Oral anticoagulant therapy in older adults.

Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.

Prediction of short-term prognosis in elderly patients with acute pulmonary embolism: validation of the RIETE score.

Essentials The RIETE score was derived to predict 10-day adverse outcomes in acute pulmonary embolism (PE). We externally validated the RIETE score in a prospective cohort of patients with PE. The RIETE score classified fewer patients as low-risk than currently recommended scores. The RIETE score was not superior to other scores in predicting 10-day adverse outcomes. SUMMARY: Introduction The Registro Informatizado de la Enfermedad TromboEmbolica (RIETE) score was derived to identify patients with pulmonary embolism (PE) at low risk of overall complications. Objective To externally validate the RIETE score and compare its prognostic performance with the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI) and the Geneva Prognostic Score (GPS). Methods In a prospective multicenter cohort, we studied 687 elderly patients with acute PE. The primary outcome was 10-day overall complications (death, recurrent PE or major bleeding); the secondary outcome was 30-day overall mortality. We compared complications and mortality in low-risk vs. higher-risk patients and the area under the receiver operating characteristic (ROC) curve across scores. Results Overall, 27 patients (3.9%) had complications within 10 days and 22 (3.2%) died within 30 days. The RIETE score classified a smaller proportion of patients as low risk (31%) than the PESI (35%), sPESI (36%) and the GPS (90%). The proportion of low-risk patients based on the RIETE score, PESI, sPESI and GPS who had complications was 1.9%, 1.7%, 1.6% and 2.9%, respectively. The RIETE score had a lower area under the ROC curve (0.60) for predicting complications than the PESI (0.67), sPESI (0.65) and GPS (0.72). The area under the ROC curve for predicting mortality was similar (0.76-0.78) for all scores. Conclusion The RIETE score classified fewer patients as low risk than the other scores. It accurately identified patients at low risk of mortality but was not superior to other scores in predicting 10-day overall complications. TRIAL REGISTRATION: http://clinicaltrials.gov. Identifier: NCT00973596.

Venous thromboembolism in the elderly: A narrative review.

Persons aged ≥65years not only account for over 60% of venous thromboembolism (VTE) events, they have also a higher mortality and VTE-related morbidity than younger patients, including anticoagulation-related bleeding and the postthrombotic syndrome. However, only few studies have focused specifically on VTE in older persons and practice guidelines commonly extrapolate study results from younger healthier patients to the multimorbid elderly. Evidence suggests that the clinical presentation is more subtle in the elderly with VTE and that commonly used diagnostic modalities, including clinical prediction rules, D-dimer tests, and planar ventilation-perfusion scans are less specific and efficient in older persons. Moreover, because preventive and therapeutic anticoagulation trials often exclude elderly multimorbid patients who have an increased risk of bleeding, the optimal prophylactic approach in medical inpatients and the best therapeutic anticoagulation strategy in patients with confirmed VTE are uncertain in such patients. In this narrative review, we summarize the evidence on the risk, prevention, diagnosis, treatment, and prognosis of VTE in older patients. We also propose a research agenda to increase the evidence basis on VTE in older patients to optimize their quality of care. Given the fact that the incidence of elderly persons with VTE is likely to rise, future VTE research should attempt to enroll elderly multimorbid patients into pragmatic clinical trials and to increasingly incorporate patient-centered universal outcomes, such as health-related quality of life, functional status, symptom burden, and active life expectancy.

[Subacute lower back pain and acute kidney failure in a 47-year old man]. / Subakute lumbale Rückenschmerzen und akute Niereninsuffizienz bei einem 47-jährigen Mann.

A 47-year-old man presented with subacute, low back pain and increased creatinine levels. A CT scan showed an extrinsic, bilateral compression of the ureters by a retroperitoneal mass with pronounced uptake of 18F-fluorodeoxyglucose in positron emission tomography. Histological findings were consistent with the diagnosis of retroperitoneal fibrosis. Urological decompression was performed. The initiated corticosteroids led to a rapid clinical improvement and regression of the retroperitoneal mass. A relapse occurred after tapering of corticosteroids with a prompt response to increase of the dosage.

Variation of the carrier-envelope phase of few-cycle laser pulses owing to the Gouy phase: a solid-state-based measurement.

The carrier-envelope phase of a laser pulse has recently become an important quantity in extreme nonlinear optics. Because of the topological Gouy phase, it changes while the pulse propagates through the focus of a lens. This variation is measured by a simple solid-state-based approach. The experimental results are analyzed by comparison with simple analytical model calculations.

Light-induced gaps in semiconductor band-to-band transitions.

We observe a triplet around the third harmonic of the semiconductor band gap when exciting 50-100 nm thin GaAs films with 5 fs pulses at 3 x 10(12) W/cm(2). The comparison with solutions of the semiconductor Bloch equations allows us to interpret the observed peak structure as being due to a two-band Mollow triplet. This triplet in the optical spectrum is a result of light-induced gaps in the band structure, which arise from coherent band mixing. The theory is formulated for full tight-binding bands and uses no rotating-wave approximation.

Evidence for third-harmonic generation in disguise of second-harmonic generation in extreme nonlinear optics.

In contrast with traditional nonlinear optics, a peak at the spectral position of the second harmonic of a laser can also be generated in an inversion-symmetric medium in the regime of extreme nonlinear optics. We describe the underlying mechanism of such third-harmonic generation in disguise of second-harmonic generation and compare theory with the optical as well as the radio-frequency spectra measured in recent experiments on thin ZnO films. The peak at twice the carrier-envelope offset frequency in the radio-frequency spectra is shown to be an unambiguous signature of such a process.

Role of the carrier-envelope offset phase of few-cycle pulses in nonperturbative resonant nonlinear optics.

We study the influence of the carrier-envelope offset phase of few-cycle pulses on nonperturbative resonant extreme nonlinear optics in a semiconductor. If the Rabi frequency becomes comparable to the light frequency, the different Rabi sidebands interfere around twice the laser center frequency, giving rise to a signal which strongly depends on the carrier-envelope offset phase. This signature should be measurable in GaAs samples.

Determining the carrier-envelope offset frequency of 5-fs pulses with extreme nonlinear optics in ZnO.

We excite ZnO samples with two-cycle optical pulses directly from a mode-locked oscillator with average powers of several tens of milliwatts. The emitted light reveals peaks at the carrier-envelope offset frequency f(ø) and at 2f(ø) in the radio-frequency spectra. These peaks can still be detected in layers as thin as 350 nm-a step toward determining the carrier-envelope offset phase itself.

[Physiotherapy for the recreational athlete]. / Physiotherapie beim Freizeitsportler.

Physiotherapy plays a significant role in the treatment of sport injuries and can be especially adapted for this purpose. The physiotherapist has two tasks: 1. As a therapist treating a well defined pathologic entity or functional deficit. 2. Instructing the patient in further self-treatment and appropriate measures, behavioral changes and preventive approaches. The therapeutic emphasis is presented in seven interdependent groups: pain/swelling, flexibility, strength, coordination, endurance, psychological measures, preventive measures. The aim of treatment is to resume training activities. For each group there is a description of clinical symptoms, diagnosis according to functional tests and recommended treatment measures. The therapy group(s) and their priorities should be listed when making an individual therapeutic decision.

Signatures of carrier-wave Rabi flopping in GaAs.

For excitation of the model semiconductor GaAs with optical pulses which are both extremely short ( 5 fs) and extremely intense ( approximately 10(12) W cm(-2)), we can meet the condition that the Rabi frequency becomes comparable to the band gap frequency-a highly unusual and previously inaccessible situation. Specifically, in this regime, we observe carrier-wave Rabi flopping, a novel effect of nonlinear optics which has been predicted theoretically and which is related to the failure of the area theorem.

[How much strength is needed for fitness?]. / Wieviel Kraft braucht die Fitness?

In order to tolerate the exertion in fitness exercise in the long term a sufficiently strong trunk musculature should be aimed at. In order to stabilize and balance the trunk and the pelvis there should be an optimal interaction of the muscles of the abdomen, the lateral trunk, the back and the flexors and extensors of the hip. If that balance is disrupted, muscular imbalance and a weakening or shortening of the muscles involved can occur. That imbalance leads to inadequate and excessive strain of the functional system of spine and pelvis. The functional anatomy of the trunk is described with clinical references in order to elucidate this context. A program of strength and stretching exercises for the trunk is presented suited to the needs of those practicing fitness exercise.

[Manual therapy in lumbo-vertebral syndromes]. / Manuelle Therapie bei Lumbovertebralsyndromen.

Based upon the shortly presented survey among the members of the Swiss Medical Association for Manual Medicine, the low back pain problems are approached by the means of manual therapy on average 805 times per year and physician. On average each case with low back pain is treated 1,4 times by a general practitioner with experience in manual medicine while specialists who are dealing with more complex cases on average 4 to 5 times. The functional disorders of the lumbar spine treated by manual therapy are superior to the physiotherapy approach or in comparison with a "placebo group" (information by general practitioner about low back pain and application of medication). An appropriate indication for manual therapy is relevant to avoid or reduce the possible risk of the treatment procedure. The physician who performs the manual therapy has to know the limits of the method. Also the knowledge of contraindications for manual therapy will reduce the incidence of possible complication. However based upon the survey among the swiss association the side effects and complications due to manual therapy of the lumbal spine are extremely seldom.

[Manual therapy in lumbovertebral syndromes]. / Manuelle Therapie bei Lumbovertebralsyndromen.

Based upon the shortly presented survey among the members of the Swiss Medical Association for Manual Medicine, the low back pain problems are approached by the means of manual therapy on average 805 times per year and physician. On average each case with low back pain is treated 1,4 times by a general practitioner with experience in manual medicine while specialists who are dealing with more complexe cases on average 4 to 5 times. The functional disorders of the lumbar spine treated by manual therapy are superior to the physiotherapy approach or in comparison with a "placebo group" (information by general practitioner about low back pain and application of medication). An appropriate indication for manual therapy is relevant to avoid or reduce the possible risk of the treatment procedure. The physician who performs the manual therapy has to know the limits of the method. Also the knowledge of contraindications for manual therapy will reduce the incidence of possible complication. However based upon the survey among the swiss association the side effects and complications due to manual therapy of the lumbal spine are extremely seldom.

[General muscle rehabilitation practice]. / Praxis der muskulären Rehabilitation.

This article presents a five-step approach to the rehabilitation of sports injuries. (1) pain management; (2) specific exercise instruction for treatment of localized functional disturbances/motion restrictions; (3) training therapy to increase localized and general physical performance; (4) patient education and instruction of an individualized home/gym program and for precautions and injury prevention; and (5) enhancement of psychological performance. Described are the negative sequelae of a sports-related injury or immobilization after surgery on joints, bones and circulatory system, with particular emphasis of the effects on the involved musculature. The negative impact of an injury on generalized physical performance is presented (deconditioning syndrome). The course of rehabilitation requires a specific functional diagnosis, so as to implement an individualized treatment plan. Regular and objective follow-up/monitoring is suggested within the context of projected goals. The specific steps are described. Pain and discomfort can impede the restoration process and must be addressed effectively. Even though many questions remain to be answered in the field of muscular rehabilitation, the present day knowledge coupled with successful empirical interventions allow the introduction of effective and efficient rehabilitation concepts.

[Stretching]. / Stretching.

Static stretching exercises have become very popular over the past fifteen years both in professional and amateur sports. In the fields of physical therapy and in manual therapy, in particular, static stretching has become part of a standard and successful treatment modality. Together with an appropriate strengthening program, static stretching techniques have become the therapy of choice for treatment of muscle imbalances associated with functional disturbances of the musculoskeletal system. Specific muscle length testing procedures have been developed to determine muscle shortening in clinical practice. In this article, the fundamental principles of the different types of muscle stretching techniques are described, including the dynamic stretching and static stretching techniques. The exercises are organized along the concepts of passive static or neuromuscular stretching principles. The pertaining neurophysiologic fundamentals are discussed, as are the benefits of the individual methods of a functional exercise program. Examples are provided for the most important muscle groups.