Preoperative geriatric assessment of urological patients: a narrative review.

PURPOSE OF REVIEW: The proportion of older people is increasing disproportionately. The age between 60 and 65 years is seen as the transition to 'old age'. Frailty is a risk factor for morbidity, mortality, and complications in the context of medical interventions or adverse effects of drug therapies. One of the core components of frailty, the age-related loss of muscle mass, is sarcopenia. Is there an influence of frailty, as well as sarcopenia and some other aspects, i.e. malnutrition, on the outcome in elderly urologic patients? RECENT FINDINGS: These phenomena of aging correlate with the incidence postoperative complication, infections, readmission rates or mortality. There are numerous studies on the value and informative value of the 5-item frailty index or the G8 questionnaire in older urological patients. SUMMARY: Geriatric assessment is becoming increasingly important in urological surgery. Simple instruments that are practicable in clinical routine are required in this clinical setting. Which method of preoperative assessment is chosen is secondary. It is important that the risk of geriatric syndromes is assessed prior to surgical interventions in order to determine the most suitable therapeutic approach for each patient.

Sarcopenia-a geriatric pandemic : A narrative review.

With growing life expectancy, the prevalence of frailty and sarcopenia will continuously increase during the next decades. Geographical differences have been described, and depending on the population studied, sarcopenia is evident in 10% of community-dwelling people, increasing up to 40 to 50% among those living in nursing homes. Sarcopenia is a complex age-related process of multifactorial pathogenesis, influenced by lifestyle, nutrition, biological processes during aging, and also immunological and endocrine mechanisms. For diagnostic criteria, physical parameters (muscle mass measurement) and functional aspects (muscle strength, gait speed, physical performance) are required. In routine clinical care, screening patients using the SARC­F questionnaire is recommended by recent guidelines of the European Workgroup for Sarcopenia.

[Coronavirus disease 2019 and frailty]. / "Coronavirus disease 2019" und Frailty.

The course of coronavirus disease 2019 (COVID-19) varies from individual to individual. People of advanced age with comorbidities have been identified as having a higher risk for severe disease or to die from COVID-19. Frailty is an essential risk factor in this respect. Approximately one fifth of the middle European population are older than 65 years, and of these 10-15% can be categorized as frail. The pandemic brings the healthcare systems in many countries to their limits. Deciding which patients should be transferred to intensive care units (ICU) raises ethical discussions. In some countries the Rockwood Clinical Frailty Scale (CFS) is used to support this decision. Patients over 80 years of age suffering from COVID-19 show a 3.6-fold increase in the risk of mortality compared to the group aged 18-49 years. The risk of frail (CFS scores 6-9) patients is three times higher than for robust patients (CFS scores 1-3). A CFS score cut-off ≥ 6 clearly correlates with mortality of COVID-19 patients older than 65 years. Additionally, mid-term and long-term survival is determined by the degree of frailty at the time before COVID-19 rather than by the severity of the disease. Patients over 60 years are particularly at risk to develop a rapid loss of muscle mass during moderate or severe COVID-19. Patients being treated on ICUs lose 20-30% of their thigh extensor muscle mass within 10 days. The extent of sarcopenia associated with COVID-19 is decisive in determining the course of the disease and makes individually tailored rehabilitation programs necessary. Up to 50% of hospitalized patients need further rehabilitation after discharge. Aerobic training of low intensity combined with resistance training as well as a sufficient supply of calories and proteins in the diet are essential in this respect.

Evaluation of thoracic impedance trends for implant-based remote monitoring in heart failure patients - Results from the (J-)HomeCARE-II Study.

AIMS: Remote monitoring by implantable devices substantially improves management of heart failure (HF) patients by providing diagnostic day-to-day data. The use of thoracic impedance (TI) as a surrogate measure of fluid accumulation is still strongly debated. The multicenter HomeCARE-II study evaluated clinically apparent HF events in the context of remote device diagnostics, focusing on the controversial role of TI. METHODS AND RESULTS: We followed 497 patients (66.6 ±â€¯10.1 years, 77% male, QRS 139.8 ±â€¯36.0 ms, ejection fraction 26.8 ±â€¯7.0%) implanted with a CRT-D (67%) or an ICD (33%) for 21.4 ±â€¯8.1 months. An independent event committee confirmed 171 HF events of which 82 were used to develop a TI-based algorithm for the prediction of imminent cardiac decompensation. Highly inter-individual variations in patterns of TI trends were observed. The algorithm resulted in a sensitivity of 41.5% (50.0%) with 0.95 (1.34) false alerts per patient year, and a positive predictive value of 7.9% overall and 27.9% in the HF event group of patients. Averaged ratio statistics showed a significant pre-hospital decrease and a highly significant in-hospital increase in TI after intensified diuresis. Recurrent decompensations turned out to be preceded by a significantly stronger decrease of TI compared to first events with a higher chance for detection (63.6% sensitivity, p < 0.05). CONCLUSIONS: Overall performance in predicting imminent decompensation by monitoring TI alone is limited due to its high inter-patient variability. TI stand-alone applications should be redirected towards a target population with more advanced symptoms where post-hospital observation aimed to maintain the patient's discharge status might be the most valuable approach. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT00711360 (HomeCARE-II) and NCT01221649 (J-HomeCARE-II).

Rheumatoid arthritis and falls: the influence of disease activity.

OBJECTIVE: To examine the correlation between disease activity of RA and the risk of falling. METHODS: Seventy-eight patients were tested. Disease activity was measured with acute-phase reactants, autoantibodies, swollen and tender joint count (SJC28, TJC28), pain on a visual analogue scale (VAS pain), patient and evaluator global assessment of disease activity (PGA, EGA), HAQ disability index (HAQ-DI), 28-joint DAS (DAS-28) and the clinical and simple disease activity indexes (CDAI, SDAI). The risk of falling was evaluated by a fall assessment consisting of Tinetti test (TIT), timed get up and go test (TUG), chair-rising test (CRT), tandem walk and tandem stand test. RESULTS: During the last 12 months, 26.9% of the participants reported a fall and 46.2% mentioned the fear of falling. The most evident link [Spearman's correlation (r(s))] with the results of the fall assessment was found in HAQ-DI (CRT: r(s) = 0.523, TUG: r(s) = 0.620, TIT: r(s) = -0.676), CDAI (CRT: r(s) = 0.460, TUG: r(s) = 0.504, TIT: r(s) = -0.472), VAS pain (CRT: r(s) = 0.441, TUG: r(s) = 0.616, TIT: r(s) = -0.548) PGA (CRT: r(s) = 0.473, TUG: r(s) = 0.577, TIT: r(s) = -0.520) and TJC (CRT: r(s) = 0.488, TUG: r(s) = 0.394, TIT: r(s) = -0.385). Patients with higher disease activity achieved poorer results in the fall assessment. CONCLUSION: The strongest correlation with falls was evident for patient-reported outcomes. Pain seems to be the common ground of these parameters. At the same time, disease activity influences pain. The results suggest an increased attention towards the risk of falling with patients of higher levels of disease activity or pain, and physio- or ergotherapeutical interventions as needed.

Dynamic mechanism for initiation of ventricular fibrillation in vivo.

BACKGROUND: Dynamically induced heterogeneities of repolarization may lead to wave-front destabilizations and initiation of ventricular fibrillation (VF). In a computer modeling study, we demonstrated that specific sequences of premature stimuli maximized dynamically induced spatial dispersion of refractoriness and predisposed the heart to the development of conduction block. The purpose of this study was to determine whether the computer model results pertained to the initiation of VF in dogs in vivo. METHODS AND RESULTS: Monophasic action potentials were recorded from right and left ventricular endocardium in anesthetized beagle dogs (n=11) in vivo. Restitution of action potential duration and conduction time and the effective refractory period after delivery of the basic stimulus (S(1)) and each of 3 premature stimuli (S(2), S(3), S(4)) were determined at baseline and during verapamil infusion. The effective refractory period data were used to determine the interstimulus intervals for a sequence of 4 premature stimuli (S(2)S(3)S(4)S(5)=CL(VF)) for which the computer model predicted maximal spatial dispersion of refractoriness. Delivery of CL(VF) was associated with discordant action potential duration alternans and induction of VF in all dogs. Verapamil decreased spatial dispersion of refractoriness by reducing action potential duration and conduction time restitution in a dose-dependent fashion, effects that were associated with reduced inducibility of VF with CL(VF). CONCLUSIONS: Maximizing dynamically induced spatial dispersion of repolarization appears to be an effective method for inducing VF. Reducing spatial dispersion of refractoriness by modulating restitution parameters can have an antifibrillatory effect in vivo.

Response of elderly patients with rheumatoid arthritis to methotrexate or TNF inhibitors compared with younger patients.

OBJECTIVE: To compare the efficacy of MTX and MTX+TNF inhibitors (TNFis) in elderly patients with RA with that in patients of younger age. METHODS: Data from two large, randomized, controlled, double-blind trials in patients with early RA using adalimumab or infliximab+MTX or MTX alone were obtained and pooled. Composite disease activity indices were calculated at baseline and 1 year of treatment, and compared in groups of patients classified by quartiles of age with the highest age group comprising 61-82 years using analysis of variance or Kruskal-Wallis test. RESULTS: Across all age quartiles, improvement on MTX was similar with respect to changes of composite disease activity indices, assessment of physical function and X-ray progression. Likewise, TNFi+MTX had similar effects across all age groups, but the effects of the combination were more profound than those of MTX monotherapy. Also in 10% of the patients with the highest age, primarily septuagenarians, improvement was seen to a similar degree as in the younger ones. CONCLUSIONS: Responsiveness of elderly patients with RA to MTX or TNFi+MTX is similar to that observed in patients of younger age.

Cryoballoon ablation of paroxysmal atrial fibrillation within the dilated coronary sinus in a case of persistent left superior vena cava.

Trigger sources of paroxysmal atrial fibrillation (PAF) are not limited to a pulmonary vein origin and may be achievable by cardiac vascular structures like the coronary sinus (CS), the vena cava superior and in some rare cases by a persistent left superior vena cava (LSVC). Cryoballoon ablation has been shown to be effective in pulmonary vein isolation. We report an unusual case of using this technique in the dilated CS in case of a persistent LSVC. A 64 year old patient presented PAF recurrences after cryo pulmonary vein isolation 4 months before. A maintaining pulmonary vein isolation could be demonstrated by transseptal mapping. Further bi-atrial mapping localized repetitive atrial trigger activity in a dilated CS proceeding to a LSVC. A cryoballoon was deployed in the CS target area and during cryoablation the triggered activity suspended. Ablation side effects were excluded by coronary angiography. During a follow up time of 8 months the patient has remained free of PAF recurrences. The current report underlines the importance of a patient-tailored ablation approach. Cryothermic balloon technology may be more applicable in delicate cardiac structures by developing new anatomically adapted balloon shapes and sizes.

Automatic magnetic-guided electroanatomical mapping and remote-controlled ablation of atypical and typical atrial flutter.

UNLABELLED: Two patients with inconclusive surface electrocardiogram patterns underwent nonfluoroscopy automatic mapping and remote-controlled ablation of nonisthmus and isthmus-dependent right atrial flutter. METHODS AND RESULTS: A 0.08 magnetic vector force and a motor drive enable a complex steering of a new 8-mm magnet tip electrode. The navigation system performs atrial electroanatomical mapping fully automatically. Total procedural fluoroscopy time for ablation of nonisthmus-related atypical and isthmus-dependent flutter was 8.5 and 3.2 minutes, respectively. CONCLUSION: Automatic electroanatomical mapping offers a promising option to effectively guide the remote-controlled ablation of atrial reentry tachycardias and to reduce fluoroscopy time.

Altered dynamics of action potential restitution and alternans in humans with structural heart disease.

BACKGROUND: Restitution kinetics and alternans of ventricular action potential duration (APD) have been shown to be important determinants of cardiac electrical stability. In this study, we tested the hypothesis that APD restitution and alternans properties differ between normal and diseased human ventricular myocardium. METHODS AND RESULTS: Monophasic action potentials were recorded from the right ventricular septum in 24 patients with structural heart disease (SHD) and in 12 patients without SHD. Standard and dynamic restitution relations were constructed by plotting APD as a function of the preceding diastolic interval. The dynamic restitution relation of both groups showed a steeply sloped segment at short diastolic intervals that was associated with the occurrence of APD alternans. Patients with SHD had a wider diastolic interval range over which APD alternans was present (mean+/-SEM 68+/-11 versus 12+/-2 ms) and showed an earlier onset (168+/-7 versus 225+/-4 bpm) and an increased magnitude (20+/-2 versus 11+/-2 ms) of APD alternans compared with patients without SHD. The occurrence of APD alternans during induced ventricular tachycardia (6 episodes) and during rapid pacing could be derived from the dynamic restitution function. CONCLUSIONS: There are marked differences in the dynamics of APD restitution and alternans in the ventricular myocardium of patients with SHD compared with patients without SHD. These differences may contribute importantly to cardiac electrical instability in diseased human hearts and may represent a promising target for antiarrhythmic substrate modification.

Progression of heart failure in right univentricular pacing compared to biventricular pacing.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves hemodynamics and symptoms of heart failure by reducing ventricular dyssynchronity. Conversely, recent studies have demonstrated that right univentricular pacing in patients with an ejection fraction below 40% aggravates heart failure. In this retrospective study, we compared progression of disease in patients with mild to moderate heart failure that were treated with a right univentricular pacing device and patients with congestive heart failure that were treated with a biventricular system. METHODS: 107 patients were included. 59 received a right ventricular pacing device and 48 a biventricular system. Patients were assessed after 1 and 6 months by NYHA class, echocardiographic parameters (EF, LVEDD) and hospitalization for heart failure. RESULTS: Hospitalization for heart failure after implantation of the devices was more frequent in patients that received a conventional pacemaker with a single lead in the right ventricle than in patients that were treated with a CRT system (12% vs. 6%, p<0.05), although heart failure was more advanced in the CRT group at baseline. Ejection fraction in the right ventricular pacing group further decreased from 43%+/-4 at baseline to 38%+/-4 after 6 months (p<0.05). Left ventricular enddiastolic diameter (LVEDD) was 51+/-7 mm and 58+/-6 mm (p<0.05) at 6 months. In the CRT group, EF was 23%+/-4 at baseline and 31%+/-7 after 6 months (p<0.05.). LVEDD improved from 56+/-4 mm before implantation to 52+/-7 mm and 6 months (p<0.05). CONCLUSION: Progression of heart failure symptoms in the right univentricular pacing group was more pronounced compared to the CRT group, despite the fact that patients assigned to the CRT group had more severe symptoms of heart failure at baseline. Biventricular pacing relieved symptoms of heart failure, whereas right univentricular pacing with subsequent conduction delay of the left ventricle further deteriorated pre-existing heart failure. Therefore, patients with an indication for pacemaker therapy because of bradycardia and co-existing mild to moderate heart failure might benefit from early implantation of a CRT system.

Challenge of cancer in the elderly.

Despite the sustained trend of decreasing overall cancer incidence, the number of elderly patients with cancer will considerably increase in the coming years, as the incidence of cancer is elevated 11-fold after the age of 65 years compared to adults up to 65 years. This soon-to-erupt tsunami of elderly patients with cancer requires adequate treatment, for which guidelines and evidence-based data are still scarce, given the longlasting under-representation of elderly patients with cancer in cancer trials. Older adults present not only with the physiological decreases of organ functions related to age, but also with an individual burden of comorbidities, other impairments and social factors that might impact on their potential for undergoing cancer care. Close collaboration with gerontologists and other health professionals to assess the personal resources and limitations of each person enables providing adequate therapy to elderly patients with cancer. There are promising achievements in each of the requirements listed, but a huge, holistic effort has still to be made.

[Guidelines for vaccination of immunocompromised individuals]. / Impfungen bei Immundefekten/Immunsuppression - Expertenstatement und Empfehlungen.

Immunosuppression of various origins is associated with an increased risk of infection; therefore the prevention of infectious diseases by vaccination is especially important in immunocompromised patients. However, the response to vaccinations is often reduced in these risk groups and the application of live vaccines is contraindicated during immunosuppression.In the following expert statement, recommendations for vaccination were created on the basis of current evidence and theoretical/immunological considerations. A first, general part elaborates on efficacy and safety of vaccinations during immunosuppression, modes of action of immunosuppressive medications and recommended time intervals between immunosuppressive treatments and vaccinations. A core piece of this part is a graduation of immunosuppression into three stages, i. e. no relevant immunosuppression, mild to moderate and severe immunosuppression and the assignment of various medications (including biologicals) to one of those stages; this is followed by an overview of possible and necessary vaccinations in each of those stages.The second part gives detailed vaccination guidelines for common diseases and therapies associated with immunosuppression. Primary immune deficiencies, chronic kidney disease, diabetes mellitus, solid and hematological tumors, hematopoetic stem cell transplantation, transplantation of solid organs, aspenia, rheumatological-, gastroenterologic-, dermatologic-, neurologic diseases, biologicals during pregnancy and HIV infection are dealt with.These vaccination guidelines, compiled for the first time in Austria, aim to be of practical help for physicians to facilitate and improve vaccination coverage in immunocompromised patients and their household members and contact persons.

[Demineralising osteopathies: new aspects of diagnostic imaging]. / Demineralisierende Osteopathien: neue Aspekte der radiologischen Diagnostik.

The wide use of multimodal radiologic analysis of bone tissue has led to a new concept of the term osteopenia towards grouping the various osteopathies as demineralizing osteopathies. With bone densitometry measurements both high precision and accuracy can be achieved, whereas conventional radiographs provide insights into the architecture of the bone to better advantage. By using both modalities discrepancies of the radiological reports with the final diagnosis may be avoided. Despite ongoing success in techniques of semi-automated data analysis and reporting the radiological and the clinical assessment of bone diseases are still an indispensable part of establishing the diagnosis.

Recurrence of paroxysmal atrial fibrillation after cryoisolation of the pulmonary veins. Is a "redo" procedure using the cryoballoon useful?

BACKGROUND: Pulmonary vein (PV) isolation with the cryoballoon technique is an effective and safe method to treat patients with paroxysmal atrial fibrillation (AF). However, the optimal treatment strategy for patients with recurrences after this ablation is unclear. AIMS: The aim of this single centre study was to evaluate the efficacy and safety of a "redo" procedure using the cryoballoon in this patient cohort. The secondary study objectives were to determine the rate of reconduction for individual PVs of the patients undergoing "redo" ablation and potential predictors of persistent PV isolation (PVI). METHODS: Between April 2006 and September 2009, all patients with paroxysmal AF recurrences after cryoballoon ablation a "redo" ablation with the cryoballoon was offered. PV conduction was determined and cryoapplications were performed in all reconnected PVs. Every 3 months, 7-day Holter ECG, symptom-driven transtelephonic ECG recordings, and questionnaires were collected for 12 months. RESULTS: Forty-seven patients underwent "redo" cryoballoon ablation. In all these patients, at least one PV with reconduction was found. Recurrent conduction was documented in 63 % of the left superior PV, 56 % of the left inferior PV, 43 % of the right superior PV, and 56 % of the right inferior PV. In 28 of the 47 patients (60 %), no AF recurrence was detectable during the 12-month follow-up (after 3 months blanking period). Rate of severe complications was low and not significantly different from that of the initial ablations. CONCLUSION: "Redo" ablation using cryoballoon technology may be an effective and safe method to treat patients with recurrence of paroxysmal AF after cryoballoon PVI.

[Early arthritis: action desired - treatment required]. / Arthritis - rechtzeitig handeln heisst behandeln.

Rheumatoid Arthritis (RA) is the most prevalent inflammatory joint disease in adults and shows a destructive course in most cases. The outcome of the disease - functional decline and invalidity - necessitates an early therapy. Recent studies demonstrate that the initiation of the treatment with a disease modifying antirheumatic drug (DMARD) treatment within the first three months after the onset of symptoms is crucial for sustained improvement of prognosis as well as therapeutic success and outcome. In the early stage of the disease, the criteria for the classification of Rheumatoid Arthritis (RA) are frequently not met. Up to over 50% of the patients show an arthritis, which cannot be classified and therefore is seen as undifferentiated arthritis (UA). Early therapeutic intervention appears to prevent the chronification of the disease; thus an early and appropriate disease modifying therapy is mandatory. Age, gender, involvement of the hands, positive rheumatoid factor, as well as the detection of anti cyclic-citrullinated peptide antibodies (anti-CCP Ab) are predictors of the development of RA. Beside conventional X-rays, there are other imaging methods such as magnetic resonance tomography imaging, Power-Doppler or contrast medium enhanced sonography, which may enable the detection not only of synovitis but also of erosive lesions at very early stages. Those patients suffering from UA carry a high risk for the development of a destructive arthritis as seen in RA, and therefore should be treated with an adequate DMARD. In these cases methotrexate is still the drug of first choice.

Targeted therapy in rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is the most common inflammatory joint disease in adults leading to pain and disability. New drugs, called biologicals, have opened up new possibilities in the treatment of RA. OBJECTIVE: Targeting pro-inflammatory cytokines such as tumour necrosis factor-α (TNF-α) or interleukin-1 (IL-1) is well established in clinical care of RA patients. However, lack or loss of clinical response occurs in up to 25% of the patients. New strategies beyond these targets, namely blocking T cells by abatacept or B cells by rituximab (RTX), have been introduced recently. METHODS: All relevant clinical trials published in peer-reviewed journals are discussed in this article. Data from abstracts presented at congresses have not been included. CONCLUSION: TNF blocking agents have significantly improved therapy of and outcome in RA patients and, therefore, are still the first choice biologicals for the treatment of RA. Alternatively, abatacept or RTX offer new options in case of inefficacy of or contraindications against anti-TNF therapy. Forthcoming drugs, such as tocilizumab, will extend our armamentarium to treat RA effectively.