[Prevalence and prognostic importance of riskfactors for long hospital stay within elderly patients admitted to a hospital; a clinical-empirical study]. / Prevalentie en prognostisch belang van risicofactoren voor lange opnameduur onder ouderen bij ziekenhuisopname; een klinisch-empirische studie.

BACKGROUND: Of elderly patients (> 70 years) admitted to a general hospital 35% suffer from loss of self-care abilities compared to the level before admission. Risk of loss of self-care ability increases with age up to 65% after tthe age of 90. In addition, for many of these patients the duration of hospitalisation is relatively long. OBJECTIVE It is important to identify in an early stage frail-elderly patients who are at risk of a relatively long hospital stay. We conducted a study of the prevalence at intake (1st of 2nd admission day) of ten clinically relevant, patient-bound risk factors for a long hospital stay among 158 patients (> 60 years), acute and planned admitted to Vlietland Hospital. In addition, the prognostic value of the dichotomous risk factors for length of hospital stay was estimated as indicator of treatment complications. The ten clinically relevant risk factors were home care, history of falling, medication (> 4), weight loss, cognitive level and functioning, self-care, psychiatric symptoms, health status and quality of life. RESULTS: There was a high prevalence of risk factors; 47.5% of the elderly patients had four or more risk factors at intake. Home care and global cognitive deterioration were significant predictors of longer length of hospital stay. Furthermore, acute admission, weight loss, psychiatric symptoms and health status seemed important. The explained variance of the prognostic model was relatively small. CONCLUSION: The findings in this explorative-observational study showed a high prevalence of clinically relevant, patient-bound risk factors in elderly people in a general hospital. Some risk-factors were of prognostic interest for long hospital stay, although the explained variance was relatively small. This indicates that a more comprehensive study should be designed and conducted to include other patient-bound risk factors like co-morbidity, caregiver issues and social environment. Moreover, non-patient-bound factors should be addressed like intrinsic and logistic factors within the hospital, and the quality of recuperation programmes. Understanding of these factors contributes to timely identification of elderly patients, who are at high risk of a long hospital stay. Future policy is to perform specific treatment programmes for elderly patients identified as being patients at risk. Multidisciplinary person-oriented interventions and case management focussed on risk factors and functional recovery will be provided parallel and after hospital treatment period. Comprehensive scientific research on the cost-effectiveness of such a programme has started at the end of 200oo9 in Vlietland Hospital, Schiedam.

Improvement of spontaneous speech in early stage Alzheimer's with rivastigmine.

OBJECTIVES: Placebo-controlled trials have shown that rivastigmine can delay cognitive deterioration in patients with mild to moderate Alzheimer's disease (AD). Benefits on cognitive functioning, as measured with the ADAS-Cog, occur on a daily dose of 6-12 mg when used for at least 6 months. The effect of rivastigmine on the adequacy of spontaneous speech is unknown. This study aimed to (i) compare the spontaneous speech of AD patients with the spontaneous speech of persons with normal cognition, (ii) compare the spontaneous speech of the same group of AD patients before and after treatment with rivastigmine. METHODS: Spontaneous speech of AD patients (n=9) was compared with that of healthy elderly volunteers (n=8). In the patient group, spontaneous speech was analysed before and after treatment with rivastigmine. RESULTS: Before treatment, 100% discrimination was found between the spontaneous speech of AD patients and of healthy volunteers based on two linguistic parameters: empty words and compound sentences. After treatment with rivastigmine the spontaneous speech of the AD patients improved on these two variables, while the ADAS-Cog scores decreased. Mean interval between the two spontaneous speech samples was 8.89 months. CONCLUSION: Assessment of spontaneous speech might be a valid parameter to discriminate between normal cognition and AD, and to evaluate the effects of anti-AD medication.

Continuous infusion of low-dose 5-Aza-2'-deoxycytidine in elderly patients with high-risk myelodysplastic syndrome.

There is no standard therapy for elderly patients with high-risk myelodysplastic syndrome (MDS). The treatment options of low-dose Ara-C and haematopoietic growth factors are disappointing in regard to response rate or response duration. We tested the treatment with a 72-h continuous infusion of low-dose 5-Aza-2'-deoxycytidine (DAC) in a group of 29 elderly patients with high-risk MDS. In 15 patients (54%) we observed a response. Eight complete responses were reached, even among patients with bad prognostic cytogenetic findings. The actuarial median survival from the start of the therapy was 46 weeks. The only (and major) toxicity was myelosuppression, leading to a prolonged cytopenic period and thus leading to five toxic deaths (17%) in this high-risk patient group. We conclude that DAC is an effective drug in the treatment of MDS patients and that it probably works via its cytotoxic activity. Myelotoxicity is its major adverse effect.

Continuous infusion of low-dose 5-Aza-2'-deoxycytidine in elderly patients with high-risk myelodysplastic syndrome.

There is no standard therapy for elderly patients with high-risk myelodysplastic syndrome (MDS). The treatment options of low-dose Ara-C and haematopoietic growth factors are disappointing in regard to response rate or response duration. We tested the treatment with a 72-h continuous infusion of low-dose 5-Aza-2'-deoxycytidine (DAC) in a group of 29 elderly patients with high-risk MDS. In 15 patients (54%) we observed a response. Eight complete responses were reached, even among patients with bad prognostic cytogenetic findings. The actuarial median survival from the start of the therapy was 46 weeks. The only (and major) toxicity was myelosuppression, leading to a prolonged cytopenic period and thus leading to five toxic deaths (17%) in this high-risk patient group. We conclude that DAC is an effective drug in the treatment of MDS patients and that it probably works via its cytotoxic activity. Myelotoxicity is its major adverse effect.

Monitoring heparin treatment with the APTT: the effect of methodological changes on the APTT.

OBJECTIVE: To assess the effect on the desired activated partial thromboplastin time (APTT) of altered practice in the laboratory control of heparin treatment. METHODS: Descriptive study of the number of APTTs in the desired range (DR) in 1987 (historical controls) and in 1992/1993. In the latter period, four changes in the implementation of heparin treatment took place: another coagulation analyser was used, laboratory control was intensified with a nomogram as guideline, and the DR was changed form 90-120 to 45-60 s. Furthermore, a standard heparin solution of 417 U/ml was supplied by the hospital pharmacy. RESULTS: The total amount of APTTs in the desired range increased from 19% in 1987 to 46% in 1992/1993, and the DR was reached in 1987 in 1 day by 14%, and in 1992/1993 by 48% of patients. The mean daily heparin dose was higher in 1992/1993 (34.1 * 1000 U, 95% CI 33.4-34.8) than in 1987 (32.3 * 1000 U, 95% CI 31.5-33.0). The starting dose of heparin of 400 U/kg during the first day, following an initial bolus injection of 70 U/kg, was correct in 44% of patients, too low in 46%, and too high in 10%. CONCLUSIONS: The new policy in the laboratory control of heparin treatment resulted in an increased number of APTTs in the DR, and a shorter time to reach this.

Anticoagulant effect of unfractionated heparin in antithrombin-depleted plasma in vitro.

The aim of the study was to determine the effect of the antithrombin concentration on the anticoagulant response to heparin in vitro. Pooled plasma was depleted of antithrombin using heparin Sepharose. Unfractionated heparin (final concentration between 0 and 1 U/ml) was added to plasma with different antithrombin concentrations, and the activated partial thromboplastin time (APTT) was determined. Plasma with an antithrombin concentration over 0.27 U/ml shows a similar response to heparin as normal plasma; at lower levels the response is diminished. Even in plasma fully depleted of antithrombin, the APTT can be prolonged to a therapeutic level, although the amount of heparin needed is twice as high. At antithrombin concentrations over 0.27 U/ml, heparin is the major determinant of the anticoagulant effect.

Systemic Fusarium nygamai infection in a patient with lymphoblastic non-Hodgkin's lymphoma.

We report the case history of a 35-year-old male patient with lymphoblastic non-Hodgkin's lymphoma who acquired a systemic infection with Fusarium nygamai during the granulocytopenic phase of cytostatic treatment. The patient survived this infection after haematological recovery and treatment with intravenous amphotericin B (total dose 543 mg). Subsequent chemotherapy courses were not complicated by fungal infections. A recent trip to Egypt and severe chemotherapy-induced mucositis were probably the major causes of this severe infection.

Diurnal changes in heparin effect during continuous constant-rate infusion. A study in nine patients with venous thromboembolism.

OBJECTIVE: To evaluate the importance of diurnal variations in the effect of a continuous infusion of unfractionated heparin. DESIGN: Twenty-four-hour follow-up. SETTING: Tertiary referral centre. SUBJECTS: Patients (five male, four female) with acute venous thromboembolic diseases. MAIN OUTCOME MEASURES: Two-hourly measurement of anti-IIa activity, anti-Xa activity, APTT (Cephotest and automated APTT), antithrombin III and cortisol for 24 h. RESULTS: The maximum anticoagulant effect was found at 04.00-06.00 hours, and the minimum effect at 12.00 hours. The difference was 0.40 U ml-1 for anti-IIa activity (95% confidence interval (CI) 0.03-0.78; P < 0.05), 0.36 U ml-1 for anti-Xa activity (95% CI-0.05-0.72; not significant [NS]), 15.1 s for Cephotest APTT (95% CI 3.3-26.9; P < 0.03), and 112.9 s for automated APTT (95% CI 7.8-218.0; P < 0.05). Antithrombin III decreased from 97.9% at the start to 82.6% 24 h later (P = 0.001). Cortisol showed a typical diurnal rhythm. Expressed as a percentage of the individual 24-h mean, a maximum was found at 04.00 hours (anti-IIa activity), 06.00 hours (both APTTs), and 08.00 hours (anti-Xa activity) and a minimum at 12.00 hours (all variables). The difference was 26% for anti-IIa activity (P < 0.05) and anti-Xa activity (NS), 22% for APTT (Cephotest; P < 0.03), and 44% for APTT (automated APTT; P < 0.05). CONCLUSIONS: A continuous intravenous infusion of unfractionated heparin has a maximum anticoagulant effect between 04.00 and 8.00 hours and a minimum effect at noon. For individual patients the moment of minimum and maximum effect varies widely. Because the most impressive changes occur between 06.00 and 08.00 hours, laboratory control can best be performed at fixed times, e.g. at 10.00 and at 22.00 hours.

Diurnal rhythm in anticoagulant effect of heparin during a low dose constant rate infusion. A study in healthy volunteers.

The objective of the study was to investigate possible diurnal rhythms in coagulation tests during a continuous intravenous infusion of unfractionated heparin. Six volunteers participated in the study, which was divided in a treatment (500 U heparin/h for 30 h) and a control experiment. Under basal conditions, no rhythm was found in coagulation tests. During heparin treatment, APTT, thrombin clotting time and anti-Xa activity showed a greater anticoagulant effect at night, with a striking decrease in the morning. In a search for the explanation of this phenomenon we looked for diurnal variations in the urinary excretion of heparin, in the plasma concentrations of antithrombin III and platelet factor 4, and in the effect of heparin added to the plasma samples in vitro. None of these studies provided the explanation.

[Bacterial meningitis in the aged. Pitfalls in medicine]. / Bacteriële meningitis bij bejaarden. Valkuilen in de geneeskunde.

Bacterial meningitis in aged patients is a diagnosis that can be difficult to make. Three case-histories, one of them being diagnosed non-purulent bacterial meningitis, are presented to demonstrate this. If classic symptoms and signs are being absent, evidence of an infection should suggest meningitis, if other common infections, like urinary tract or respiratory infections, are excluded, and even in these cases a concomitant meningitis may be possible. Even then a high mortality should be taken into account. Only tenacity at diagnostics will be able to reduce this.