Eric Bercoff

Fecal incontinence in the institutionalized elderly: incidence, risk factors, and prognosis.

PURPOSE This study was conducted to evaluate the incidence, identify the risk factors, and assess the prognosis of elderly institutionalized patients who develop fecal incontinence. PATIENTS AND METHODS We enrolled 1,186 patients 60 years of age and older living in long-term care facilities who did not have fecal incontinence. We assessed their medical history, treatment, mobility, and cognitive function. Patients were followed up for 10 months to determine the incidence of fecal incontinence, defined as at least one involuntary loss of feces. Independent risk factors associated with fecal incontinence were identified using Cox proportional hazards models. The prognosis of incontinent patients was assessed by comparing their survival rate with that in the continent patients. RESULTS Fecal incontinence occurred in 234 patients (20%), and was usually associated with acute diarrhea or fecal impaction. We identified five risk factors for the development of fecal incontinence: a history of urinary incontinence (rate ratio [RR]: 2.0, 95% confidence interval [CI] 1.5 to 2.6); neurological disease (RR: 1.9, 95% CI 1.0 to 3.4); poor mobility (RR: 1.7, 95% CI 1.2 to 2.4); severe cognitive decline (RR: 1.4, 95% CI 1.1 to 1.9); and age older than 70 years (RR: 1.7, 95% CI 1.0 to 2.8). Ten-month mortality in the 89 patients with long-term (> or = 8 days) incontinence was 26%, significantly greater than that observed in the continent group (6.7%) or in the 145 patients with transient incontinence (10%). CONCLUSIONS Long-lasting or permanent fecal incontinence was associated with increased mortality, suggesting that this symptom is a marker of poor health in older patients. Actions that improve mobility might help prevent fecal incontinence in elderly patients.

Drug‐Drug Interactions Related to Hospital Admissions in Older Adults: A Prospective Study of 1000 Patients

OBJECTIVE: To investigate the frequency, nature, and side effects of drug‐drug interactions (DDI) in a group of geriatric inpatients.

Differences in the Signs and Symptoms of Hyperthyroidism in Older and Younger Patients

OBJECTIVES: To determine if aging modifies the clinical presentation of hyperthyroidism and the signs of thyrotoxicosis in older people.

Discrepancy Between Wedged Hepatic Venous Pressure and Portal Venous Pressure After Acute Propranolol Administration in Patients With Alcoholic Cirrhosis

In patients with alcoholic cirrhosis, wedged hepatic venous pressure closely reflects portal venous pressure. This study was carried out to determine if propranolol-induced reductions in portal venous pressure are accurately evaluated by the measurement of wedged hepatic venous pressure. Hepatic venous cannulation and percutaneous transhepatic catheterization of the portal vein were simultaneously performed in 7 patients with alcoholic cirrhosis. One hour after oral administration of 40 mg of propranolol, wedged hepatic and portal venous pressures significantly decreased from 24.3 +/- 3.5 (mean +/- SD) to 19.0 +/- 3.0 mmHg, and from 24.7 +/- 3.9 to 22.4 +/- 3.6 mmHg, respectively. Although no significant difference was found between baseline wedged hepatic and portal venous pressures, a significant difference was found between these pressures after propranolol administration. We concluded that during acute administration of a drug acting on the splanchnic circulation, the measurement of wedged hepatic venous pressure may not provide a reliable estimation of the magnitude of the changes in portal venous pressure. There is, however, no evidence that the direction of the changes might not be adequately assessed by wedged hepatic venous pressure measurement.

Is presentation of bacteremia in the elderly the same as in younger patients

OBJECTIVE To compare the presentation of bacteremia in young and elderly patients. PATIENTS AND METHODS Seventy-one elderly (mean age 80.4 years) and 34 younger inpatients (mean age 45.7 years) with bacteremia were prospectively studied. These were compared with a control group of 187 geriatric patients (mean age 81.3 years) with clinical signs of bacteremia but in whom blood cultures were negative. Bacteremia was defined as one or more positive blood cultures showing a pathogenic bacteria in patients with clinical signs of bacteremia. In all 105 patients with bacteremia, 16 common clinical or biological signs of the disease were immediately investigated after blood culture. Patients were classified into three groups: elder patients and young patients with bacteremia and elderly patients without bacteremia. RESULTS Only three clinical findings of the 16 studied were found in at least 70% of the bacteremic elderly patients: fever, increased erythrocyte sedimentation rate, and a clinical indication of the source of infection. These three signs were found statistically more often in bacteremic elderly compared with nonbacteremic elderly patients (P < 0.01). Seven other signs (hypothermia, altered mental state, leukopenia, and lymphopenia) had a specificity above 80%. On a logistic regression analysis, four variables were significantly and independently associated with bacteremia in the elderly: rapid onset of infection (defined as a period < or = 48 hours between the earliest manifestation of bacteremia and the time of blood blood sample), fever, altered general state, and clinical indication of the source of infection. Younger infected patients had more chills, sweating, alter general state, altered mental state or lymphopenia than did the bacteremic elderly patients. Bacteremic elderly patients had statistically few symptoms than the young infected patients (P < 0.001). CONCLUSIONS In elderly patients with early stage bacteremia, most of the signs or symptoms that are considered typical in the literature appear irregularly. None appeared pathognomonic. Elderly patients with bacteremia had fewer signs or symptoms than younger infected patients.

Acute Effects of Captopril on Systemic and Renal Hemodynamics and on Renal Function in Cirrhotic Patients With Ascites

The reduction of angiotensin II production by captopril--an angiotensin-converting enzyme inhibitor--could suppress hyperaldosteronism without impairment of renal function and could thereby be useful in the treatment of ascites in patients with cirrhosis. Systemic and renal hemodynamics and renal function were studied in 6 nonazotemic patients with cirrhosis and ascites with a low-sodium diet before and after oral administration of 25 mg of captopril. Cardiac output and renal blood flow did not change significantly after administration of captopril, whereas mean arterial pressure significantly decreased. Systemic and renal vascular resistances were significantly reduced. There was a statistically significant reduction of glomerular filtration rate, filtration fraction, and urinary output. Plasma renin activity significantly increased in all patients after administration of captopril. A statistically significant correlation was found between the decrease in mean arterial pressure and the reduction of glomerular filtration, but no relationship was found between basal values of plasma renin activity and the other observed variations. We concluded that captopril mainly induces hypotension due to an increase in renal vasodilatation in ascitic patients with cirrhosis.

The evaluation of CA 19‐9 antigen level in the early detection of pancreatic cancer: A prospective study of 866 patients

To establish if CA 19‐9 could detect early pancreatic cancer, we measured its serum concentration in 866 patients admitted for benign diseases and observed for 2 years. All patients with an elevated CA 19‐9 level (>40 units (U)/ml) were submitted to a computed tomography (CT) scan of the pancreas. The CA 19‐9 level was increased in 117 patients. One hundred fifteen of these 117 patients had false‐positive elevations. The CA 19‐9 concentration was elevated mostly in benign hepatobiliary diseases. In this group of patients, CA 19‐9 was correlated to alkaline phosphase values. Eleven patients showed an elevated CA 19‐9 level for 10 months without any malignancy developing. One patient had a normal CA 19‐9 concentration 8 months before clinical signs of pancreatic carcinoma developed. We conclude that CA 19‐9 measurement is of no value for the early detection of this malignancy.

Does Age Play a Role in Clinical Presentation of Hypothyroidism

OBJECTIVE: To determine if aging modifies the clinical presentation of hypothyroidism.

A Randomised Controlled Study of Propranolol for Prevention of Recurrent Gastrointestinal Bleeding in Patients with Cirrhosis

Summary74 cirrhotic patients with a history of variceal or gastric bleeding were randomly assigned to treatment with propranolol (40 to 360 mg/day) or placebo. The patients were all in good condition and doses of propranolol were titrated until a 25% reduction in heart rate was achieved.After 2 years, the cumulative percentage of patients free from rebleeding was significantly greater among the patients receiving propranolol (79%) than in the placebo group (32%; p<0.0001). Similarly, the percentage of surviving patients was significantly greater with propranolol (90%) than with placebo (57%; p<0.02) after 2 years.It was concluded that in cirrhotic patients in good condition, propranolol reduced both the risk of recurrent gastrointestinal haemorrhage and the mortality rate during a 2-year period of continuous administration of the drug.

PURPLE URINE BAGS: A GERIATRIC PRESENTATION OF LOWER URINARY TRACT INFECTION

Critical to the program’s philosophy and operations is the maintenance of a network of personal relationships. The community workers know the patients in their own homes, know their neighbors and friends, and know the surrounding community. (Some patients are so attached to particular workers that special planning for vacations is necessary.) The workers regularly visit the outpatient clinic, where they know the nurses, physicians, and pharmacists, all of whom may pause to discuss how best to address a particular diffi-