Oreste Terranova

Constipation in the acutely hospitalized older patients.

The aim of this work was to establish the factors that determine the onset of constipation in acutely hospitalized older patients with a view to contributing towards an evidence-based identification of which patients warrant early, specific preventive measures. To evade the problem posed by the definition of constipation, we have considered parameters that are part of the daily routine in the hospital ward, such as the prescription of laxatives, also paying attention to how the co-operative older person subjectively interpret this condition. One thirds of the 192 hospitalized older patients needed a laxative at least once every 3 days. Multivariate analysis identified the use of laxatives at home as the only risk factor for objective constipation while in hospital (odds ratio (OR)=3.0). A significant risk of being dissatisfied with their bowel emptying emerged among patients who were bedridden for more than 2 weeks (OR=6.0), and in those who experienced cerebrovascular events (OR=3.1). The use of laxatives at home and awareness that satisfaction with bowel movements drops in patients obliged to stay in bed for lengthy periods of time and in those who have suffered cerebrovascular damage, should provide the grounds for a screening program to establish rational guidelines on bowel movement therapy.

Ischemic colitis in the elderly: predictors of the disease and prognostic factors to negative outcome.

Abstract Objective. Ischemic colitis (IC) poses a challenge for physicians, especially in elderly patients. The aim of this study was to identify predictors of the disease and to assess the factors predicting its evolution in elderly people. Material and methods. A retrospective study was undertaken in patients with IC admitted to Padua General Hospital between 2003 and 2008. Only patients with biopsy-proven IC were considered. Fifty control subjects were randomly selected from those seen at our units for acute geriatric disease during the same interval. Patients with IC were classified as having either a positive or negative outcome. Results. A total of 46 patients were considered. The risk factors for IC identified from univariate analysis were analyzed in a multivariate logistic regression model and constipation [adjusted odds ratio (OR) 4.8; 95% confidence interval (CI) 1.1–20.1], vasculopathy (OR 4.9; 95% CI 1.4–16.6), hepatitis C virus (HCV) (OR 9.9; 95% CI 1.1–92.9) and cancer (OR 7.5; 95% CI 2.1–26.9) confirmed their independent significance as risk factors. Hematochezia was predictive of a positive outcome (OR 0.07; 95% CI 0.02–0.40), while cancer (OR 3.2; 95% CI 1.2–11.9), HCV positivity (OR 9.6; 95% CI 1.6–56.5), signs of peritonism (OR 4.7; 95% CI 1.2–18.4), localization in the right colon (OR 5.75; 95% CI 1.5–21.9) and increased levels of lactate dehydrogenase (LDH) and urea were independently predictive of a negative outcome. Conclusions. Elderly patients with IC are characterized by significant comorbidities. The absence of hematochezia and the presence of a concomitant malignancy, HCV, a marked increase in urea and LDH and disease involving only the right colon are factors that may predict a negative outcome in elderly patients.

Does the Multidimensional Prognostic Index (MPI), based on a Comprehensive Geriatric Assessment (CGA), predict mortality in cancer patients? Results of a prospective observational trial

OBJECTIVE Despite the lack of definitive data on the impact of Comprehensive Geriatric Assessment (CGA) in the geriatric oncology setting, the broad use of any form of CGA is strongly recommended before any treatment decision in elderly cancer patients (ECP); currently there is no consensus about the best format for this geriatric assessment. The aim of this study was to firstly test the Multidimensional Prognostic Index (MPI) in ECP with locally advanced or metastatic disease. MATERIALS AND METHODS Patients aged ≥70years with inoperable or metastatic solid cancer consecutively admitted to our Program of Geriatric Oncology were assessed by a multidisciplinary team and received a basal CGA to calculate the MPI score. RESULTS A hundred and sixty patients entered the study. In the Coxs regression model, MPI, CIRS-SI, BSA, GDS, MMSE, chemotherapy and a diagnosis of primary lung cancer were associated with mortality at 6 and 12months. The ROC curves confirmed the prognostic value of MPI, with the best discriminatory power for mortality at both 6 and 12months. CONCLUSION The present study is the first to indicate that the MPI retains its prognostic value even in elderly cancer patients with advanced stage of disease. The CIRS-SI and the GDS may potentiate the prognostic value of MPI.

Esophagitis in frail elderly people.

Introduction We studied the clinical course of elderly patients acutely hospitalized for various diseases, assessing any differences between patients with and without esophagitis. Study A case-control study on the presence of esophagitis was conducted on the clinical records of all in-patients undergoing gastroduodenoscopy at Padova Geriatric Hospital from 1997 to 2001. Data were examined on 338 sex-matched patients: 169 with a diagnosis of esophagitis and 169 with a negative endoscopy. Results Admissions for acute respiratory disorders [odds ratios (OR) 2.68; 95% confidence interval (CI) 0.89-8.01], a remote diagnosis of esophagitis (OR 11.34; 95%CI 2.68-48.07), obesity (OR 3.36; 95%CI 0.91-12.48), and being bedridden (OR 6.84; 95%CI 3.27-14.29) were found to be independent risk factors for the presence of esophagitis. The symptoms prompting the endoscopic diagnoses included: gastrointestinal bleeding (OR 7.61; 95%CI 2.76-21.0), heartburn (OR 4.58; 95%CI 1.86-11.28), and cough (OR 3.59; 95%CI 1.34-9.62). Steroids (OR 2.68; 95%CI 1.11-6.44) and calcium antagonists (OR 1.50; 95%CI 0.79-2.87) were associated with esophagitis as risk factors, whereas proton pump inhibitors (OR 0.46; 95%CI 0.25-0.87), nitrates (OR 0.14; 95%CI 0.02-0.78), and sucralfate in males (OR 0.09; 95%CI 0.01-0.92) were associated as protective factors. Patients with esophagitis were discharged with an endocrinologic/metabolic-type diagnosis. Deaths were significantly higher among patients with esophagitis (25 vs. 9); more severe esophagitis was characterized by a higher Charlson comorbidity index and a greater presence of anorexia and nausea. Conclusions These findings seem to substantiate the theory that esophagitis is a characteristic which exacerbates frailty in hospitalized elderly people and its identification may be helpful in these patients.

Infrapopliteal arterial reconstructions for limb salvage in patients aged ≥80 years according to preoperative ambulatory function and residential status

BACKGROUND Although numerous studies have addressed peripheral revascularizations for critical limb ischemia (CLI) in patients aged > or =80 years, few have focused exclusively on infrapopliteal arterial reconstructions. This study aimed to analyze early and long-term outcomes in very elderly patients who underwent surgical infrapopliteal revascularization for CLI according to their pre-operative ambulatory function and residential status. METHODS Over an 18-year period, all consecutive patients aged > or =80 years referred to our institution for CLI requiring primary infrapopliteal or inframalleolar arterial reconstruction were enrolled in the study. All procedures were completed by the same surgeon with patients under regional anesthesia. Patency, limb salvage, amputation-free survival, and cumulative survival rates were assessed by Kaplan-Meier analysis. The patients pre- and postoperative ambulatory function and residential status (at home vs in a nursing home) were also analyzed. The mean follow-up was 6.2 years (range, 0.1-11.5) and was obtained for 98% of patients. RESULTS In all, 197 patients (134 men; mean +/- SD age, 82.8 +/- 1.7 years) with 201 critically ischemic limbs were enrolled in the study. No deaths or fatal major complications occurred in the peri-operative period (first 30 days); the local complication rate was 6%. After 1 and 7 years, the primary patency rates were 88% and 68%, the limb salvage rates were 96% and 87%, the amputation-free survival rates were 88% and 39%, and the survival rates were 91% and 44%, respectively. At last follow-up or death, 80% of the patients were ambulatory and 20% were not; 80% lived at home and were independent, another 9% lived at home with assistance, and 76% of the sample lived at home and were ambulatory. CONCLUSION Infrapopliteal arterial revascularization in the very elderly with CLI proved safe, effective, and durable, confirming that age per se and concomitant comorbidities do not necessarily affect technical and clinical outcomes. Ambulatory function and independent living status are well preserved because, despite a relatively short life expectancy, the majority of very elderly revascularized CLI patients can be expected to spend their remaining years ambulatory and at home. In contrast, patients with poor ambulatory function or who required assistance pre-operatively were less likely to improve their status after limb revascularization despite a successful technical result.

Pluriannual experience in stapled haemorrhoidopexy in the elderly

Background Compare two groups of patients, ≥ 70 years old and < 70 years old, diagnosed with III-IV grade haemorrhoids that underwent a stapled haemorrhoidopexy. [1]

Implementation of a guideline versus use of individual prognostic factors to prioritize waiting lists for upper gastrointestinal endoscopy

Background Studying factors associated with positive gastroscopies in dyspeptic patients can help limit and rationalize waiting lists for endoscopies. Dyspepsia guidelines have a controversial role because their main purpose is to provide specifications on efficient global management of primary care patients. Aim To assess and weigh the risk of major endoscopic diagnoses against different age groups, gender, Helicobacter pylori infection, compliance with European Society of Primary Care Gastroenterology (ESPCG) guideline statements, and participation of prescribing general practitioners in a quality improvement programme for dyspepsia management, based on these guidelines. Methods We consecutively studied the outcomes of 752 gastroscopies with respect to two sets of useful results: the first considered diagnoses of carcinoma, gastric and duodenal ulcer; the second excluded duodenal ulcer. Results A diagnosis of cancer or gastric/duodenal ulcer was associated with male sex (odds ratio (OR)=1.81, P=0.016), age above 41 years (OR=3.24, P=0.009) and particularly with positivity to H. pylori (OR=4.49, P<0.001), while the risk increased by two and a half times in gastroscopies conforming with ESPCG guidelines (OR=2.47, P=0.003). In the second set of analysis, we noted a statistically significant correlation between cancer or gastric ulcer and compliance with ESPCG guidelines (OR=4.69, P=0.013), but not with H. pylori positivity (OR=1.83, P=0.11); a linear relationship was observed across age groups, with a 60% increase in the risk of disease with every 5-year increase in age (OR=1.59, P=0.002). Conclusion Participation of general practitioners in the Dyspepsia Management Programme (DMP) was not significantly associated with a positive gastroscopy.

Clinical and prognostic aspects of gastric carcinoma in the elderly

The aim of the present study was to analyze the influence of various factors on the prognosis for elderly patients with gastric carcinoma. Forty-eight patients aged =>65 years admitted to Padova General Hos-pital were divided into two groups by age (<75 or >75 years). They all had a histologically confirmed diagnosis of gastric adenocarcinoma. Information on their clinicopathological characteristics was col-lected from the Padova Hospital medical records. On univariate analysis, significant prognostic factors in the two age groups were gender, stage, histotype (Lauren’s intestinal type), Charlson index, and type of surgery (curative resection, palliative resection, and no surgery). On multivariate analysis, inde-pendent prognostic factors were the Charlson index, tumor stage, and age group. The 52-month survival rate was 72.7% for females and 12.5% for males for patients =>75 years (P = 0.01), while for the whole series of patients it was 67.5% for females and 29.9% for males (P = 0.003). The 17-month survival rate was 55.6% for surgically treated patients and 0% for the untreated cases in stage 4 (P = 0.03). Gastric cancer should be treated with conventional surgery even in the very elderly, since the survival rate for this age group does not differ significantly from the figures for younger patients.

Effects of aging on abdominal wall healing in rats

PURPOSE The aim of this study was to assess abdominal wall healing in old and young adult rats. METHODS On average, young animals were 110 days old and old animals were 762 days old. A 4.0 cm median laparotomy was performed under anesthesia, followed by laparorrhaphy on two synthesis planes, i.e. peritoneum-muscle-aponeurosis and skin, using continuous 5.0 nylon sutures. The animals were evaluated on the 3rd, 7th, 14th and 21st postoperative days. The resistance of the two planes was studied separately and a histopathologic analysis was performed on sections stained with hematoxylineosin and Sirius Red. Immunohistochemical analysis was also carried out using PCNA, LCA and CD34. RESULTS The skin scars gained resistance in a similar manner at the initial time points, but those of young rats were more resistant on the 21st day (p=0.0029). Total and type III collagen content was similar in the two groups and type I collagen content was higher in young animals on the 14th day. Inflammatory cell infiltration was more marked in the skin wounds of young animals on the 3rd day (p=0.0190). Reepithelialization was similar and angiogenesis was more intense in the skin wounds of young animals on the 14th day (p=0.0062). The peritoneum-muscle-aponeurosis wounds gained similar resistance during the early phases, but were more resistant on the 14th day (p=0.0005) and on the 21st day (p=0.0023) in old rats Collagen concentration was higher in the wounds of old animals on the 3rd day (p=0.0112) and in the wounds of young animals on the 21st day (p=0.0348). The inflammatory reaction was more intense in the wounds of old animals on the 3rd day (p=0.0060) and angiogenesis was more intense on the 14th day (0.0432). CONCLUSION Although there are some differences in the healing course between young and old animals, age, of itself, does not impair the healing of abdominal wall wounds in rats.

The Bassini Operation

The Byzantine Medical School cured inguinal hernias by the removal of the ipsilateral testicle. Guy de Chauliac (1300–1368), a great surgeon of the French school, wrote the Grande Chirurgie, the book of reference for centuries. In cases of inguinal hernia, the author suggested this cure: