Atrial fibrillation in the elderly: anticoagulation strategies and indications in the very elderly

With increasing life expectancy and the older mean age of the general population, the prevalence of atrial fibrillation is likely to increase, making this arrhythmia an even more important public health problem, especially in the elderly. While atrial fibrillation is increasingly common in the elderly, paradoxically, the data on intervention trials in atrial fibrillation among the elderly are limited. When considering anticoagulation in the elderly patient with atrial fibrillation, the following five questions should be addressed. 1) Is there a definite indication (for example, atrial fibrillation plus risk factor[s])? 2) Is there a high risk of bleeding or strong contraindication against anticoagulation? 3) Will concurrent medication or disease states significantly increase bleeding risk or interfere with anticoagulation control? 4) Is drug compliance and attendance at anticoagulant clinic for monitoring likely to be a problem? 5) Will there be regular review of the patient, especially with regard to risks and benefits of anticoagulation? Careful and continuing evaluation of the elderly patient with atrial fibrillation is necessary to ensure that the risks of bleeding do not outweigh the benefits from anticoagulation.     

Older people and ethics

This article examines the following questions and issues. Is there common agreement about ethical principles or are there variations according to culture, time and place? Are there special issues in policy and research relating to older people compared with other age groups? Why is there interest in ethical issues and older people? It then examines three final questions. Is the medical model for ethical approval (especially for research) suitable for social care and the social sciences? Are there specific ethical issues for different groups ‐ policy makers, practitioners. researchers and older people themselves? How helpful are guidelines?     

Controversies in the management of Kawasaki disease

While there is a generally accepted standard approach to the management of Kawasaki disease (KD) in North America, controversy still exists regarding certain aspects of treatment. Do all patients require treatment with intravenous immunoglobulin (IVIG)? What is the appropriate dose of aspirin (ASA) during the acute phase of the disease? Is there a role for corticosteroids in those who fail IVIG? How should patients with atypical, incomplete or late presentations of KD be managed? What is the appropriate long-term management and follow-up, particularly for those without coronary artery abnormalities (CAA)? Is there a role for surgical intervention, particularly transplantation? These questions, among others, are explored with reference to the pertinent literature.IVIG has been well studied and shown to be efficacious in a number of studies and in two meta-analyses, with clear evidence to support the use of 2g/kg in a single dose. The appropriate dose of ASA during the acute phase is less clear but, increasingly, data suggest that lower doses of ASA are adequate and perhaps more appropriate. Corticosteroids appear to have a role in those who have failed IVIG but this requires further study before being embraced as accepted treatment. The management of less typical presentations of KD remains controversial, with inadequate data to direct us, although there is a general trend towards treating such patients with IVIG. Careful follow-up of all patients is recommended and, while there are guidelines for this, there is no clear consensus on the most appropriate monitoring investigations for those with and without CAA. There is an expanding role for transplantation, with clearly defined indications for this intervention.     

Ethical confrontations in the incapacitated aged

Effective factors that have made it possible for an increasing proportion of the population to reach old age have nevertheless presented society with new problems and ethical dilemmas. Several questions that arise include:1) What are the responsibilities of the medical profession in providing medical care or supervision for patients who manifest irreversible decremental processes associated with old age; C); 2) Under what circumstances is there a moral imperative to preserve life, especially in patients who manifest an irreversible loss of awareness or are sustained by purely mechanical means?; 3) What are the limits of the resources which can be allocated to health care in general, and to the aged in particular, in a society in which resources are no longer infinite and allocations may become necessary; C0 4) what is the profession's responsibility for identifying decremental aging changes and characterizing them, even it this information is personally threatening and socially disturbing to those who would prefer to consider them diseases, and thus reversible by traditional means?; and 5) Is there a moral mandate to identify mechanisms of aging and techniques for slowing the process, in order to prolong life beyond what appears to be the normal biologic limit of three generations?     

Epidemiology of osteoporosis

Osteoporosis is a major public health problem through its association with fracture. The problem may be alleviated substantially by appropriate early intervention before fracture occurs. This chapter discusses the epidemiology of osteoporosis and addresses the following questions: How should osteoporosis be defined? What is the incidence and prevalence of osteoporosis and fracture? Is there geographical variation in the occurrence of osteoporosis? What are the risk factors for osteoporosis and do they explain the occurrence of osteoporosis and osteoporotic fracture?     

Biological considerations in the development of a human immunodeficiency virus vaccine

Over the last 12 years, many human immunodeficiency virus (HIV) vaccine candidates have been tried in humans, with disappointing results. In particular, recombinant envelope proteins have failed to elicit strong cellular immune responses or neutralizing antibody against many wild-type isolates of HIV-1. Attenuated strains of simian immunodeficiency virus (SIV), although capable of protecting against virulent strains of SIV, often retain residual pathogenicity. These difficulties suggest that it will be necessary to address a number of biological questions that underpin the rational development of an AIDS vaccine: (1) Will natural infection with HIV protect against superinfection? (2) Is partial protection induced by an HIV vaccine adequate to prevent AIDS? (3) What are the immune correlates of protection for an AIDS vaccine? (4) Will a monotypic HIV-1 vaccine confer cross-clade immunity? (5) Is mucosal immunity important for an effective AIDS vaccine? (6) Is there a rationale for therapeutic immunization? Ongoing research that is addressing these questions should lead to the formulation of a safe and effective AIDS vaccine.     

H. pylori and GERD: is less more?

Does chronic Helicobacter pylori gastritis prevent gastroesophageal reflux disease (GERD) and its sequelae? Yes, no, life should be so simple. A quick Medline search on the paired terms identified 527 citations since 1988 and that tells you something right there. Evidently, this is a complex relationship and attempting to reduce it to a yes/no answer is just not going to work. Perusing the literature, it becomes apparent that some combination of three component questions are in fact being asked: (i) Is it biologically plausible that H. pylori gastritis will reduce the occurrence of GERD? (ii) Is there an inverse epidemiological relationship between H. pylori infection and GERD? and (iii) Will the eradication of H. pylori unleash an epidemic of GERD? Each of these questions entails a unique set of consideration. We will consider each in turn.     

Surveying the elderly about health, medical care and living conditions. Some issues of response inconsistency

A sample of elderly persons (75-84 years old) in Sweden was surveyed twice on home conditions, health and medical care. Two data collection methods were used: interviews and a mail survey. It has been shown that it is possible to carry out a mail survey (with low non-response) among the elderly in this group. However, what about other aspects of quality? Is it really possible to use a mail survey instead of the much more expensive and complicated techniques involved in interviewing? The results show that for certain groups of variables there are fairly large differences between how respondents reply in the mail survey and in personal interviews carried out by district nurses. These differences apply both to the degree of inconsistency in answers and to shifts in marginal distributions. Among other things, more ailments are mentioned at interview. The demand for information on the elderly and the differences between the methods in the cost of gathering this information make reliability and validity studies of methods of surveying the elderly increasingly important.     

Treatment strategies in advanced stage follicular lymphoma

Although the introduction of anti-CD20 monoclonal antibodies has improved the outcome of patients with follicular lymphoma, a curative treatment is still not available. Many questions still remain to be answered: when should treatment be initiated? Is there an optimal first line treatment and can this treatment be individualized on the basis of prognostic markers? What is the best treatment strategy for relapsed follicular lymphoma and what is the place of the many novel agents? Should maintenance treatment be given to all patients and how? In the present review we will address these questions.     

The genetics of Hirschsprung disease

Understanding the genetics of Hirschsprung disease will naturally expand our understanding of other neurocristopathies, the enteric nervous system, and autonomic system biology. As other disorders of gastrointestinal motility are investigated, genetics may resolve certain clinical questions. For example, isolated hypoganglionosis without aganglionosis has been reported as a primary cause of intestinal pseudo-obstruction. Is such hypoganglionosis merely a forme-fruste of Hirschsprung disease, or a result from an entirely different pathogenetic mechanism? Can irritable bowel syndrome or severe constipation be related to specific mutations, polymorphisms, or haplotypes? How might an understanding of derangements of the ENS be translated to understanding derangements of the CNS? Clearly, we should anticipate improved prognostication, counseling, and hopefully, therapies with future genetic insights.     

Thoracotomy for repair of esophageal atresia: not as bad as they want you to think!

Is it outdated now to do a thoracotomy to repair esophageal atresia (EA)? Our practices and the literature on the subject of thoracoscopic and open thoracotomy repair of EA were reviewed, seeking answers to the following questions: Is it correct to compare the new thoracoscopic approach for the repair of EA against the thoracotomy techniques of 15–30 years ago? Should post‐thoracotomy scoliosis/thoracic deformity reported in up to 56% of patients be a significant current concern? Are the clips used to close the fistula in thoracoscopic repairs as safe as open suture closures? Is the leak and stricture rate similar with thoracoscopic surgery? Are the anesthesia, period of ventilation, pain, time to first feeding, and the length of hospital stay significantly different with current thoracotomy techniques compared with thoracoscopic methods? Is the cosmetic result of a thoracoscopic repair significantly better? Is the learning curve for EA thoracoscopic repair harming patients for minimal long‐term benefit? These questions were scientifically unanswerable at this time. The limited EA thoracotomies currently performed have a track record of proven safety and minimal morbidity. The results published by surgeons who are pioneers in thoracoscopy may not be generalizable, and the complication rate from teams with less experience is likely underreported. In selected patients and with experienced teams, thoracoscopic EA repair is appropriate. However, EA repair via thoracotomy should, for now, remain as the ‘gold standard’. Further registry‐based, multicenter, comparative studies on EA repair methodologies and outcomes should provide important answers.     

Reviewing a complicated geriatric drug regimen

This qualitative review offers guidance in avoiding the pitfalls of geriatric prescribing. A thorough yet time-sparing method for reviewing complex geriatric drug regimens is presented. This method has been used extensively during geriatric clinical pharmacology ward rounds by physicians in training. The tool, consisting of 10 questions pertaining to the appropriateness and safety of the drug plan, can contribute to a better understanding of geriatric clinical pharmacology and the special needs of older patients, as well as to the better use of health care resources. The 10 questions are: 1/ Are the indications for each drug still valid? 2/ What are the therapeutic objectives? Have they been reached? 3/ Is there a need for an additional treatment (new, synergistic, preventive)? 4/ Are there any low therapeutic index drugs? 5/ Are there any complicating factors? (Drug allergies? Kidney failure? Hepatic failure?) 6/ Should the drug dosages be adapted? 7/ Are there any clinically relevant drug-drug interactions? 8/ Do any of the prescribed drugs affect the patient's mobility, continence, cognition or eating? 9/ Is compliance with the prescribed drug plan feasible? 10/ Is the drug regimen in conformity with drug laws, rules and regulations? Special consideration is also given to elaborating therapeutic objectives likely to make a difference in an elderly patient's life because they are specific, measurable, acceptable, realistic and time-framed (SMART).     

A Swiss indication for varicose vein surgery in patients over 60?

A retrospective investigation into 100 patients operated on after the age of 60 led to the following two conclusions: in 55 p. cent, the motivation for the operation was aesthetic, due to third age vanity; pedestrian activity at retirement age is considerable. The frequent appearance of cramp symptomology of various types prompts us to make a thorough investigation of the arterial circulation of all the older patients. Is there really a Helvetian indication? Certainly not as far as aesthetics are concerned, since this is a general tendency among retired people. But definitely yes when arterial causes of cramps during walking can be excluded.     

Female subfertility

With an average monthly fecundity rate of only 20%, human beings are not fertile mammals. 10-15% of couples have difficulties conceiving, or conceiving the number of children they want, and seek specialist fertility care at least once during their reproductive lifetime. Dependent on the two main factors that determine subfertility, duration of childlessness and age of the woman, three questions need to be addressed before treatment is offered. Is it time to start the routine fertility investigation?--ie, has sufficient exposure to the chance of conception taken place? Are cost-effective, safe, and reliable treatments available for the disorder diagnosed? And, should the couple be referred straightaway for assisted reproduction?     

Dopamine: precursor or neurotransmitter in sympathetically innervated tissues?

Dopamine represents 1-5% of the total catecholamine pool in sympathetically innervated tissues. A substantial proportion of this dopamine is located in vesicles, and nerve activation results in liberation of dopamine as well as noradrenaline. In certain tissues, there is neurochemical and functional evidence for the existence in addition of separate populations of dopaminergic sympathetic nerves. Some of the unsolved questions relating to the neural release of dopamine are: Is intravesicular dopamine in noradrenergic nerves a stable storage pool? Do noradrenergic nerves release dopamine and noradrenaline by identical mechanisms? What physiological roles do the sympathetic dopaminergic nerves play? What are the diagnostic and therapeutic implications of neural dopamine release?     

Natural history of primary hyperparathyroidism.

Primary hyperparathyroidism has evolved into a disorder that is largely asymptomatic. Nevertheless, there is ample evidence of target organ effects even in asymptomatic patients. Recent data suggest that the disease is stable in most asymptomatic patients. Little change is observed in biochemical parameters or bone mineral density over time. A subgroup of asymptomatic patients shows biochemical evidence of disease progression, although, in the author's series, no overt clinical complications developed. Surgical cure is associated with biochemical normalization and increased bone density. Several important questions remain: What are the neuropsychiatric and cardiovascular features of the disease? Are these features progressive over time, and do they regress with cure? What implications do any cardiovascular manifestations have on mortality? Is there an increase in fractures associated with mild asymptomatic disease? Is there an increase in fractures at more cortical sites, with a decrease in vertebral fractures in affected postmenopausal women? Although ongoing targeted research should answer some of these questions, a large multicenter trial is necessary to provide the data needed concerning the natural history of primary hyperparathyroidism.     

Medical Treatment for Thoracic Aortic Aneurysm – Much More Work To Be Done

A 45 year old executive presents to your office for risk assessment after learning that his sister required an ascending aortic aneurysm repair. He is a well-informed man, concerned about his personal risk for aortic disease, and undergoes a cardiac screen which reveals a dilated ascending aortic aneurysm, measuring a maximal diameter of 4.4 cm. His aortic valve is tricuspid. He is non-Marfanoid and asymptomatic. He realizes that he does not yet meet guideline criteria for aortic surgery, but he is also cognizant of the fact that he is approaching the cut-off for surgical intervention. He wishes to minimize his future risk of aortic rupture, dissection and aortic expansion and seeks your input. Should ‘medical treatment’ should be employed at this stage? Is there sufficient basis to initiate any form of pharmacotherapy? Would you start a beta-adrenergic receptor blocker, an angiotensin receptor blocker, a matrix metalloproteinase inhibitor (doxycycline), or a statin to reduce his aortic risk for rupture, dissection or need for surgical repair? Does your clinical decision match evidence from existing data? Our paper will address these issues among other questions relevant to the role of medical therapy for thoracic aortic disease.     

Laparoscopic pancreatic reconstruction technique following laparoscopic pancreaticoduodenectomy

With the advance of laparoscopic experiences and techniques, it is carefully regarded that laparoscopic pancreaticoduodenectomy (lap‐PD) is feasible and safe in managing perimapullary pancreatic pathology. Especially, laparoscopic management of remnant pancreas can be a critical step toward completeness of minimally invasive PD. According to available published reports, there is a wide range of technical differences in choosing surgical options in managing remnant pancreas after lap‐PD. For the evidence‐based surgical approach, it would be ideal to test potential techniques by randomized controlled trials, but, currently, it is thought to be very difficult to expect those clinical trials to be successful because there are still a lack of expert surgeons with sound surgical techniques and experience. In addition, lap‐PD is so complicated and technically demanding that many surgeons are still questioning whether this surgical approach could be standardized and popular like laparoscopic cholecystectomy. In general, surgical options are usually chosen based on following question: (1) Is it simple? (2) Is it easy and feasible? (3) Is it secure and safe? (4) Is there any supporting scientific evidence? It would be interesting to estimate which surgical technique would be appropriate in managing remnant pancreas under these considerations. It is hoped that a well standardized multicenter‐based randomized control study would be successful to test this fundamental issues based on sound surgical techniques and scientific background.     

Collagenous colitis and rheumatology

Conclusions Careful observation of the unusual but not rare cases of collagenous colitis may help to unravel important pathogenetic mechanisms, and this may eventually help in the control of common diseases. Specifically, some important queries remain to be addressed. Are the rheumatologic and autoimmune syndromes secondary to collagen colitis, or are these patients more prone to develop collagenous colitis? Is lymphocytic colitis associated with the same extraintestinal manifestations as collagen colitis? Can antirheumatic drug therapy induce any of these forms of colitis? Is there a genetic predisposition? How reversible is the fibrosis? Collagenous colitis is yet another reason for close interaction between rheumatology and gastroenterology.