[Geriatric assessment-evidence and application in otorhinolaryngology]. / Geriatrisches Assessment ­ Evidenz und Anwendungsmöglichkeiten in der HNO-Heilkunde.

BACKGROUND: Like most medical disciplines, otorhinolaryngology is confronted with an increasing number of elderly and very old patients. In addition to the challenges of diagnostics and treatment, questions related to the influence of geriatric multimorbidity and functional limitations on treatment decisions and success also arise. MATERIALS AND METHODS: A literature search was performed on the use of geriatric assessment instruments in otorhinolaryngology. RESULTS: While there are already a great deal of data on the interaction of hearing disorders and cognition, the importance of other common functional deficits for otorhinolaryngology is poorly understood. CONCLUSION: This article provides an overview of the most important instruments of geriatric assessment, including a discussion of their potential applicability in otorhinolaryngology.

[Operative risk of geriatric patients in cardiac surgery]. / Operatives Risiko geriatrischer Patienten in der Herzchirurgie.

BACKGROUND: Despite substantial progress in interventional cardiology, there are still many geriatric patients who require cardiac surgery. Estimation of the operative risk is therefore of great importance. OBJECTIVE: The prognostic value of the geriatric assessment for estimation of the operative risk was evaluated. MATERIAL AND METHODS: Between 2008 and 2009 a geriatric assessment was carried out on 500 patients before an urgent or elective cardiac surgery intervention. The primary endpoints were in-hospital death, death within 30 days after the intervention and stroke. A secondary endpoint was the combination of death, stroke and in-hospital complications. RESULTS: The average age of the patients was 77.1 ± 4.6 years and 44.3% of the particpants were women. Aortic stenosis was the primary reason for surgery in 49.2% of patients and coronary artery disease in 38.8% of patients. Half of the patients (56.5%) showed functional impairments in one or more evaluated domains. Significant limitations in cognitive function were present in 11.8% and in mobility in 2.4% of the patients. The 30-day mortality was 2.9% and stroke occurred in 1.4% of the patients. After multivariate analysis cognitive impairment remained independently associated with the operative mortality (odds ratio OR 3.8, 95% confidence interval CI 1.2-12.7). CONCLUSION: The perioperative mortality of older patients in cardiac surgery is low. A limited functional status detected in the geriatric assessment is associated with an increased mortality. Impaired cognitive function is an independent predictor of postoperative mortality.

Treatment of dementia patients with fracture of the proximal femur in a specialized geriatric care unit compared to conventional geriatric care.

To prove the efficiency of a specialized geriatric ward (cognitive geriatric unit, CGU) for patients with a fracture of the proximal femur and additional dementia, we conducted a matched-pair analysis comparing 96 patients with fracture of the proximal femur and additional dementia matched for age, sex, surgical treatment and the degree of cognitive impairment by MMSE score. A total of 48 patients were treated in the CGU, offering extended geriatric assessment, special education of staff, and architecture appropriate for patients with cognitive decline. Target criteria were a gain in the Barthel index and Tinetti score, the length of stay, new admissions to nursing home, the frequency of neuroleptic, antidepressant, and antidementive medication, and the number of specified clinical diagnoses for the dementia syndrome. Length of stay was significantly longer in the CGU. The increase of the Tinetti score was significantly higher in the patients in the CGU, regardless of the length of stay (analysis of covariance: treatment (CGU/non-CGU): F(1/93) = 9.421, p = 0.003; covariate (length of stay): F(1/93) = 3.452, p = 0.066, η(2) = 3.6%). In the intervention group, the number of definite diagnoses concerning the dementia syndrome was also higher. Comparison of drug treatment and the percentage of new admission to a nursing home did not differ between groups. Treatment in a specialized, "cognitive geriatric unit" seems to result in better mobility of demented patients with proximal fractures of the femur.

[Evidence-based treatment for elderly patients in cardiology]. / Evidenzbasierte Therapie für ältere Patienten in der Kardiologie.

More than half of all patients hospitalized with cardiovascular disease today are older than 75 years. The evidence level for recommendations in cardiovascular guidelines is often low despite the large number of randomized trials. This is especially true for elderly patients who have not been represented well in cardiovascular trials. All efforts should be made to establish a database sufficient for treatment recommendations in the growing group of elderly patients with cardiovascular diseases.

Antibody levels against Chlamydia pneumoniae and outcome of roxithromycin therapy in patients with acute myocardial infarction. Results from a sub-study of the randomised Antibiotic Therapy in Acute Myocardial Infarction (ANTIBIO) trial.

BACKGROUND: Results of studies concerning prevention of cardiovascular disease by treatment with macrolide antibiotics targeting C. pneumoniae infection are still controversial. This study describes the results of different tests for infection with C. pneumoniae as well as the effect of treatment with roxithromycin in patients with acute myocardial infarction (AMI) in relation to their serostatus against C. pneumoniae. METHODS: We analysed blood of 160 patients who came from the ANTIBIOtic therapy after an AMI ( ANTIBIO-) study, a prospective, randomised, placebo-controlled, double-blind study to investigate the effect of roxithromycin 300 mg/OD for 6 weeks in patients with an AMI. Anti- Chlamydia IgG-, IgA-, and IgM-antibodies of these patients were analysed by means of different test systems. RESULTS: There was a good correlation between the two IgG and IgA methods (r = 0.900, p < 0.001 and r = 0.878, p < 0.001, respectively), but marked differences in the prevalence of positive tests. This resulted in only moderate concordance values, as expressed by the Kappa coefficients, for IgG kappa = 0.611 (95% CI = 0.498-0.724, p < 0.001) and for IgA kappa = 0.431 (95% CI: 0.322-0.540, p < 0.001). No significant association between positive C. pneumonia titers and the combined clinical endpoint during the 12 month follow-up could be found. In all test systems used, patients with positive anti- C. pneumoniae titers did not benefit from roxithromycin therapy (p = ns). CONCLUSION: Depending on the test system used, there are large differences in the prevalence of anti- C. pneumoniae seropositive patients. Clinical events during the 12 month follow-up after AMI did not depend on serostatus against C. pneumoniae and treatment with roxithromycin did not influence these events, independently of the serostatus against C. pneumoniae. However, the power of this subgroup analysis was low to detect small but significant differences.

[Use of heparin in acute myocardial infarction in routine clinical practice in Germany. Results of the MITRA and MIR registries]. / Stellenwert des Heparins in der aktuellen Therapie des akuten Myokardinfarktes in Deutschland--Ergebnisse der MITRA- und MIR-Register.

OBJECTIVE: Among other adjunctive medication, heparin is widely used in the therapy of acute myocardial infarction (AMI) today. Large randomized trials, however, have shown inconclusive data on the benefit of adjunctive heparin therapy for patients with AMI. The aim of this study was to describe the use of heparin and complication rates in routine clinical practice today. METHODS: MITRA and MIR were multicenter registries of AMI patients in Germany. During the years 1994 to 1998, 22,697 patients were registered with MITRA and MIR. Of these patients 49.9% received reperfusion therapy. RESULTS: 21,004 patients (92%) received heparin during acute therapy of AMI. The following factors were associated with withholding heparin: Bleeding at admission (OR 4.7; CI 3.2-6.8), cardiogenic shock (OR 1.8; CI 1.4-2.3) and fibrinolytic therapy with streptokinase (OR 2.1; CI 1.8-2.3). Complication rates of patients with heparin were only slightly higher than among those without heparin: 1.7% strokes and 1.9% bleedings were reported among the patients with fibrinolysis and heparin compared to 1.3% strokes and 1.4% bleedings among patients without heparin (p = ns). Mortality rates were 14.1% for patients with and 27.3% for patients without heparin (p < 0.001). CONCLUSIONS: Of the patients in MITRA and MIR 92% received heparin during AMI. Patients with active bleeding or in critical condition received heparin significantly less often. The selection of critically ill patients may have contributed to the high mortality of patients without heparin for AMI. Bleeding complication rates of patients with adjunctive heparin were only slightly higher than reported in randomized trials.

Characterization and clinical course of patients not receiving aspirin for acute myocardial infarction: results from the MITRA and MIR studies.

BACKGROUND: Clinical trials have shown the efficacy of aspirin for acute myocardial infarction (AMI). However, not all patients receive aspirin for AMI. The aim of this study was to provide information on characteristics and clinical course of patients not treated with aspirin for AMI. METHODS: We analyzed the data of the Myocardial Infarction Registry (MIR) and the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) registry. MITRA and MIR were prospective multicenter registries of patients with ST segment elevation myocardial infarction in Germany. RESULTS: Of 22,572 patients registered from 1994 to 1998, 1767 (7.8%) did not receive aspirin within the first 48 hours after admission. Multivariate analysis revealed two main factors associated with withholding aspirin for AMI: relative contraindications to aspirin (gastric ulcer [odds ratio (OR) 4.9, 95% confidence interval (CI) 3.7-5.7], renal insufficiency [OR 1.4, 95% CI 1.1-1.8]), and critical clinical state at admission (cardiogenic shock [OR 1.5, 95% CI 1.2-2.1] and prehospital resuscitation [OR 1.8, 95% CI 1.4-2.2]). In addition, these patients were significantly less likely to receive reperfusion therapy and adjunctive medical therapy such as beta-blockers and angiotensin-converting enzyme inhibitors. In-hospital mortality after adjustment for baseline characteristics was 27.2% in patients without aspirin compared with 11.1% in patients treated with aspirin. CONCLUSIONS: Only a minority of AMI patients (7.8%) did not receive aspirin. Relative contraindications to aspirin and a critical clinical state at admission were the main factors associated with withholding aspirin for AMI. Even after adjustment for patient characteristics, the mortality of patients without aspirin was almost three times higher.