médiane de survie était de 13,2 mois (intervalle: 0 à 33,6). A la fin du suivi, les taux de décès étaient de 4,6% pour les cas cliniques aigus, 19,0% pour les cas atypiques, 19,2% pour les cas aigus sévères et 23,5% pour les cas non classifiables. L'analyse multivariée a révélé que la forme clinique de l'IVC à l'admission était indépendamment associée à la survie à long terme (forme atypique: HR = 2,38; IC95%: 2,15-2,62; forme aiguë sévère: HR = 2,40; IC95%: 2,17-2,64; forme inclassable: HR = 2,28; IC95%: 2,06-2,51). CONCLUSION: La forme clinique lors de la présentation avec IVC a un impact significatif sur la survie à long terme. La prise en charge des patients atteints d'ICV devrait être adaptée à la forme clinique lors de l'admission.

Peri-operative complications of lumbar spine surgery in patients over eighty five years of age: a retrospective cohort study.

PURPOSE: To compare peri-operative complication rates in ≥ 85-year-old patients who underwent decompression surgery with or without instrumented fusion for degenerative disorders. METHODS: This study involved 907 patients who underwent lumbar spine surgery for degenerative disorders between January 2006 and June 2012. Of these, 33 patients (3.6% of the entire population) were over 85 years of age (85-94 years). Decompression-alone and instrumentation groups were compared in terms of comorbidities, American Society of Anesthesiologists (ASA)-physical status (PS) class, peri-operative complications, and Japanese Orthopedic Association (JOA) scores. RESULTS: Thirty-three ≥ 85-year-old patients underwent surgery. All were ASA-PS class 2 (94%) or 3. The decompression-alone (n = 19) and instrumentation (n = 14) groups did not differ in comorbidity (95 vs. 100%, P = 0.383) or ASA-PS class (P = 0.561). Both exhibited improved JOA scores (decompression-alone: 13.4/29 to 22.7/29; instrumentation: 8.6/29 to 17.9/29; P = 0.9068) and had similar peri-operative complication rates (21.0 vs. 28.5%, P = 0.374). CONCLUSIONS: Although instrumentation is considered more invasive than decompression, we detected no statistically significant differences in peri-operative complication rates between these two types of surgery in ≥ 85-year-old patients. Surgeons should perform instrumentation even in the patients over 85 years with ASA class 3 or less.

Clinical Outcome of Ischemic Stroke in Old Patients Versus Oldest-Old.

BACKGROUND: It is unclear whether very old patients benefit from stroke unit. The aim of our work was to compare the clinical outcome of patients with ischemic stroke aged either 70 or 80 (G 1) versus oldest-old greater than or equal to 81 years (G 2). METHODS: Of 1187 patients admitted with stroke during 5 years in our stroke unit, we included 252 patients with independent functional status (modified Rankin scale, [mRS] ≤ 2) before the stroke. All patients underwent clinical examination, blood test, electrocardiography, brain imaging, and cerebrovascular ultrasound. Clinical outcome was assessed with the mRS and National Institutes of Health Stroke Scale (NIHSS) at discharge. We considered favorable outcome mRS 0-2 at discharge. RESULTS: Of 252 patients included, 55% were male, 150 (59.5%) patients belonged to G1 and 102 (40.5%) G2. We detected a significant increase of atrial fibrillation, bronchoaspiration, mortality, higher NIHSS at admission, and worse functional status at discharge in G2. No significant differences in other demographic, vascular risk factors, hospital stay, NIHSS at discharge or subtype of stroke were found. NIHSS at discharge was the only independent predictor of good functional status (odds ratio 0.4; 95% confidence interval, 0.3-0.6; P < .001). CONCLUSIONS: Oldest-old patients showed similar NIHSS at discharge than younger patients despite having higher neurological severity at admission. Our results support the hypothesis that oldest-old patients have good recovery potential, and should not be excluded from the stroke unit. The worse functional status detected at discharge in these patients could be attributed to others factors and not to neurological severity.