A sudden decline in mobility status as an early sign of acute infection in elderly patients: evidence from three case reports.

Early diagnosis of infections is often a challenge in older patients, since this age group may have atypical presentation. We report here the cases of 3 old patients, in whom a sudden decline in mobility status occurred shortly before the onset of the classically recognized features of infection. The decline was interpreted as an anticipatory marker of imminent infection. We discuss the possible implications of our findings and the opportunity that they offer to improve routine clinical practice in older patients.

The -308 (G/A) single nucleotide polymorphism in the TNF-alpha gene and the risk of major depression in the elderly.

OBJECTIVE: The immune system (IS) plays a key role in the mechanisms underlying major depression (MD) and pro-inflammatory cytokines seem to be particularly involved in the pathogenesis of the disease. There is growing evidence of a relationship between commonly studied single nucleotide polymorphisms (SNPs) in cytokine genes and an increased risk of MD.The aim of our study was to investigate the association between the -308(G/A) SNP in the tumour necrosis factor-alpha (TNF-alpha) gene and late-life MD in elderly people without dementia. METHODS: Blood samples were obtained from 50 subjects enrolled at the Geriatric Department of the San Gerardo Hospital in Monza, Italy, after screening with the geriatric depression scale (GDS > or = 15) and mini-mental state evaluation (MMSE > or = 24). The -308 (G/A) SNP was genotyped by SSP-PCR amplification. Two hundred and forty age-matched healthy volunteers were taken as the control group. RESULTS: Genotype and allele distributions in patients with MD were significantly different from those of the controls. In subjects affected by MD we found a higher percentage of the GG genotype (84 vs. 68,3%; p = 0.007) and thus of the G allele (92 vs. 81,9%; p = 0.05).The GG genotype was associated with a greater risk of developing the disease (OR 2.433, CI 1.09-5.43). CONCLUSIONS: Our study suggests that the -308 (G/A) polymorphism in the TNF-alpha gene could play a role in determining susceptibility to MD. An activation of the TNF-alpha system could contribute to the development of MD in the elderly.

Sarcopenia and malnutrition in acutely ill hospitalized elderly: Prevalence and outcomes.

BACKGROUND & AIMS: Data about the prevalence of sarcopenia among hospitalized patients is lacking and it is unclear whether the diagnostic criteria commonly used in community-dwellers is applicable in acutely ill subjects. The aims of this report are: (i) to assess the prevalence of sarcopenia among hospitalized patients; (ii) to assess whether the European Working Group on Sarcopenia in Older People (EWGSOP) criteria are applicable in an acute care setting; and (iii) to assess the mortality rate at 3 months. METHODS: 103 patients admitted to the Acute Geriatric Clinic were enrolled. Inclusion criteria were: age ≥65 years and malnutrition or risk of malnutrition, according to the Mini Nutritional Assessment Short Form. Sarcopenia was diagnosed using the EWGSOP criteria by means of bioimpedance analysis, handgrip strength and gait speed, within 72 h of admission. Information on deaths was obtained by telephone interview at 3 months following discharge. RESULTS: Sarcopenia was diagnosed in 22 patients (21.4%). Twenty-three patients (22.3%) were not able to perform the gait speed and/or the handgrip strength because bedridden or requiring intensive treatments. In this group, a definite diagnosis of sarcopenia was not possible, lacking at least one EWGSOP criteria. Eleven (10.7%) patients died within the 3 months post-discharge period. Kaplan-Meier survival curves showed that sarcopenic patients died significantly more frequently than others (log-rank p ≤ 0.001). CONCLUSIONS: In a population of hospitalized elderly malnourished or at risk of malnutrition, sarcopenia is highly prevalent and associated with an increased risk to die in the short-term. Furthermore, the EWGSOP criteria cannot be satisfactorily applied in a relevant proportion of patients.

Real-time US-CT/MRI image fusion for guidance of thermal ablation of liver tumors undetectable with US: results in 295 cases.

PURPOSE: This study was designed to assess feasibility of US-CT/MRI fusion-guided ablation in liver tumors undetectable with US. METHODS: From 2002 to 2012, 295 tumors (162 HCCs and 133 metastases; mean diameter 1.3 ± 0.6 cm, range 0.5-2.5 cm) detectable on contrast-enhanced CT/MRI, but completely undetectable with unenhanced US and either totally undetectable or incompletely conspicuous with contrast-enhanced US (CEUS), were treated in 215 sessions using either internally cooled radiofrequency or microwave with standard ablation protocols, guided by an image fusion system (Virtual Navigation System, Esaote S.p.A., Genova, Italy) that combines US with CT/ MRI images. Correct targeting and successful ablation of tumor were verified after 24 hours with CT or MRI. RESULTS: A total of 282 of 295 (95.6 %) tumors were correctly targeted with successful ablation achieved in 266 of 295 (90.2 %). Sixteen of 295 (5.4 %) tumors were correctly targeted, but unsuccessfully ablated, and 13 of 295 (4.4 %) tumors were unsuccessfully ablated due to inaccurate targeting. There were no perioperative deaths. Major complications were observed in 2 of the 215 treatments sessions (0.9 %). CONCLUSIONS: Real-time virtual navigation system with US-CT/MRI fusion imaging is precise for targeting and achieving successful ablation of target tumors undetectable with US alone. Therefore, a larger population could benefit from ultrasound guided ablation procedures.

Intraprocedural contrast-enhanced ultrasound (CEUS) in liver percutaneous radiofrequency ablation: clinical impact and health technology assessment.

OBJECTIVES: To assess the clinical and the economic impacts of intraprocedural use of contrast-enhanced ultrasound (CEUS) in patients undergoing percutaneous radiofrequency ablation for small (<2.5 cm) hepatocellular carcinomas. METHODS: One hundred and forty-eight hepatocellular carcinomas in 93 patients were treated by percutaneous radiofrequency ablation and immediate assessment by intraprocedural CEUS. Clinical impact, cost effectiveness, and budget, organisational and equity impacts were evaluated and compared with standard treatment without intraprocedural CEUS using the health technology assessment approach. RESULTS: Intraprocedural CEUS detected incomplete ablation in 34/93 (36.5 %) patients, who underwent additional treatment during the same session. At 24-h, complete ablation was found in 88/93 (94.6 %) patients. Thus, a second session of treatment was spared in 29/93 (31.1 %) patients. Cost-effectiveness analysis revealed an advantage for the use of intraprocedural CEUS in comparison with standard treatment (4,639 vs 6,592) with a 21.9 % reduction of the costs to treat the whole sample. Cost per patient for complete treatment was  4,609 versus  5,872 respectively. The introduction of intraprocedural CEUS resulted in a low organisational impact, and in a positive impact on equity CONCLUSIONS: Intraprocedural use of CEUS has a relevant clinical impact, reducing the number of re-treatments and the related costs per patient. TEACHING POINTS: • CEUS allows to immediately asses the result of ablation. • Intraprocedural CEUS decreases the number of second ablative sessions. • Intraprocedural CEUS may reduce cost per patient for complete treatment. • Use of intraprocedural CEUS may reduce hospital budget. • Its introduction has low organisational impact, and relevant impact on equity.

Takotsubo cardiomyopathy in an elderly patient with severe Alzheimer's disease: a case report.

We report on an 80-year-old woman with Alzheimer's disease who presented with Takotsubo cardiomyopathy. As usual for this condition, our patient showed clinical symptoms of chest pain, electrocardiographic changes, elevated myocardial markers, and transient left ventricular apical ballooning in the absence of significant coronary artery disease. Because Takotsubo cardiomyopathy is frequently associated with emotional stress, which triggers an increase in circulating catecholamines, our case suggests that this event should not be neglected in Alzheimer's disease patients and promotes the adoption of a "prosthetic" approach for individuals with dementia.