Orthostatic hypotension in acute geriatric ward: is it a consistent finding?

BACKGROUND: Orthostatic hypotension (OH) is a common finding among older patients. We designed a study to examine the prevalence and consistency of OH during the day. METHODS: A total of 502 inpatients (241 men and 261 women) with a mean age of 81.6 years were included in the study. Orthostatic tests were performed 3 times during the day, 30 minutes after meals. In 13 patients only 2 sets of measurements were obtained, and they were omitted from some of the calculations. Orthostatic hypotension was defined as a fall of at least 20 mm Hg in systolic blood pressure and/or 10 mm Hg in diastolic blood pressure on assuming an upright posture. RESULTS: Three hundred thirty-two (67.9%) of 489 patients experienced OH at least once during the day. Of these, 170 patients (34.8% of the 489) had OH at least twice (persistent OH) and 162 patients (33.1%) experienced OH only once (variable OH). Diastolic OH was more prevalent than systolic OH (57.3% vs 43.4%; P<.001). The intraindividual consistency of OH was low (kappa = 0.2). Orthostatic hypotension was observed less frequently during the evening than during the morning and afternoon (P<.05 vs morning and P =.003 vs afternoon). The difference between meals' constituents (light vs heavy meals) did not affect the prevalence of OH. CONCLUSIONS: Orthostatic hypotension is very common in the elderly, and diastolic OH is more common than systolic OH. The prevalence of OH is the lowest during the evening, and meals do not increase the prevalence of OH. The intraindividual consistency of OH during the day is poor. Thus, in elderly patients, more attention should be paid to diastolic OH and the diagnosis should be based on repeated measurements.     

Acute neurological events associated with influenza vaccination: are the WHO criteria for assessing causality adequate?

We identified neurological admissions temporally associated with influenza vaccine to determine the likelihood of causality using World Health Organization (WHO) criteria. Although all cases were categorized as possibly related to the vaccine, most had a compelling alternative explanation. This observation suggests that the current WHO criteria may not be sufficient in determining if an adverse event is truly vaccine related.     

Managing multiple myeloma in the elderly: are we making progress?

Treatment of multiple myeloma has evolved rapidly over the last decade due to novel therapeutic agents. Improved upfront and salvage options have resulted in enhanced survival; however, this has been less pronounced in elderly patients compared with their younger counterparts. Indeed, treatment-related toxicities in older patients may have subverted the survival benefit made by newer treatment modalities. However, owing to the immaturity of current published data, the true survival impact made by novel agents in the elderly patient subgroup is far from being fully appreciated. Improved responses, along with increased salvage options, imply that progress for elderly patients is being made. The current challenge to improve survival for elderly patients not only rests with continued research into tolerable novel treatment regimens, but also, scrupulous supportive care and the judicious use of current novel agents in appropriate dosing, combinations and sequence. Here, we review the outcomes of elderly patients with multiple myeloma over recent years and focus on the current treatment options available for this group.     

Are recist criteria adequate in assessing the response to therapy in metastatic NEN?

Response to therapy criteria, known as RECIST (Response Evaluation Criteria in Solid Tumours), are widely used to evaluate neuroendocrine tumours (NET) metastatic to the liver, under treatment. RECIST criteria does not take in account many various distinct features such as tumour growth, secretory capacity and anatomical localisation with wide variation in clinical and biological presentation of different NETs. Key features of RECIST includes definitions of the minimal size of measurable lesions, instructions on how many lesions to measure and follow, and the use of unidimensional, rather than bidimensional, measures for overall evaluation of tumour burden. These measures are currently done with computed tomography (CT) or Magnetic Resonance Imaging (MRI). RECIST criteria are accurate in assessing tumour progression but sometimes inaccurate in assessing tumour response after locoregional therapy or under molecular targeted therapy, tumour vessels being part of the target of such treatments. There is poor correlation between a so called tumour necrosis and conventional methods of response assessment, which poses questions of how best to quantify efficacy of these targeted therapies. Variations in tumour density with computed tomography (CT) could theoretically be associated with tumour necrosis. This hypothesis has been studied proposing alternative CT criteria of response evaluation in metastatic digestive NET treated with targeted therapy. If preliminary results upon the poor relationship between density measured with CT (derived from CHOI criteria) evolution curves at CT and PFS are confirmed by further studies, showing that the correlation between density changing and response to non-targeted treatment is weak, the use of contrast injection, will probably be not mandatory to enable appropriate evaluation.

     

Aortic valve replacement in elderly patients: what are the limits?

PURPOSE OF REVIEW: Increased life expectancy has led to a growing elderly population frequently presenting with aortic stenosis. This review focuses on modalities of aortic valve replacement designed to cope with the risks from multiple co-morbidities prevalent in the elderly. RECENT FINDINGS: Cardiac surgery is safe in octogenarians; very low risks are associated with aortic valve replacement. Good short-term and medium-term results are seen with early surgical intervention for aortic stenosis in the relatively asymptomatic patient. The benefits seen with minimally invasive surgery make it more acceptable. A hybrid approach that deploys a drug-eluting stent for concomitant moderate coronary artery disease has shown promising results. An extension of this concept is the percutaneous aortic valve implantation that offers hope to the nonsurgical candidate. A systematic approach of minimally invasive surgery in patients with prior coronary artery bypass grafting minimizes injury to grafts. Bioprosthetic tissue valves are the valves of choice in all the above interventions. SUMMARY: Cardiac surgery is used increasingly for aortic stenosis in elderly patients. Current experiences in minimally invasive and percutaneous approaches have opened the doors to hybrid strategies, which may be the mainstay of treatment for older patients needing aortic valve replacements in the future.     

Primary Sjögren's syndrome in children and adolescents: are proposed diagnostic criteria applicable?

OBJECTIVE: To compare the proposed criteria for the diagnosis of primary Sj?gren's syndrome (pSS) in childhood to the validated American-European Consensus Group (AECG) classification criteria for pSS in adults. METHODS: Charts of 7 children with pSS seen at British Columbia's Children's Hospital (BCCH) and data on 128 children identified through Medline in the English language literature between 1963 and 2003 were reviewed for pediatric and AECG criteria for pSS. The presence of > or = 4 criteria was required to satisfy the respective classification criteria. The expert clinical opinion of pediatric rheumatologists was considered the gold standard for diagnosis. RESULTS: A total of 24/62 (39%) cases satisfied the AECG criteria; 47/62 (76%) satisfied the proposed pediatric criteria. Inclusion of recurrent parotitis increased the sensitivity of the pediatric clinical criteria. From the cases, 78/133 (59%) satisfied the pediatric oral symptom criteria; only 6/78 (8%) had xerostomia in the absence of recurrent parotitis. There was no reported case of recurrent conjunctivitis in the absence of keratoconjunctivitis sicca. We found 101/130 (78%) cases had at least one positive autoantibody test result [antinuclear antibodies (ANA), rheumatoid factor (RF), SSA, SSB]; 78/123 (63%) had autoantibodies to SSA or SSB. CONCLUSION: The AECG adult criteria for pSS should not be applied to children as the sensitivity is unacceptably low. The inclusion of recurrent parotitis increases the sensitivity of the pediatric criteria, and recurrent parotitis should alert the clinician to the possibility of pSS. The inclusion of recurrent conjunctivitis did not improve the sensitivity over the AECG ocular criteria. The addition of ANA and RF to the AECG criteria did not change the number of patients satisfying the criteria for pediatric pSS.     

Does vitamin D deficiency increase orthostatic hypotension risk in the elderly patients?

Orthostatic hypotension (OH) is closely associated with falls, cardiovascular events and mortality in the elderly patients. The aim of the study is to evaluate the OH prevalence among patients over the age of 65 years, to find out the impact of this condition on daily living activities, and to determine the possible effects of vitamin D levels on OH in elderly patients. Eight hundred and forty nine geriatric patients who had undergone comprehensive geriatric assessment were retrospectively evaluated and 546 patients were included in the study. The patient's demographic characteristics, blood pressures, comorbid diseases, polypharmacy status, cognitive and nutritional states, basic and instrumental daily living activity indexes and laboratory values were obtained from hospital files. Serum 25-hydroxyvitamin D [25(OH)D] was measured by radioimmunoassay. The prevalence of OH was found to be 27.5%. Both daily living activity indexes were significantly lower in older patients with OH (p < 0.02), and serum 25(OH)D levels were significantly lower in older patients with OH (p < 0.01). Our findings suggest that vitamin D deficiency may be a factor in OH development. Because this condition is also preventable and correctable, serum vitamin D levels should be checked during the evaluation of OH patients and any detected deficiency should be treated accordingly.     

Irritable bowel syndrome according to varying diagnostic criteria: are the new Rome II criteria unnecessarily restrictive for research and practice?

OBJECTIVES: It has been suggested that the variation in the prevalence of irritable bowel syndrome (IBS) may be due to the application of different diagnostic criteria. New criteria for IBS have been proposed (Rome II). It is unknown whether persons meeting different criteria for IBS have similar psychological and symptom features. The aim of this study was to measure the prevalence of IBS according to Manning and Rome definitions of IBS and to evaluate the clinical and psychological differences between diagnostic categories. METHODS: A total of 4500 randomly selected subjects, with equal numbers of male and female subjects aged > or = 18 yr and representative of the Australian population, took part in this study. Subjects were mailed a questionnaire (response rate, 72%). Characteristics measured were gastrointestinal symptoms over the past 12 months, neuroticism and extroversion (Eysenck Personality Questionnaire), anxiety and depression (Delusions-Symptoms-States Inventory), mental and physical functioning (SF-12), and somatic distress (Sphere). RESULTS: The prevalence for IBS according to Manning, Rome I, and Rome II was 13.6% (95% confidence interval [CI] = 3.5-5.1%), 4.4% (CI 6.0-7.8%), and 6.9% (CI 12.3-14.8%), respectively [corrected]. Only 12 persons with Rome I did not also meet Rome II criteria; 196 persons with Manning criteria did not meet Rome II cut-offs. Having IBS regardless of which criteria were used was significantly associated with psychological morbidity, but psychological factors were not important in discriminating between diagnostic categories. However, pain and bowel habit severity independently discriminated between diagnostic groups. CONCLUSIONS: IBS is a relatively common disorder in the community. The new Rome II criteria may be unnecessarily restrictive in practice.     

Do the diagnostic criteria for subclinical hypercortisolism exist?

“Subclinical hypercortisolism” (SH) refers to a condition associated with a mild chronic increase in cortisol secretion. By definition, patients with SH do not exhibit specific symptoms of overt Cushing's syndrome (such as purple striae, easy bruising, proximal muscle weakness), SH has been preferred to “subclinical Cushing's syndrome”, a semantic ambiguity since Cushing's syndrome is, by definition, a set of symptoms; and to the term “preclinical Cushing syndrome” because the progression toward overt clinical hypercortisolism is very rare. However, SH still is misnomer as a number of studies suggest that this condition may induce long-term non-specific adverse conditions related to the mild cortisol excess (i.e. diabetes, hypertension, obesity, and osteoporosis). Various attempts have been made to define SH that remains a matter of controversies and uncertainties.     

Fever response in elderly nursing home residents: are the older truly colder?

OBJECTIVE: To test the hypothesis that many nursing home residents with an apparently blunted fever response (maximum temperature less than 101 degrees F) may actually have a significant change in temperature (delta T greater than or equal to 2.4 degrees F) which is not recognized because of a low baseline temperature. DESIGN: Retrospective chart review for cases of infection that met specific criteria and for chart-recorded baseline and infection temperatures. Chart-recorded baseline temperatures were prospectively compared with re-measurement of morning temperatures. SETTING: Nursing Home Care Unit of the VAMC West Los Angeles. PATIENTS: Random review of 40 residents' charts resulted in the detection of 69 infections among 26 residents over a 20-month period. Fifty randomly selected residents prospectively underwent comparison of chart-determined and actual re-measurement of baseline temperatures. RESULTS: In 50 randomly selected residents, the mean oral baseline temperature of 97.4 +/- 0.2 (degrees F +/- SEM) closely approximated the mean nurse-recorded measures in the charts (97.6 +/- 0.1). Chart review detected 69 infections among 26 residents, with 53 episodes having a temperature recorded during the infection. The mean maximum temperature (Tmax) during an infection was 101.3 +/- 0.3 (degrees F +/- SEM) but 47% (25/53) of the episodes had a "blunted" fever response (Tmax less than 101 degrees F). Of the 25 "blunted" fevers (Tmax less than 101 degrees F), about one-fourth demonstrated an adequate change in temperature from baseline (delta T greater than or equal to 2.4 degrees F) but failed to reach 101 degrees F because of a low baseline. Most infections (89%) had a Tmax greater than 99 degrees F. CONCLUSION: Establishing a nursing home patient's basal temperature and monitoring for changes in temperature (delta T greater than 2.4 degrees F) and/or lowering the threshold for recognition of fevers (to 99 degrees or 100 degrees F) in nursing home residents with a change in function should assist in early recognition of infections.     

Cancer in the elderly: is it preventable?

It is the goal of the American Cancer Society to decrease the mortality from cancer by 50% and the incidence of cancer by 25% by the year 2015 in the United States. Achieving this goal requires intervention at the primary (incidence) and secondary (mortality) prevention stages, and will involve a concerted effort of the individual practitioner, governmental agencies, local, state, and national interest groups, and the population at large. Primary care practitioners must increase their level of enthusiasm for cancer prevention, and actively counsel patients about cancer risks and preventive measures. Practitioners should encourage inclined patients by providing support and specialty resources, such as dieticians, exercise therapists, and smoking and alcohol cessation programs. The greatest effort lies in the general population, who must adopt a healthier lifestyle, including appropriate diet, smoking cessation, control of obesity, and daily exercise. None of these lifestyle changes are easy to embrace, but once educated about lifestyle and risk of cancer, people have a powerful incentive to change. Continued public awareness campaigns and encouragement from health care providers are essential for the success of such programs. The success in smoking cessation shows that achieving societal lifestyle changes on a large scale is possible. The elderly are especially prone to benefit from primary and secondary prevention techniques, and it must not be assumed that only the young will realize the benefits of prevention and screening. The association of age and cancer risk will always be present, but need not be as consequential as it is now. Although cancer prevention may have a limited role in antiaging per se, the feasibility of cancer risk reduction has a definite role in aging successfully.     

Is it time to change the neurofibromatosis 1 diagnostic criteria?

Neurofibromatosis 1 is a complex inherited neurocutaneous disease that is often difficult to diagnose early because of its age-dependent presentation. The diagnosis is also extremely difficult to communicate to patients and their parents because of the disease's clinical variability, unpredictable evolution, and uncertain prognosis. Since 1988, the year of publication of the last Consensus Conference statement concerning the diagnosis of neurofibromatosis 1, our understanding of the disease has naturally increased and, in addition to the availability of increasingly precise molecular analyses, some new clinical signs have been reported such as anaemic nevi, unidentified bright objects, choroidal hamartomas, and a typical neuropsychological phenotype. We critically review the current diagnostic criteria, and suggest the addition of new signs on the basis of published findings and our own clinical experience. This proposal aims to improve diagnostic power in paediatric age, securing a better and more reliable healthcare transition toward adult age. We finally recommend a new Consensus Conference in order to revise the diagnostic criteria, possibly differentiated by age of presentation.