Long-term dialysis treatment in advanced age

In Europe 40% of patients under regular dialysis therapy (RDT) are aged over 55. In our hospital 40% of patients under RDT are aged over 70%. The causes of terminal renal failure in the aged are similar to those of the younger patients. 45% of patients between 60 and 70 years and 25% of those between 70 and 80 years survive 5 years after initiation of RDT. Quality of life under RDT is good enough for the elderly to be grateful for prolongation of their lives. A general upper age limit for RDT is difficult to set. In rare instances RDT may become questionable in the aged, mainly when cerebral dysfunction becomes prominent. In these cases it might be ethical not to start, or to withdraw from RDT.     

Long-term treatment with coumarin preparations in advanced age

It is reported on the occurrence of haemorrhagic complications at old age in patients treated with coumarin. Altogether 352 patients were examined, 96 of them were older than 70 years. A small part of the patients, above all men with obliterating vascular occlusions of the lower extremity were additionally given also thrombocyte aggregation inhibitors. The effective prothrombin level was nearly the same in the two, groups, i.e. in the patients younger and older than 70 years. There was no difference in frequency and severity of the haemorrhages with the exception of macrohaematuria which, however, appeared above all in the younger age group and in women older than 70 years. Under observation of the indications and with a regular control a long-term treatment with coumarin preparations can performed without any particular risk also at old age.     

高龄急性脑血栓形成的改良型等容血液稀释疗法的研究

目的　前瞻性对比观察改良型等容血液稀释疗法对高龄老人急性脑血栓形成的疗效 ,并探讨其作用机制。方法　采用随机化配对设计 ,以传统有效的常规药物治疗为对照 ,采用改良型血液稀释术治疗 4 6例高龄急性脑血栓形成患者 ,动态观察两组治疗前后血凝全套指标和血小板聚集率变化、血脂水平、血液流变学 (尤其是红细胞压积 )和微循环变化 ,对比测定脑动脉血流速度和静息心电图QTcd值 ,并临床评估患者神经功能恢复程度。结果　改良型血液稀释术能通过抗凝、抗血小板聚集作用及调脂作用 ,改善血液流变和微循环 ,尤其是能显著降低红细胞压积 ,使患者脑动脉血流速度由 (90± 1.2 )cm/s增至 (97± 2 .1)cm/s ,同时使心肌缺血指标QTcd值由 (4 6 .2± 11.1)ms缩短至 (32 .4± 9.3)ms(P <0 .0 5 ) ,治疗后的总有效率 (93.4 % )显著高于传统的常规药物治疗 (77.8% ,P <0 .0 5 ) ,未见明显不良反应。结论　改良型等容血液稀释疗法机制合理 ,疗效确切 ,能有效地改善高龄老人急性脑血栓形成后受损的临床神经功能     

Progress in the treatment of gastroenterologic diseases in advanced age

Therapeutic advances in gastroenterology benefit patients of all ages, although the elderly ones receive more benefits than others. The latter is especially true for operative endoscopy where, in some cases, otherwise high-risk patients can be spared an operation. Peptic stenosis, which is common in elderly patients as a result of reflux oesophagitis, can be treated by bougienage. Bleeding from gastric and duodenal ulcers can cause problems in the elderly. In most cases endoscopic treatment by electro- or laser coagulation, or by sclerotherapy can avoid the need for surgery, or at least the conversion of an emergency operation into an elective one with a better prognosis is possible. Adenomata in the colon are common causes of chronic blood loss and can become malignant. They should be removed endoscopically. Another typical age-dependent finding, which can be treated by electro- or laser coagulation in the colon are angiodysplasia, which can be the origin of massive haemorrhage. It is now becoming accepted that in an elderly patient, stones in the common bile duct should be managed by endoscopic sphincterotomy and gallstone removal. This approach is safer and quicker than conventional surgery. The practice of endoscopic drainage by insertion of a prosthesis in cases of malignant obstructive jaundice is although increasing in older patients.     

Desmoid tumors in familial adenomatous polyposis: a pilot project evaluating efficacy of treatment with pirfenidone

OBJECTIVES: Pirfenidone (Deskar, Marnac Inc., Dallas, TX), 5-methyl-1-phenyl-2-(1H)-pyridone, is a broad-spectrum, noncytotoxic, oral antifibrotic agent that is reported to inhibit or block the action of cytokine growth factors: transforming growth factor beta1, platelet-derived growth factor, epidermal growth factor, and fibroblast growth factor, and to prevent formation of new fibrotic lesions. METHODS: We enrolled 10 women and four men with extensive familial adenomatous polyposis (FAP)-associated desmoid disease in a 2-yr open-label treatment trial with oral pirfenidone. Imaging of desmoids was conducted at baseline and 6, 12, and 24 months. RESULTS: No drug toxicity or drug intolerance was encountered. Seven patients dropped out (three because of progressive disease), and seven continued for at least 18 months. Of those that continued, two had partial but significant reduction in the size of all desmoids beginning in the first 6 months of treatment, and two others experienced relief of symptoms without change in desmoid size. Three patients experienced no change in tumor size or symptoms. CONCLUSIONS: Pirfenidone is well tolerated by patients with FAP-associated desmoid tumors. Some patients with FAP/desmoid tumors treated with pirfenidone had regression of tumors, some had progression, and some had no response. Patients with rapidly growing tumors did not respond to pirfenidone. A placebo-controlled trial is needed to determine whether there is a subset of patients for whom pirfenidone may result in partial shrinkage of desmoid tumors, because the natural history of desmoid tumors is not predictable or understood.     

Results of surgical treatment for lung cancer in advanced age

In this study, 24 patients aged 70 and over who were operated for primary bronchogenic carcinoma were reviewed retrospectively and their results were compared with those of 90 patients under 70, whom operated for the same intent. The mean age and age range of the group were 74.6 +/- 3.3 and 70-86, respectively, and it consisted of 21 male and three female patients. The histology of the tumor revealed epidermoid carcinoma in 16 (67%) patients, adenocarcinoma in 6 (25%), and large cell carcinoma in 2 (8%). Twelve of the elderly patients had associated diseases (six had coronary artery disease and/or hypertension, four had chronic obstructive pulmonary disease and two had diabetes) that increased the operative risk. The resection type used most frequently was lobectomy (67%), followed by limited resection (25%). In postoperative staging, nine patients were found to have stage I disease, nine stage II disease, four stage IIIA disease and two stage IIIB disease. Three (13%) patients developed major complications, and postoperative mortality rate within 30 days was 4% with one patient. In the patients aged under 70, the last two variables were noted in 10 (%11) cases and in 1 (%1) case respectively, and the difference between the two groups was statistically insignificant. As a result, with appropriate patient selection and vigorous postoperative care, morbidity and mortality of the pulmonary resections in elderly is not higher than in young patients, and a curative resection should be preferred.     

Follow up and treatment of pacemaker-patients in advanced age (author's transl)]

Most of the pacemaker-patients are in the eight decade of life. The continuous follow ups of the patient with a pacemaker system have to reguard the often advanced age, the cardiac basic disease, other concomitant diseases and futhermore technical details of the device, the date of implantation and the expected longevity of the power source. The risk of the patient by pacemaker failure in the underlying rhythm disturbance can be estimated by short extinguish of the pacing activity. The additional medical treatment is determined by the findings and must be adapted to the mentioned circumstances.     

The home environment and quality of life-related outcomes in advanced old age: findings of the ENABLE-AGE project

With the present research, we further exploited the potential of the ENABLE-AGE Project, more precisely the Swedish and German data. We hypothesised that the magnitude of accessibility problems (MAP) in the home environment and external housing-related control beliefs (HCB) play a substantial role for a range of outcomes related to quality of life. Our sample at T1 consisted of 847 single-living and community-dwelling individuals aged between 80 and 89 years, from urban regions in Sweden and Germany, 636 of whom were re-assessed 1 year later. MAP was measured with the Housing Enabler instrument, while external HCB assessment was based on a questionnaire proved useful in earlier research. Outcomes were assessed with established measures of ADL independence/dependence, general well-being, positive and negative affect and depression. Cross-sectional regressions underscored that MAP and external HCB were rather consistently associated with outcomes, with MAP being more strongly associated with ADL independence/dependence and external HCB more strongly with well-being related outcomes. Furthermore, significant and marginally significant interaction terms underscored that being high in external HCB in the situation of large MAP was linked with more negative outcomes, while external HCB did not play a role in the situation of small MAP. In the longitudinal regression analysis, MAP at T1 was predictive for T1–T2 change in ADL independence/dependence and depression, while external HCB did not show substantial relations with any change in outcomes. Our study underlines and qualifies substantial relations between objective and perceived person–physical environment measures and a range of outcomes. Such evidence is required to further improve housing-oriented prevention and intervention strategies in advanced old age.     

Idiopathic pulmonary hemosiderosis in a patient of advanced age

Idiopathic pulmonary hemosiderosis (IPH) is a rare disease of unknown etiology characterized by hemoptysis, diffuse pulmonary infiltrates and iron-deficiency anemia. It is typically found in children and young adults. Finding that the concentration of siderophages exceeds 20% in bronchoalveolar lavage indicates a diagnosis of IPH. We report the case of a 72-year-old man with repeated diagnoses of respiratory infection, bronchiectasis and melena. Because such a clinical picture is rare for IPH, the final diagnosis was obtained by open lung biopsy.     

高龄冠状动脉左主干狭窄病变患者的外科治疗

目的总结高龄冠心病左主干病变患者接受冠状动脉旁路移植术的经验。方法2005年至2014年,101例冠心病左主干病变患者接受非体外循环冠状动脉旁路移植术,其中男82例,女19例,平均(81.4±1.7)岁,左主干狭窄(≥70%)76例,<70%者25例,平均左心室舒张末径(48.2±8.3)cm,心脏射血分数>50%89例,30~50%12例,合并二尖瓣关闭不全14例,合并室壁瘤1例,纽约心功能分级I~Ⅱ级56例,Ⅲ~Ⅳ级45例。加拿大心绞痛分级(CCS)I~Ⅲ级99例,Ⅳ级2例,合并急性心肌梗死13例,术前使用主动脉内球囊反搏6例。结果101例手术均顺利完成,平均手术(3.9±0.8)h,平均桥血管使用(3.0±1.0)根,ICU监护(50.2±46.0)h,呼吸机辅助呼吸(42.9±68.5)h,二次开胸止血6例(5.9%),二次气管插管5例(4.9%),术后持续透析4例(4.0%),主动脉内球囊反搏使用术中3例(2.9%),术后11例(10.9%),围术期心肌梗死2例(2.0%),术后院内死亡8例(7.9%)。中位随访时间6(1~11)年,全因死亡17例(16.8%)。结论尽管高龄、左主干狭窄病变这两种冠状动脉搭桥手术的独立高风险因素同时存在,非体外循环冠状动脉旁路移植术以及围手术期的相关处理仍然是目前安全、有效的治疗方法。     

卡泊芬净治疗高龄患者侵袭性真菌病29例临床分析

目的 观察卡泊芬净治疗高龄患者侵袭性真菌病(IFD)的疗效和安全性. 方法 回顾分析我院老年病房接受过卡泊芬净治疗的IFD患者的临床资料. 结果 2007年1月至2009年8月共有29例患者接受卡泊芬净治疗,且均为80岁以上高龄患者.除1例于用药当天死亡外,28例可评价疗效的患者中,痊愈13例(46.4%),显效6例(21.4%),进步3例(10.8%),无效6例(21.4%),总有效率为67.8%.13例痊愈者中,12例为念珠菌菌血症患者,1例为拟诊肺白念珠菌病患者.无效6例患者中,2例为念珠菌菌血症患者,1例为拟诊肺念珠菌病患者,3例为疑诊肺IFD患者.治疗过程中1例患者出现谷丙转氨酶升高,考虑为与用药有关的肝功能受损. 结论 卡泊芬净是治疗高龄患者侵袭性真菌病的安全有效药物.     

Immunological system and preventive treatment of chronic infections in advanced age (author's transl)

Immunological system, preventive treatment, chronic infection, advanced age. The author reports on the immunological system in advanced age and postulates that prevention in terms of early and thorough identification of the reasons underlying chronic infections in advanced age, especially in the urinary tract and in the respiratory system, as well as their consistent control always have positive results.