Acute changes in circulating hormones in older patients with impaired ventricular function undergoing on-pump coronary artery bypass grafting.

OBJECTIVES: Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) causes an acute stress response characterized by changes in the levels of several hormones, which might play a role in the high complication rate experienced by older patients after CABG. Thus, the aim of the study was to investigate changes in the circulating levels of anabolic and catabolic hormones in old people undergoing CABG with CPB. DESIGN: Intervention case study. METHODS: 19 patients (12 males, 7 females) aged 70.1 +/- 6.1 yr (age range 62-80) with coronary artery disease and an ejection fraction <40% who underwent cardiac surgery. Cortisol (Cort), DHEA, DHEAS, LH, estradiol (E2), total testosterone (Te), SHBG, IGF-I were measured the day before, on the day of the procedure and 1, 2, 3, 4, and 30 days after CABG. RESULTS: After surgery, serum IGF-I levels decreased (p<0.001), while levels of Cort, DHEAS and E2 significantly increased in both men and women. Alterations in Te levels differed between the two sexes with a significant decline in men and a significant increment in women. CONCLUSION: CABG with CPB resulted in a dramatic drop in Te levels in old men and a significant decline in IGF-I in both sexes. Serum Cort levels also significantly increased in both sexes. These hormonal changes may, at least partially, explain why the elderly need prolonged rehabilitation after CABG.

Pituitary function in chronic heart failure in the elderly.

Heart failure is a complex syndrome characterized by the activation of hemodynamic, immunologic and neurohormonal systems, which have beneficial effects in the short run, but will ultimately lead to secondary end-organ damage with worsening of LV remodeling and subsequent cardiac decompensation. A very important role seems to be played by modifications of the pituitary hormone systems. Due to the neurohormonal activation there is an increase in the activity in the renin angiotensin system, in the adrenergic nervous system, and in the cytokine system. In heart failure there is a decrease in many anabolic hormones, such as a decrease of GH and IGF-I, of DHEA/DHEAS with normal or increased F, and a decrease of LH and sex steroids, resulting in an important catabolic drive, capable of contributing to the development of cardiac failure and to sarcopenia and/or cachexia, frequently observed in the advanced stages of the disease. However, these hormone alterations have been described in relatively young patients with chronic heart failure, since the mean age of all the subjects studied was of about 60 yr and none of the studies have specifically addressed this issue in the very old patients, who represent the largest portion of population affected by this pathological condition. The role of hormone replacement therapy needs to be verified in a population of elderly patients with heart failure.

Giving bad news: a GPs' narrative perspective.

The purpose of this study was to explore GPs' perspectives on giving bad news during consultations. To this end, 168 GPs were asked to recall, and record on the first page of a questionnaire, an occasion when they had given medically related bad news to a patient. The stories were analysed with a qualitative and interpretative approach. Two axes, each with a semantic polarity, were identified: a relational axis (semantic polarity: escape vs accompanying) and an ethical axis (semantic polarity: the doctor's choice vs the patient's choice). Furthermore, two main topics appeared to be common to almost all the narratives: the need to reassure the patient and the account of the doctor's emotions. Two different relational patterns appear to be described by doctors. A substantial number of GPs implicitly describe a disease- or doctor-centred consultation: in these cases the physicians refer to signs and symptoms, diagnosis and treatments; they decide for themselves whether to tell the truth or not. On the other hand, a smaller number describe consultations that could be defined as patient centred: these doctors consider that their duty of care for the individual ill person is paramount and try to respect the patient's right to decide. In both these relational patterns, GPs feel it is a fundamental professional duty to reassure the patient; furthermore, they feel the most difficult aspect is managing their own emotional responses.