Heart failure in frail elderly patients: diagnostic difficulties, co-morbidities, polypharmacy and treatment dilemmas.

BACKGROUND: Heart failure (HF) is difficult to diagnose and treat in older patients. Symptoms may be non-specific and the presence of co-morbidities and polypharmacy complicate treatment strategies. There are, however, few data to quantify the extent of these problems in the very elderly. METHODS: A retrospective study of 116 patients (median age 86; range 65-98) with an established diagnosis of HF during their hospital admission. MAIN OUTCOME MEASURES: the accuracy of diagnosis of heart failure according to the European Society of Cardiology (ESC) definition. The aetiology and frequency of associated co-morbidities and the nature of drug treatment. RESULTS: The specificities of clinical signs, chest X-rays and abnormal ECGs for heart failure (ESC definition) were 50%, 20% and 9%, respectively. Only 28% of patients were admitted for worsening symptoms which could be attributed to HF. None of the patients had HF as their only medical problem. Co-morbidities included chest disease (30%), incontinence (29%), cerebrovascular disease (26%), musculoskeletal problems (41%). Barthel (activities of daily living) score was < or = 16/20 in 35%. Mental state questionnaire (MSQ) score was < or =7/10 in 38%. Ninety percent were taking four or more different medications. Thirty-nine percent were on psychotropic drugs. On discharge, a total of 88% of patients returned home to live independently and 35% were monitored by regular day hospital attendance. CONCLUSION: Heart failure in frail elderly patients is often compounded by other major illnesses and polypharmacy which have a profound impact on their functional status. This has implications for the most effective targeting of evidence based treatment.     

Localized contractions in the normal human bladder and in urinary urgency

OBJECTIVE: To describe an observational study to establish whether localized activity arises in the normal human bladder, and whether there is any correspondence between changes in such activity and reported sensation. PATIENTS, SUBJECTS AND METHODS: The generation of sensory information by the bladder depends on afferent stimulation by increased tension within the bladder wall. Autonomous bladder activity is apparent in several species, which is often localized and multifocal, giving rise to localized areas of stretch. Thus afferent activity may partly result from localized distortions of the bladder wall. Fourteen women patients presenting with increased bladder sensation during filling-phase cystometry were compared with six asymptomatic women volunteers. Localized bladder activity was assessed by the micromotion detection (MMD) method, using eight electrodes mounted on a Silastic balloon; local displacements of the electrodes were recorded as changes in electrical resistance, which were used to compute changes in the distance between each pair of electrodes. RESULTS: In two of the six volunteers, micromotions were seen in the extraperitoneal (ventral) portion of the bladder. Women with increased sensation on filling cystometry had a significantly higher prevalence of localized activity than the control group during MMD recording. The localized activity was more sustained and at a higher frequency than in asymptomatic women. All nine women reporting urinary urgency during MMD recording had localized contractile activity, while only four had phasic increases in detrusor pressure during the episodes of urgency. CONCLUSIONS: By measuring localized contractions within the bladder wall, we established a significant difference in the prevalence of localized activity between the groups studied, but there was no objective difference with conventional urodynamic studies. There was also a difference in the character of the localized contractions, with the exaggerated activity in the symptomatic group corresponding with the reported sensations. These findings suggest that localized distortion of the bladder wall stimulates afferent activity, and that the human detrusor may be functionally modular.     

Origin of the cholinergic response of the rabbit intestine to stimulation of its extrinsic sympathetic nerves after exposure to sympathetic blocking agents

The effect of guanethidine and of bretylium on the response to nerve stimulation has been studied on two types of isolated innervated preparations of rabbit intestine. One preparation was that of the rabbit ileum in which the periarterial (mainly sympathetic) nerves were stimulated: the other was the doubly innervated rabbit colon where either parasympathetic (pelvic) or sympathetic (lumbar colonic) nerves were stimulated. In both preparations guanethidine and bretylium in appropriate dosage specifically blocked the inhibitory effect of sympathetic nerve stimulation while leaving the response to parasympathetic nerve stimulation and to acetylcholine unaltered: the response to noradrenaline was unaltered or potentiated. In the ileum, after the addition of guanethidine or of bretylium, the inhibitory response to periarterial nerve stimulation was replaced in every preparation by a motor response which had the same frequency sensitivity as parasympathetic nerves. In the colon a motor response to sympathetic nerve stimulation was rarely obtained after blocking the inhibitory response. When such a motor response was uncovered it had similar characteristics to the motor response in the ileum. Furthermore, if the parasympathetic nerves were stimulated for prolonged periods both the parasympathetic and sympathetic motor responses were reduced. These results do not support the idea that post-ganglionic sympathetic nerves to the intestine are generally cholinergic and are themselves responsible for the motor responses. The experimental results are more conveniently explained by assuming a mixture of cholinergic and adrenergic fibres in the nerves stimulated.     

Spinal-induced hypotension in elderly patients with hip fracture. A comparison of glucose-free bupivacaine with glucose-free bupivacaine and fentanyl

Intraoperative hypotension is a common and potentially deleterious event in elderly patients undergoing spinal anaesthesia for repair of hip fractures. The synergism between intrathecal opioids and local anaesthetics may allow a reduction in the dose of local anaesthetic and cause less sympathetic block and hypotension, while still maintaining adequate anaesthesia. We studied 40 elderly patients having either an insertion of a dynamic hip screw or a hemiarthroplasty and compared 9.0 mg glucose-free bupivacaine with added fentanyl 20 microg (group BF) with 11.0 m glucose-free bupivacaine alone (group B). Hypotension was defined as a fall in systolic blood pressure to less than 75% baseline or less than 90 mmHg. The incidence and frequency of hypotension in group BF were less than in group B. Similarly, falls in systolic, diastolic and mean blood pressures were all less in group BF than in group B. However, there were four failed blocks in group BF and one in group B.     

Invited commentary

OBJECTIVE: Preoperative imaging modalities for endovascular abdominal aortic aneurysm repair (EVAR) include conventional computed tomography (CT), aortography with a marking catheter, and three-dimensional computed tomography (3D CT). Although each technique has advantages, to date no study has compared in a prospective manner the reproducibility of measurements and impact on graft selection of all three modalities. The objective of this study was to determine the most useful imaging studies in planning EVAR. METHODS: Twenty patients being considered for EVAR were enrolled prospectively to undergo a conventional CT scan and aortography. The CT scans were then reconstructed into 3D images using Preview Treatment Planning Software (Medical Media Systems, West Lebanon, NH). Four measurements of diameter and six of length were made from each modality in determining the proper graft for EVAR. RESULTS: Measurements from all three modalities were reproducible with intraobserver correlation coefficients of 0.79 to 1.0 for aortography, 0.87 to 1.0 for CT, and 0.96 to 1.0 for 3D CT. Measurements between observers were also similar from each modality; interobserver correlations were 0.70 to 0.97 for aortography, 0.76 to 0.97 for CT, and 0.73 to 0.99 for 3D CT. Significant differences ( P < .01) in diameter measurements were noted at D2 with aortography compared with 3D CT, whereas differences in length measurements were found between CT and 3D CT at L4 (nonaneurysmal right iliac) ( P < .01). The correlation between CT and 3D CT for most length measurements was acceptable (0.63 to 1.0). Aortography for diameters correlated poorly (0.35 to 0.67) with 3D CT. When the endograft selected by aortography/CT or 3D CT alone was compared with the actual endograft used, there was agreement in 11 of 11 patients when adjusted for +/- one size in diameter or length. CONCLUSION: Reproducible and comparable measures of diameter and length can be obtained by each of three imaging modalities available for endograft sizing. As a single imaging modality, 3D CT appears to have the best correlation for both diameters and lengths; however, the difference is not sufficient enough to alter endograft selection. Three-dimensional CT may be reserved for challenging aortic anatomy where small differences in measurements would affect patient or graft selection for EVAR.