Emilia Frangos

Transcatheter aortic valve implantation in nonagenarians: Effective and safe

BACKGROUND The number of nonagenarians is rising dramatically. These patients often develop severe aortic stenosis for which transcatheter aortic valve implantation (TAVI) is an attractive option. The aim of this study was to analyze the outcome of TAVI performed in a cohort of nonagenarian patients. METHODS Between August 2008 and November 2012, 23 consecutive patients in their 90th year of age or older underwent TAVI in our institution after having been assessed by the local heart team. Data concerning baseline characteristics, procedural details and outcome were prospectively entered into a dedicated database. Transthoracic echocardiography and clinical follow-up were performed pre-procedure, at discharge, at 6 and 12 months and then annually post TAVI. RESULTS Patients were male in 52% with a mean age of 90.3 ± 2.3 years. Mean logistic EuroSCORE and STS score were 26.6 ± 14.5% and 8.7 ± 2.9%, respectively. Transcatheter heart valve (THV) could be implanted in all but one patient. Mortality at 30 days was 8.7% overall and 4.8% for transfemoral approach. At 30 days the rate of stroke was 4.3%, paravalvular leak grade ≥ 2 was 8.7%, life-threatening bleeding was 13.0% and pacemaker implantation was 13%. Device success was 73.9%. The rate of all-cause mortality increased to 27.3% at one-year follow-up and 42.8% at a median follow-up of 417 days. CONCLUSIONS TAVI is safe and effective even in a selected population of nonagenarians. Consequently, these patients should not be refused such a procedure based only on their age. Multi-disciplinary assessment is essential in order to properly select candidates.

Effects of widely used drugs on micronutrients: a story rarely told.

Vitamins and trace elements are essential to the body, however, deficiencies are frequently observed in the general population. Diet is mostly responsible for these deficiencies but drugs also may play a significant role by influencing their metabolism. These effects are rarely assessed in clinical practice, in part because of limited data available in the literature. Drug-induced micronutrient depletions, however, may be the origin of otherwise unexplained symptoms that might sometimes influence medication compliance. We present various examples of widely prescribed drugs that can precipitate micronutrient deficiencies. This review aims at sensitizing physicians on drug-micronutrient interactions. High-risk population groups also are presented and supplementation protocols are suggested.

Diabetes, comorbidities and increased long-term mortality in older patients admitted for geriatric inpatient care

AIMS To study the specific impact of diabetes on long-term mortality in very old subjects with multiple comorbidities and functional disabilities. METHODS The prevalence of vascular disorders, global comorbidity load (cumulative illness rating scale [CIRS]) and functional disabilities (activities of daily living [ADL] and Lawtons instrumental ADL [IADL] scores) were determined according to diabetes status in a cohort of 444 patients (mean age 85.3±6.7 years; 74.0% women) admitted to our geriatric service. Also, the specific impact of diabetes on 4-year mortality was analyzed using Cox proportional-hazards models. RESULTS Diabetic patients had higher BMI scores (27.1±4.9 vs. 23.4±4.7 kg/m(2) in controls; P<0.001), and higher prevalences of hypertension (81.9% vs. 65.1%, respectively; P=0.003) and ischaemic heart disease (33.7% vs. 22.2%, respectively; P=0.033), but not of stroke and renal insufficiency. They also had more comorbidities (CIRS score excluding diabetes: 15.1±4.5 vs. 13.8±4.8, respectively; P=0.016) and functional disabilities. Diabetes was associated with mortality (HR: 1.42, 95% CI: 1.02-1.99; P=0.041) after adjusting for age, gender and BMI, and this persisted after adjusting for individual vascular comorbidities, but disappeared after adjusting for CIRS, ADL or IADL scores. CONCLUSION Diabetes was associated with 4-year mortality after adjusting for the inverse relationship between mortality and BMI. This association was better accounted for by the global comorbidity load and functional disabilities than by the individual vascular comorbidities. These findings suggest that the active management of all--rather than selected--comorbidities is the key to improving the prognosis for older diabetic patients.

Malnutrition in very old hospitalized patients: A new etiologic factor of anemia?

BackgroundAnemia and malnutrition are highly prevalent, frequently concomitant and associated with negative outcomes and mortality in the elderly.ObjectivesTo evaluate the association between these two entities, and test the hypothesis that protein-energy deficit could be etiology of anemia.DesignProspective case-control study. Setting: Geriatric and Rehabilitation Hospital, Geneva University Hospitals, Switzerland.Participants392 patients (mean age 84.8 years old, 68.6% female).Main outcome measuresHematological (hemoglobin (Hb)), chemical (iron work up, cyanocobalamin, folates, renal function, C-Reactive Protein (CRP)) and nutrition (albumin, prealbumin) parameters, and mini nutritional assessment short form (MNA-SF).ResultsThe prevalence of anemia (defined as Hb<120 g/l) was 39.3%. Anemic patients were more frequently malnourished or at risk of malnutrition according to the MNA-SF (p=0.047), with lower serum albumin (p <0.001) and prealbumin (p <0.001) levels. Thirty-eight percent of these patients had multiple causes and 14.3% had no cause found for anemia. Among the latter 90.9% of patients with unexplained anemia had albumin levels lower than 35g/l. After exclusion of iron,vitamin B12 and folic acid deficits, anemic patients had lower albumin (p<0.001) and prealbumin (p 0.007) levels. Albumin level explained 84.5% of the variance in anemia. In multivariate analysis albumin levels remain associated with Hb only in anemic patients, explaining 6.4% of Hb variance (adj R2) and 14.7% (adj R2) after excluding inflammatory parameters (CRP>10).ConclusionsAlbumin levels are strongly associated with anemia in the elderly. Screening for undernutrition should be included in anemia assessment in those patients. Further prospective studies are warranted in order to explore the effect of protein and energy supplementation on hemoglobin level.

A Rare Case of Adrenal Insufficiency Induced by Inhaled Corticosteroids

1. Christensen PB, Jensen TS, Tsiropoulous I et al. Incidence and prevalence of myasthenia gravis in western Denmark: 1975–1989. Neurology 1993;43:1779–1783. 2. Phillips LH, Torner JC. Epidemiology evidence for a changing natural history of myasthenia gravis. Neurology 1996;47:1233–1238. 3. Schon F, Drayson M, Thompson RA. Myasthenia gravis and elderly people. Age Aging 1996;25:56–58. 4. Aragon es JM, Bol ıbar I, Bonfill X et al. Myasthenia gravis: A higher than expected incidence in the elderly. Neurology 2003;60:1024–1026. 5. Vincent A, Clover L, Buckley C et al. UK Myasthenia Gravis Survey. Evidence of underdiagnosis of myasthenia gravis in older people. J Neurol Neurosurg Psychiatry 2003;74:1105–1108. 6. Lawrence H, Phillips LH. The epidemiology of myasthenia gravis. Semin Neurol 2004;1:17–20. 7. Matsui N, Nakane S, Nakagawa Y et al. Increasing incidence of elderly onset patients with myasthenia gravis in a local area of Japan. J Neurol Neurosurg Psychiatry 2009;80:1168–1171.