Luisa Costanzo

Efficacy of a Physician-Led Multiparametric Telemonitoring System in Very Old Adults with Heart Failure

To evaluate the effect of an innovative model integrating telemonitoring of vital parameters and telephone support on 6‐month survival and hospital admissions of elderly adults with heart failure (HF).

Fibrate therapy and flow-mediated dilation: A systematic review and meta-analysis of randomized placebo-controlled trials

Flow-mediated dilation (FMD) of the brachial artery reflects endothelium-dependent vasodilator function; since it correlates with coronary endothelial function, its reduction could predict cardiovascular events. Several studies have investigated the potential impact of fibrates therapy on endothelial function, but clinical findings have not been fully consistent. We aimed to conduct a meta-analysis of randomized placebo-controlled trials in order to clarify whether fibrate therapy could improve endothelial function. A systematic search in PubMed-Medline, SCOPUS, Web of Science and Google Scholar databases was performed to identify randomized placebo-controlled trials investigating the effect of fibrates on endothelial function as estimated by FMD. A random-effects model and generic inverse variance method were used for meta-analysis. Sensitivity analysis, risk of bias evaluation, and publication bias assessment were carried out using standard methods. Random-effects meta-regression was used to evaluate the impact of treatment duration on the estimated effect size. Fifteen trials with a total of 556 subjects met the eligibility criteria. Fibrate therapy significantly improves FMD (weighted mean difference [WMD]: 1.64%, 95% CI: 1.15, 2.13, p<0.001) and the result was confirmed in both subgroups with treatment durations ≤8 weeks (WMD: 1.35%, 95% CI: 0.85, 1.86, p<0.001) and >8 weeks (WMD: 2.55%, 95% CI: 1.21, 3.89, p<0.001). When the analysis was stratified according to the fibrate type, a significant effect was observed with fenofibrate but not with gemfibrozil, though difference between the two subgroups was not significant. Meta-analysis of data from trials where nitrate mediated dilation (NMD) was available did not suggest a significant change in NMD following treatment with fibrates. The results of this meta-analysis suggest that fibrates may exert beneficial effects on endothelial function, even over a short-term treatment course.

Diagnosis and prognostic value of restrictive ventilatory disorders in the elderly: A systematic review of the literature

Although less extensively studied compared to pulmonary obstructive diseases, restrictive lung disease (RLD) is highly prevalent and frequently disabling in the adult and, more, the elderly population. The underlying conditions may be either primarily pulmonary diseases, such as idiopathic pulmonary fibrosis, or non respiratory conditions secondarily affecting the lung, e. g. congestive heart failure, or else conditions affecting the lung expansion, e. g. obesity or rib cage deformity. The diagnosis is frequently based on the measurement of surrogate indexes such as the forced vital capacity (FVC) used as a proxy for total lung capacity (TLC). As a consequence, diagnosis of RLD is often characterized by poor specificity. In the elderly, worsening in the quality of life and poor prognosis are variably, but significantly, associated to RLD, being the underlying condition an important source of variability. Several causes of RLD are preventable and treatable conditions. A prompt identification of these conditions may allow to slow the decline of respiratory reserve and, thus, to preserve both personal independence and resistance to acute respiratory infections. This review gives an update on the latest evidence available on the prevalence and the prognosis of RLD in the elderly. Studies were identified through systematic searches of the electronic database MEDLINE. Reference list of eligible papers were also manually searched.

Physical Function and Exercise in Older Patients with Cardiovascular and Respiratory Conditions

The increase of life expectancy together with the decline of birth rates implies a global aging of populations living in industrialized countries. Since advanced age is associated with an exponential consumption of health care resources, this phenomenon is likely to pose a substantial threat to the stability of public health systems. Prevention of physical disability represents a major public health priority. Since disability is considered an irreversible condition, every effort should be made to prevent the onset of the disabling cascade and/or delay the physical function decline. The need for strategies against disability has led researchers to look for the most relevant risk factors potentially determining or accelerating the disabling cascade. In this context, cardiovascular and respiratory conditions have been indicated as playing prominent roles in the determination of frailty. Moreover, the high prevalence of these conditions among older persons makes them particularly amenable to targeting for preventive interventions. The aim of the present review is to show the impact of cardiovascular and respiratory conditions on physical function. Moreover, we will discuss the relationship of these conditions with the disabling process, and the importance of their assessment in the design of preventive interventions against disability in older persons.

Dietary intake of elderly outpatients with chronic obstructive pulmonary disease

PURPOSE Chronic obstructive pulmonary disease (COPD) is often associated with malnutrition, which is in turn associated with poor outcomes. Accordingly, in COPD patients adequate nutrition might improve several clinical and functional outcomes. Nevertheless, information about nutrient intake of older populations with COPD is still scanty. MATERIALS AND METHODS We analysed data of 523 elderly attending a geriatric ambulatory. Of these, 165 had a diagnosis of COPD, while 358 were control participants, matched for demographic characteristics and free from respiratory diseases. COPD was diagnosed according to the global initiative for chronic obstructive lung disease (GOLD) criteria. The intake of micro and macronutrients was recorded using the European prospective investigation into cancer and nutrition (EPIC) questionnaire. Nutrient intake of COPD patients was compared with that of the control group and with recommended dietary allowances RDA. RESULTS COPD patients had a lower energy intake, as compared with control participants (29.4 vs 34.4 kcal/kg of ideal weight; P<.0001), due to reduced intake of carbohydrates and proteins. Accordingly, in the energy intake was lower than recommended in 52% of COPD patients, vs 30% of controls (P<.0001). The intake of calcium, potassium, folate, cholecalciferol, retinol, and thiamine was lower than RDA in over 75% of COPD patients. CONCLUSIONS The diet of elderly COPD outpatients does not provide the recommended energy intake, nor does it meet the RDA for many micronutrients. Such deficits are more severe than in age matched non- respiratory subjects.

Malignant transformation of well-differentiated papillary mesothelioma 13 years after the diagnosis: a case report

Well‐differentiated papillary mesothelioma (WDPM) is a rare mesothelial tumour affecting mostly the peritoneum of women in their reproductive age, but it may occur also at other sites, including the pleura. It is considered a specific pathological entity different from diffuse malignant mesothelioma as it displays a characteristic histological pattern and is associated with a slowly progressive clinical course. We report the case of a 79‐year‐old man with a history of right pleural WDPM at age 64, which was successfully treated with chemotherapy, radiotherapy and talc pleurodesis. Thirteen years after the first diagnosis, he presented with mediastinal lymph nodes metastasis and with an extremely rare pattern of tracheal and bronchial infiltration that was detected at bronchoscopy. Biopsy samples revealed loss of histological differentiation of the neoplastic cells. This case report highlights that WDPM is a tumour of uncertain malignant potential that may undergo transformation over many years. Finally, the role of immunohistochemistry in the diagnosis of WDPM and the possible mechanisms leading to this unique way of metastatisation are discussed.

Analysis of volatile organic compounds: an innovative approach to heart failure characterization in older patients

BACKGROUND Analysis of exhaled volatile organic compounds (VOCs) may be applied for diagnostic purposes in some chronic diseases, but there are no data on their role for discriminating people with congestive heart failure (CHF), particularly in older patients where natriuretic peptides have lower accuracy. We evaluated whether VOCs analysis can discriminate patients with or without CHF, stratify CHF severity and predict the response to therapy of decompensated CHF. METHODS AND RESULTS We recruited 89 subjects admitted to an acute care ward with acutely decompensated CHF, 117 healthy controls and 103 chronic obstructive pulmonary disease (COPD) controls. CHF patients performed echocardiography. VOCs were collected using the Pneumopipe® and analyzed with the BIONOTE electronic nose. Partial least square analysis was used to evaluate the discriminative capacity of VOCs. Accuracy in discrimination of CHF versus healthy and COPD controls was 81% and 69%, respectively; accuracy did not decrease in a sensitivity analysis excluding subjects younger than 65 and older than 80 years. In CHF patients VOCs pattern could predict with fair precision ejection fraction and systolic pulmonary arterial pressure, but not changes in weight due to therapy. CONCLUSIONS VOCs pattern is able to discriminate older CHF patients from healthy people and COPD patients and correlates with cardiac function markers.

Breath-Printing of Heart Failure in Elderly

Comorbidity represents a confounding factor in exhaled breath analysis, in particular with elderly population, which often shows both respiratory and heart diseases. Congestive heart failure (CHF) is the first cause of hospitalization and a primary cause of death and disability in the elderly population. CHF has important metabolic implications, thus exhaled VOCs analysis may support CHF severity assessment and CHF discrimination against controls. VOCs pattern in CHF has not been yet investigated so far, even if an increase in acetone and pentane has been observed. Here, breathprint based CHF diagnosis and severity classification have been studied. Moreover, studying an elderly population, Chronic Obstructive Pulmonary Disease (COPD) patients have been enrolled, being COPD an important comorbidity in aged population.

A rare cause of chronic diarrhoea in an elderly patient.

good safety of rt-PA in older adults, although there is an increased risk of intracerebral hemorrhage, above all symptomatic, in older adults, which cannot be ignored. Based on our findings and the findings of Mione et al. obtained by a prospective and retrospective approach, respectively, as well as on the results of other cohort studies, thrombolysis seems to be effective in patients aged >80 years, albeit to a lesser extent than in younger subjects, and is fairly safe, at the price of an acceptable increase in the hemorrhagic risk. However, we are aware that cohort studies show some relevant shortcomings in the design, principally the lack of randomization. In the randomized clinical trial IST-3, contrary to expectations, the statistical analysis based on the adjusted effect of treatment on the primary outcome between patients aged ≤80 years or >80 years seemed to show a greater (P-value 0.029) benefit of thrombolysis in those aged >80 years. However, what is clinically more relevant is the fact that approximately 44% of the patients aged >80 years received e.v. rt-PA within 3 h, compared with just 8.6% of those aged <80 years. The more favorable time frame of rt-PA administration in older people is likely to underlie the apparent greater benefit of treatment in this group, whereas the time to randomization was found to have a statistically significant effect on the primary outcome (0–3 h: adjusted OR 1.64 in favor of treatment). Furthermore, the 11-year IST-3 study enrolled 3035 patients from 156 centers (277 patients per year, an average of 1.7 patients/center/ year): the enrolment was not consecutive in most centers, which is likely to have entailed a selection bias. Therefore, all the studies that have so far examined the question whether thrombolysis in older adults improves the prognosis show some methodological pitfalls, even the randomized IST-3. In conclusion, although the question as to thrombolysis in octagenarians and nonagenarians: to do or not to do? remains, to a certain extent, open, as no clear evidence has been provided to exclude older adults from thrombolytic treatment, we can safely say that this subgroup of stroke patients can be treated, irrespective of the age, based on clinical judgment, with a reasonably good probability of a favorable risk–benefit ratio. Disclosure statement