Neoadjuvant chemoradiotherapy followed by esophagectomy does not increase morbidity in patients over 70

Esophagectomy in elderly esophageal carcinoma patients is correlated with a high morbidity and even mortality. Studies on neoadjuvant chemoradiotherapy (NT) in elderly patients are scarce. The aim of this study was to evaluate the effect of advanced age in combination with NT in esophageal carcinoma patients who underwent an esophagectomy. Patients who underwent NT prior to esophagectomy between 1993 and 2010 were divided into three groups: <70, 70–74, and ≥75 years. Toxicity of NT and postoperative morbidity were compared between groups. Primary endpoints were toxicity, complication rate, and survival. Two hundred thirteen patients underwent NT during the study period, 26 were aged 70–74 years, and 17 were ≥70 years. Toxicity of NT was comparable for younger and elderly patients (46% vs. 54% vs. 47%, P = 0.263). Overall complications occurred in 62% of younger patients versus 73% and 71% among patients aged 70–74 years and ≥75 years, respectively (P = 0.836). Cardiac complications occurred in 14% of younger patients versus 27% and 41% of elderly patients (P = 0.021). Three‐year survival rates were 59% versus 44% versus 31% among patients aged <70, 70–74, and ≥75 years, respectively (P = 0.237). Higher age (odds ratio 1.750, P < 0.001) was an independent risk factor for development of cardiac complications. Toxicity of NT and postoperative complications are comparable for patients aged <70, 70–74, and ≥75 years, with the exception of cardiac complications. Therefore, we consider NT followed by esophagectomy in elderly patients a safe treatment modality in our center.     

Influence of fast-track recovery after coronary artery bypass in the elderly

We retrospectively analyzed 711 consecutive patients who had isolated coronary artery bypass grafting between January 2000 and December 2004; 572 younger patients (< 70 years) were compared with 139 elderly patients (> or = 70 years). A rapid recovery program based on an anesthetic protocol for early extubation was applied to all patients. The overall hospital mortality rate was 3.3% for the younger group and 4.3% for the elderly group. There were no significant differences in rates of hospital mortality and postoperative complications between the two groups. Early extubation was achieved in significantly more younger (71%) compared to elderly (57%) patients. Rapid recovery with discharge before the 5(th) postoperative day was achieved in 19% of the elderly compared to 48% of the younger patients. Patients in the younger group were discharged from hospital earlier (6.8 +/- 0.3 vs 8.0 +/- 8.5 days). Application of fast-track treatment in an elderly population appears to be a safe and effective approach if used on a selective basis when criteria for early extubation are met.     

Hepatocellular Carcinoma in the Elderly: Results of Surgical and Nonsurgical Management

OBJECTIVE: This study evaluated the results of surgical and nonsurgical treatments of hepatocellular carcinoma (HCC) in the elderly to determine the optimal management strategy. METHODS: Clinicopathological data and treatment results of 222 elderly (> or = 70 yr) and 1116 younger patients with HCC managed between 1989 and 1997 were prospectively collected and compared between the two groups. RESULTS: The resection rate in the elderly (14%) was lower than in younger patients (27%) (p < 0.001). Among patients who underwent resection, there were no significant differences in morbidity rate (48% vs 40%, p = 0.354), hospital mortality rate (10% vs 6%, p = 0.431), or long-term survival (median, 38 vs 42 months, p = 0.940). Comparing the periods 1989-1992 and 1993-1997, hospital mortality rate in the elderly was reduced from 25% to 4% (p = 0.079). Sixty-seven elderly and 317 younger patients underwent transarterial oily chemoembolization (TOCE), with similar morbidity rate (24% vs 26%, p = 0.775), mortality rate (7% vs 5%, p = 0.365), and long-term survival (median, 12 vs 9 months, p = 0.277). The results of other nonsurgical treatments were also similar between the two groups. CONCLUSIONS: Hepatic resection for HCC is safe in selected elderly patients, and the improved results in recent years indicate that more elderly patients could benefit from surgical management. TOCE is well tolerated in elderly patients and is the treatment of choice for unresectable HCC. The overall management strategy of HCC in the elderly should not be different from that in younger patients.     

Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy

The incidence of esophageal malignancy continues to increase worldwide. At the same time, average life expectancy levels continue to climb, ensuring that more patients will present in their 70s, 80s, and 90s. The aim of this pooled analysis is to compare short‐ and long‐term outcomes for elderly and younger patients undergoing esophagectomy for malignancy. Studies comparing the outcomes of esophagectomy for malignancy in elderly and young cohorts of patients were included. The minimum threshold age used to define the elderly cohort was 70 years. Primary outcomes were in‐hospital mortality, overall and cancer‐related 5‐year survival. Secondary outcomes were the length of hospital stay, the incidence of anastomotic leak, conduit ischemia, cardiac and pulmonary complications, and the use of neoadjuvant therapy. Twenty‐five publications comprising 9531 and 2573 operations on younger and elderly cohorts of patients respectively were analyzed. Elderly patients were less likely to receive neoadjuvant therapy (14.6% vs. 29.47%; pooled odds ratio [POR]= 0.48; 95% confidence interval [C.I.]= 0.35–0.65; P < 0.05). Esophagectomy in elderly patients was associated with increased in‐hospital mortality (7.83% vs. 4.21%; POR = 1.87; 95% C.I. = 1.54–2.26; P < 0.05), as well as increased pulmonary (21.77% vs. 19.49%) and cardiac (18.7% vs. 13.17%) complications. Subset analysis of studies using an age threshold of 80 years showed an even more significant association between in‐hospital mortality and elderly age (pooled odds ratio = 3.19; 95% C.I. = 1.6–6.35; P < 0.05). There were no significant differences between the groups in length of hospital stay, incidence of anastomotic leak, or conduit ischemia. The elderly group showed reduced overall 5‐year survival (21.23% vs. 29.01%; pooled odds ratio = 0.73; 95% C.I. = 0.62–0.87; P < 0.05) and reduced cancer‐free 5‐year survival (34.4% vs. 41.8%; POR = 0.75; 95% C.I. = 0.64–0.89; P < 0.05). Elderly patients are at increased risk of pulmonary and cardiac complications, and perioperative mortality following esophagectomy, and show reduced cancer‐related 5‐year survival compared with younger patients. These patients represent a high‐risk cohort, who requires thorough assessment of medical comorbidity, targeted counseling, and optimized treatment pathways.     

Clinical outcome and survival after esophagectomy for carcinoma in elderly patients

Advances in perioperative management have allowed more and more elderly patients to undergo major surgery with postoperative morbidity and mortality rates comparable to those of younger individuals. The aim of this study was to evaluate the impact of age on the clinical outcome and long-term survival of patients with esophageal carcinoma undergoing esophagectomy. Nine-hundred patients with esophageal carcinoma were divided into two groups: A (n = 403) with age > or = 65 years, and B (n = 497) with age < 65 years. One-hundred and fifty three (38%) patients of group A underwent surgery compared to 272 (55%) of group B (P < 0.01). Postoperative mortality, and the prevalence of anastomotic leak and respiratory complications were similar in both groups; conversely, there was a higher prevalence of cardiovascular complications in group A (13% vs 3%, P < 0.01). Five-year survival was about 35% in both groups. In conclusion, advanced age should no longer be considered an absolute contraindication to esophagectomy for carcinoma in selected patients. In fact, the postoperative mortality and long-term survival rates of elderly patients undergoing resection are comparable to that of younger individuals.     

Changes in acute myocardial infarction risk and patterns of practice for patients older and younger than 70 years, 1987-90.

OBJECTIVE: To evaluate temporal changes in risk and patterns of hospital practice for acute myocardial infarction (AMI). DESIGN/PATIENTS: Retrospective analysis of age-related medical therapy and outcome of 342 consecutive patients (132 at least 70 years old and 210 younger than 70) with AMI between July 1, 1989, and June 30, 1990, and comparison with data from two previous analyses of AMI practice in 1987 (n = 207) and 1988-89 (n = 402). SETTING: Tertiary care medical centre. INTERVENTIONS: No direct interventions; results of the two previous AMI practice pattern analyses, however, were propagated during the practice time of the most recent analysis. RESULTS: In 1989-90, hospital mortality was higher (19%) among patients at least 70 years old compared with patients younger than 70 (8%) (P less than 0.01). Therapies proven by repeated clinical trials to be effective in reducing AMI risk were all used less frequently in patients aged at least 70 years: thrombolysis (20 versus 43%); beta-blockers (41 versus 62%); acetylsalicylic acid (71 versus 87%); and nitrates (86 versus 97%). Qualitatively, these age-specific patterns of AMI mortality and therapy were similar to previous studies. Quantitatively, however, comparing 1987 with 1989-90 demonstrated parallel and marked increases in the use of all proven medications in both age groups, ranging from 42 to 230% (P less than 0.01). There was also a significant overall decrease in mortality from the 1987 patient cohort (20%) to the 1989-90 cohort (13%) (P less than 0.05). The decrease in mortality was entirely due to decreased mortality within the group 70 years or older; 35% in 1987 versus 19% in 1989-90 (P less than 0.05). Mortality in the AMI patients younger than 70 years old remained unchanged from 1987 to 1989-90. CONCLUSIONS: Pattern of practice analyses were associated with, and may have contributed to, improved patient care and outcomes in AMI. Increased use of effective AMI medical therapy had a greater benefit in elderly higher risk AMI patients than lower risk younger patients. Persisting age-specific differences in AMI therapy may respond to more direct quality improvement measures, such as critical path management.     

Community-acquired pneumonia in very elderly patients: causative organisms,clinical characteristics,and outcomes

We performed an observational analysis of prospectively collected data on 1,474 adult patients who were hospitalized for community-acquired pneumonia; 1,169 patients were under 80 years of age and 305 (21%) patients were over 80 years ("very elderly"). Mean patient ages were 60 years in the former group and 85 years in the latter group. Severely immunosuppressed patients and nursing-home residents were not included. Comorbidities significantly associated with older age were chronic obstructive pulmonary disease, chronic heart disease, and dementia. The most common causative organism was Streptococcus pneumoniae (23% in both groups). Aspiration pneumonia was more frequent in the very elderly (5% in younger patients versus 10% in the very elderly); Legionella pneumophila (8% in younger patients versus 1% in the very elderly) and atypical agents (7% in younger patients versus 1% in the very elderly) were rarely recorded in the very elderly. While very elderly patients complained less frequently of pleuritic chest pain, headache, and myalgias, they were more likely to have absence of fever and altered mental status on admission. No significant differences were observed between groups as regards incidence of classic bacterial pneumonia syndrome (60% versus 59%) in 343 patients with pneumococcal pneumonia. The development of inhospital complications (26% in younger versus 32% in very elderly patients) as well as early mortality (2% in younger versus 7% in very elderly patients) and overall mortality (6% in younger versus 15% very elderly patients) were significantly higher in very elderly patients. Acute respiratory failure and shock/multiorgan failure were the most frequent causes of death, especially of early mortality. Factors independently associated with 30-day mortality in the very elderly were altered mental status on admission (odds ratio, 3.69), shock (odds ratio, 10.69), respiratory failure (odds ratio, 3.50), renal insufficiency (odds ratio, 5.83), and Gram-negative pneumonia (odds ratio, 20.27).     

Esophagectomy in patients aged over 80 years with esophageal cancer

BACKGROUND/AIMS: Esophagectomy for esophageal cancer is one of the most invasive surgical procedures. However, with the recent aging of the population, clinicians are increasingly encountering patients with advanced age (over 80 years) who require treatment for esophageal cancer. Patients in this age group tend to be regarded as at high risk in terms of surgical treatment. In the present study, the authors examined perioperative complications and clinical outcome in esophagectomy in patients aged over 80 years compared with those aged 70-79 and discuss the risk and appropriateness of esophagectomy in the older group. METHODOLOGY: Of patients with esophageal cancer at our institute, 25 were aged over 80 years, while 95 were aged 70-79 years. We statistically compared those who underwent esophagectomy; 8 in the older group and 62 in the younger group. The oldest patient was an 84-year-old man. Among the 8 older patients, 7 were male and 1 was female. All cases were histologically confirmed as squamous cell carcinoma and this series included 1 case in Stage 0, 3 in Stage I and 4 in Stage III. Total thoracic esophagectomy was performed in 5 patients, transhiatal blunt dissection in 2 and lower thoracic esophagectomy in 1. RESULTS: Rate of surgical treatment was significantly lower in the older group than in the younger group (32.0% vs. 65.3%, p < 0.001). No significant difference was observed in postoperative complications or mortality. Regarding clinical postoperative outcome in the older group, there were 5 deaths: 1 related to surgery, 2 to other causes (at 5 and 12 months), 2 to cancer (4 and 11 months). The remaining patients were alive at 31, 60, and 88 months. No significant difference was observed in overall or disease specific survival after surgery between the 2 groups. CONCLUSION: No statistically significant differences were apparent in morbidity, mortality or clinical outcome in the 2 groups. Since surgery seems to confer similar symptomatic improvements and survival in patients aged over 80 to those expected for patients aged 70-79, we believe that surgeons should not withhold esophagectomy in patients aged over 80 years because of advanced age alone.     

Experience with implantable cardioverter defibrillator therapy in elderly patients

AIMS: Concern exists about the benefit of implantable defibrillatortherapy in elderly patients. We assessed the utility of implantabledefibrillator therapy and its effect on mortality in patients70 years and older and compared results in this group to thosein younger patients. METHODS AND RESULTS: Thirty-two out of 200 consecutive patients (16%) were 70 yearsor older at the time of implantation of a defibrillator. Whencomparing elderly to younger patients no significant differenceswere noted with respect to presenting arrhythmia, left ventricularejection fraction or presence of an old myocardial infarction.Elderly patients had a higher prevalence of ischaemic heartdisease, while in the younger group more patients had idiopathicventricular tachycardia. Cumulative survival curves (Kaplan-Meiermethod) for all-cause mortality, sudden cardiac death and non-suddencardiac death were constructed for elderly and younger patients.No significant differences for cumulative survival from all-causemortality (75 vs 74%), sudden cardiac death (0 vs 4%) and non-suddencardiac death (97 vs 93%) were found. The incidence of appropriateshocks during follow-up was comparable (65 vs 72%). CONCLUSION: Implantable defibrillator therapy was effective in preventingsudden cardiac death in the elderly. Total mortality was similarto younger patients at a follow-up of 19±14 and 25±19months, respectively. Age itself should be no contraindicationto implantable cardioverter defibrillator therapy.     

Effect of age on the outcome of angioplasty for acute myocardial infarction among patients treated at the Mayo Clinic

PURPOSE: Elderly patients, especially those 80 years of age and older, have been excluded from most studies of thrombolysis or primary coronary angioplasty in patients with acute myocardial infarction. We compared the outcomes of elderly patients who underwent coronary angioplasty with the outcomes of younger patients and determined whether there were any temporal trends in survival. PATIENTS AND METHODS: We reviewed the outcomes of 1,597 consecutive patients who underwent primary coronary angioplasty between 1979 and 1997, including 127 patients who were 80 years of age or older (mean [+/-SD] age, 83 +/- 3 years, 47% male). Their in-hospital and long-term outcomes were compared with those of 524 patients who were 70 to 79 years old, 527 patients who were 60 to 69 years old, and 419 patients who were 50 to 59 years old. The oldest group of patients was divided into two groups, based on whether they had intervention through the end of 1993 (n = 56) or between 1994 and 1997 (n = 71). The survival rate of the patients who had no complications and left the hospital was compared with expected survival based on age- and sex-adjusted data. RESULTS: Patients 80 years of age or older had more adverse baseline characteristics, including risk factors and comorbid conditions, than the younger patients. The clinical success rate of primary angioplasty in this group was lower than those in the other three groups (61% versus 74% in those aged 70 to 79 years, 73% in those aged 60 to 69 years, and 81% in those aged 50 to 59 years, P < 0.001). The in-hospital mortality rate among patients 80 years of age or older was significantly greater than among patients in the other three groups (21% in those aged 80 years or older, 13% in those aged 70 to 79 years, 9% in those aged 60 to 69 years, and 4% in those aged 50 to 59 years, P < 0.001 ). The clinical success rate of the angioplasty improved significantly in the more recent period (75% versus 45%, P = 0.0006) and in-hospital mortality declined (16% versus 29%, P = 0.07). During follow-up, mortality in the oldest age group in whom angioplasty was successful was significantly greater than in the three younger groups, but was similar to the expected survival in the general US population. CONCLUSIONS: The mortality associated with primary angioplasty for acute myocardial infarction in octogenarians remains high, although there has been significant improvement in the clinical success rate. The long-term prognosis following a successful angioplasty is not different from that in an age- and sex-adjusted U.S. white population.     

Acute pulmonary embolism in elderly: clinical characteristics and outcome

OBJECTIVE: To evaluate the clinical characteristics and outcome of acute pulmonary embolism in elderly in comparison to the younger patients. METHODS: Study population consisted of 136 patients with a confirmed diagnosis of acute pulmonary embolism. Clinical characteristics and thromboembolic risk factors were analyzed between the elderly (> or =65 years of age) and the younger (<65 years of age) patients. In-hospital mortality was used as a measure of outcome. RESULTS: Elderly group consisted of 70 patients (age 76.4+/-8.3 years, range 65-96 years; females 58%) and younger group of 66 patients (age 48.5+/-12 years, range 18-64 years, females 59%). Syncope was more frequent in elderly group (19% vs. 6%, P=0.03) but the symptoms of shortness of breath and pleuritic chest pain were not significantly different between groups. Malignancy was the most common risk factor for thrombo-embolism, but immobilization predominated among patients in elderly group (21% vs. 6%, P=0.01). Tachycardia was common in younger patients compared to the elderly. Ventilation-perfusion scan was used more commonly in younger patients (76% vs. 57%, P=0.02), whereas, helical computed-tomography scan was used equally in both groups. Most of the patients had lower extremity duplex study (97% in each group). Inferior vena cava filter placement was common and thrombolytic therapy rare among elderly patients. Patients in elderly group had higher in-hospital mortality (17% vs. 5%, P=0.02). CONCLUSIONS: Syncope is a more frequent presenting symptom and immobilization a common risk factor in elderly patients with acute pulmonary embolism. In addition, they have higher in-hospital mortality.     

Endocarditis in the elderly: clinical, echocardiographic, and prognostic features.

AIMS: Infective endocarditis (IE) is more and more frequent in elderly persons and it has been associated with various clinical, bacteriological, and prognostic features. The aim of the study was to define the clinical, echographic, and prognostic characteristics of IE in a large population of elderly patients from four European centres (three French, one Italian). METHODS AND RESULTS: Three hundred and fifteen consecutive patients with definite IE underwent clinical evaluation, echocardiography, blood cultures, and follow-up. Patients were separated into three groups: group A: 117 patients aged <50 years, group B: 111 patients aged >50 and <70 years, group C: 87 patients aged >70 years.Elderly patients (group C) presented more frequently than other groups with digestive or urinary portal of entry, pacemaker endocarditis, and anaemia. S bovis endocarditis was less frequent and S aureus endocarditis more frequent in younger (group A) patients than in other groups. No difference was observed among groups concerning echocardiographic data as well as the incidence and localization of embolic events. Elderly patients were operated on as frequently as younger patients and their operative risk was similar than in other groups (11%, 3%, and 5% in groups C, B, and A, respectively, P=ns). Overall mortality in elderly patients was low (17%) but significantly higher than in younger patients (10% in group A, 7% in group B, P=0.02). By multivariate analysis, the only risk factors for in-hospital mortality were age (P=0.003), prosthetic valve (P=0.002), and cerebral embolism (P=0.006). Conversely, surgical management was associated with a lower in-hospital mortality (P=0.03). CONCLUSIONS: In this largest series of elderly patients with IE, IE in elderly carries specific features when compared with younger patients, although the echographic characteristics and embolic risk are similar. The overall mortality rate in elderly patients is higher than in younger, but the mortality in operated patients is low and similar than that of younger patients.     

Short-term postoperative outcomes after liver resection in the elderly patient: a nationwide population-based study

BackgroundLiver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.MethodsIn this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.ResultsIn total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02–1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.ConclusionThirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.     

老年急性白血病患者50例临床特征分析

目的:探讨老年急性白血病(AL)的临床特点,以利于有效治疗。方法:回顾分析50例60岁以上的老年AL患者的临床资料,包括年龄分布、基础疾病、主要症状、临床特征、骨髓(BM)象、染色体、免疫分型、化疗的完全缓解(CR)率、BM抑制程度、病程及病死率。并与同期住院的66例中青年患者进行比较。结果:老年AL发病率占同期成人AL的27%(50/185)。AML的CR率35.7%(15/42),ALL的CR率33%(2/6)。其基础疾病的发病率86%、MDS转化为AML占20%、病程(35.5±16.5)d、BM抑制时间(18.5±6.5)d、病死率20%、染色体核型为-5、-7、+8、+21,以上均高于同期的中青年组(均为P<0.01)。结论:老年AL患者并存基础疾病和染色体核型异常是其病死率高的主要原因,目前尚无早期诊断和有效治疗老年AL的满意策略,呼吁重视此方面的研究。     

Clinical features and prognosis of infective endocarditis in the elderly

INTRODUCTION AND OBJECTIVES: In recent decades the mean age of patients with infective endocarditis has progressively increased. The objective of the present study was to describe the clinical features and prognoses of infective endocarditis in the elderly. METHODS: A prospective study was performed of 125 non drug abuser patients over the age of 14 years and admitted from 1987 until 1997 in a single institution. Twenty-one patients were older than 65 years. RESULTS: No significant differences were observed among the age groups with respect to delay in diagnosis, clinical signs, site of the infection and the rate of negative blood cultures. Prosthetic valve endocarditis was more frequent in elderly than in younger adults (41 and 33%, respectively). S. viridans and enterococcus were more frequent (47 compared with 29% in younger adults, p < 0.05). Elderly patients underwent surgery less frequently (46 versus 56%) and most surgery was performed on an emergency basis. The in hospital mortality was higher in the elderly (50 versus 15%), p < 0.05. CONCLUSIONS: Prosthetic valve endocarditis and severe complications during the active phase are more frequent in the elderly and this is related to a worse prognosis in the short and intermediate term. A higher rate of elective surgery during the active phase could improve the prognosis of infective endocarditis in the elderly.     

Good outcomes from cardiac surgery in the over 70s

OBJECTIVE: To determine the early mortality and major morbidity associated with cardiac surgery in the elderly. DESIGN: Retrospective case record review study of 575 patients >/= 70 years old who underwent cardiac surgery at the Manchester Heart Centre between January 1990 and December 1996. SETTING: Regional cardiothoracic centre. SUBJECTS: Patients >/= 70 years old who underwent cardiac surgery. MAIN OUTCOME MEASURES: Comparison of 30 day mortality and incidence of major morbidity between patients >/= 70 years old and patients < 70 years old. RESULTS: Of 4395 cardiac surgical operations, 575 operations (13.1%) were in patients aged >/= 70 years (mean (SD) 73.1 (3.2) years). The proportion of elderly patients rose progressively from 7.9% in 1990 to 16.5% in 1996. 334 patients (58.1%) had coronary artery bypass grafting alone, 91 patients (15.8%) had valve surgery alone, and 129 patients (22.4%) had combined valve surgery and bypass grafting. For isolated coronary artery bypass grafting, 30 day mortality in patients >/= 70 years was 3.9% compared with 1.3% in patients < 70 years (p < 0.001). 30 day mortality for isolated valve surgery in patients >/= 70 years was 7.7%. Isolated aortic valve replacement was the most common valvar procedure in patients >/= 70 years and carried the lowest mortality (4.3%). Additional coronary artery bypass grafting increased the mortality rate in patients >/= 70 years to 9.3% for all valve surgery and to 8.0% for aortic valve replacement. Major morbidity in patients >/= 70 years was low for all procedure types (stroke 1.9%, acute renal failure requiring dialysis 1.6%, perioperative myocardial infarction 0.5%). CONCLUSIONS: Early mortality and major morbidity is low for cardiac surgery in elderly patients. Concerns over the risk of cardiac surgery in the elderly should not prevent referral, and elderly patients usually do well. However, unconscious rationing of health care may affect referral patterns, and studies that assess the cost effectiveness of cardiac surgery versus conservative management in such patients are lacking.     

Recent major improvement in long-term survival of younger patients with multiple myeloma

In the past, most patients with multiple myeloma (MM) died within 5 to 10 years after diagnosis. Within the past decade, several new therapeutic interventions have been introduced, including autologous stem-cell transplantation, thalidomide, lenalidomide, and bortezomib. We estimated trends in age-specific 5- and 10-year relative survival of patients with MM in the United States from 1990-1992 to 2002-2004 from the 1973-2004 database of the Surveillance, Epidemiology, and End Results (SEER) Program. Techniques of period analysis were used to show most recent developments. Overall, 5-year relative survival increased from 28.8% to 34.7% (P < .001), and 10-year relative survival increased from 11.1% to 17.4% (P < .001) between 1990-1992 and 2002-2004. Much stronger increases were seen in the age group younger than 50 years, leading to 5- and 10-year relative survival of 56.7% and 41.3% in 2002-2004, and in the age group 50 to 59 years, leading to 5- and 10-year relative survival of 48.2% and 28.6% in 200-2004. By contrast, only moderate improvement was seen in the age group 60 to 69 years, and essentially no improvement was achieved among older patients. Our period analysis discloses a major increase in long-term survival of younger patients with MM in recent years, which most likely reflects the effect of recent advances in therapy and their dissemination in clinical practice.     

The management of bleeding peptic ulcer in the elderly with heater probe thermocoagulation

BACKGROUND/AIMS: The aim of this study was to compare the clinical characteristics of bleeding peptic ulcers in the elderly with those in younger patients, retrospectively. METHODOLOGY: Between 1986 and 1994, 274 patients with bleeding peptic ulcers were treated with heater probe endoscopically. They were divided into 2 groups: 48 in the elder group (70 years of age or older) and 226 in the younger group (<70). We evaluated the rate of concomitant disease, rebleeding rate, incidence of emergency surgery, mortality and blood transfusion requirement between the 2 groups. RESULTS: The incidence of concomitant disease was significantly higher in the elderly group (83.3%) than in the younger group (33.3%) (p<0.01). The rate of rebleeding (younger group 23.5% vs. elderly group 31.3%), the incidence of emergency surgery (5.8% vs. 6.3%, respectively) and the rate of mortality due to hemorrhage (2.2% vs. 4.2%, respectively) were similar in the 2 groups. There was no significant difference in the mean volume of blood transfused. CONCLUSIONS: It was revealed that aggressive endoscopic hemostasis improved the mortality rate and the incidence of emergency surgery in elderly patients as well as in younger patients, provided that their general condition was monitored carefully.     

Outcomes and early revascularization for patients > or = 65 years of age with cardiogenic shock

Hospital survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock has improved during recent years. It is unclear whether this mortality benefit also applies to elderly patients with cardiogenic shock. Elderly residents (age > or = 65 years) of the Worcester, Massachusetts metropolitan area (1990 census population = 437,000) hospitalized with confirmed AMI and cardiogenic shock in all metropolitan Worcester, Massachusetts hospitals between 1986 and 1997 constituted the sample of interest. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in a cohort of 166 cardiogenic patients treated early in the reperfusion era (1986 to 1991) compared with 144 patients with AMI treated approximately 1 decade later (1993 to 1997). There was a significant increase in the use of an early revascularization strategy over time (2% vs 16%, p <0.001). Marked increases in use of antiplatelet therapy, beta blockers, and angiotensin-converting enzyme inhibitors were also observed over the decade-long experience. In-hospital case fatality declined significantly over time, from 80% (1986 to 1991) to 69% (1993 to 1997) in elderly patients who developed cardiogenic shock (p = 0.03). After adjusting for differences in potentially confounding prognostic characteristics between patients hospitalized in the 2 study periods, an even more pronounced reduction in hospital mortality (42%) was observed for the most recently hospitalized cohort. The most powerful predictor of in-hospital survival was use of an early revascularization approach to treatment. Thus, hospital mortality has declined for patients > or = 65 years of age with AMI complicated by cardiogenic shock, and this decline has occurred in the setting of broader use of early revascularization and adjunctive medical therapy for this high-risk population.     

Cardiac rehabilitation after myocardial infarction in the community.

OBJECTIVES: The aim of this study was to examine participation in cardiac rehabilitation after myocardial infarction (MI) by age and gender and the association of participation with survival. BACKGROUND: Lesser participation in cardiac rehabilitation has been reported for women and the elderly. METHODS: All incident MIs in Olmsted County were validated. Baseline characteristics and outcomes were ascertained from the medical record. Logistic regression examined the association between participation, age, and gender. Propensity scores were used to examine the association between participation and outcome. RESULTS: Among 1,821 persons with incident MI (58% men, 46% age >70 years), 55% participated in cardiac rehabilitation. Participants were more likely to be men, younger, and have fewer comorbidities (p < 0.01 for all comparisons). After adjustment, women were 55% less likely to participate than men (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.34 to 0.60), and persons 70 years or older were 77% less likely to participate than persons younger than 60 (OR 0.23, 95% CI 0.16 to 0.33). Participants had a lower risk of death and recurrent MI at three years (p < 0.001 and p = 0.049, respectively). The survival benefit associated with participation was stronger in more recent years (relative risk [RR] for 1998 vs. 1982 0.28, 95% CI 0.18 to 0.43; RR for 1990 vs. 1982 0.41, 95% CI 0.33 to 0.52). CONCLUSIONS: Approximately half of the patients participated in cardiac rehabilitation after MI. Participation did not increase over time. Women and elderly persons were less likely to participate, independently of other characteristics. Participation in rehabilitation was independently associated with decreased mortality and recurrent MI, and its protective effect was stronger in more recent years.