Renato Giua

Lung function changes in older people with metabolic syndrome and diabetes

Restrictive lung dysfunction (RLD; defined as reduced forced vital capacity [FVC] in the presence of normal forced expiratory volume in 1 s [FEV1]/FVC ratio) is highly prevalent in the elderly, and is associated with diabetes, metabolic syndrome (MetS) and abdominal obesity. The aim of this study was to assess the relative contribution of diabetes, MetS and abdominal obesity in characterizing RLD in the elderly.

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.

Colistin bladder instillation, an alternative way of treating multi-resistant Acinetobacter urinary tract infection: a case series and review of literature

The multiresistant Acinetobacter species bacteria are frequently involved in urinary or respiratory tract infections, and one of the most effective drugs, colistine, is associated with significant nephrotoxicity and neurotoxicity. Given that very high concentrations of colistine into biological fluids are safe for the human organism, attempts have been made at delivering the drug topically, by aerosol, or, occasionally, intratechally or intraventricularly for meningitis. These topical treatments could eradicate the Pseudomonas sp. from the lung of patients with cystic fibrosis or bronchiectasis and the Acinetobacter baumannii from lung and meninges. However, only one case of colistin topic treatment in urinary tract infection is described. We report a case series of three patients successfully undergone colistin bladder instillations for multi drug resistant Acinetobacter urinary tract infection, and we review the literature about colistin topic treatment.

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.

GOLD Staging System is Appropriate to Predict Mortality in Older People With Chronic Obstructive Pulmonary Disease

INTRODUCTION In the new GOLD classification the reduction of FEV1, expressed as percentage of predicted value (FEV1PP), is considered an important prognostic factor. However, the use of FEV1PP may introduce bias, especially if based on equations derived from populations different from the one under study. We evaluated how well the GOLD classification stratifies the mortality risk when FEV1PP is based on an equation developed in the same population that gave rise to cases, externally developed equations, or as FEV1 divided by cubed height (FEV1/Ht3). METHODS We studied 882 participants aged ≥65 years. Bronchial obstruction was defined using a fixed cut-off of 0.7 for FEV1/FVC. Predicted values of FEV1 were derived from equations based on the same sample of the cases included in this study and from the European Respiratory Society equations. Severity of bronchial obstruction was also classified according to quartiles of FEV1/Ht3. RESULTS All the classification systems showed a non-statistically significant linear tendency with 5-years mortality risk. For the 15-years mortality, the linear trend across severity stages is more evident for GOLD classifications, with significant increments in the hazard ratio. Stratification by FEV1/Ht3 could better discriminate the functional status of participants. CONCLUSION The severity of bronchial obstruction according to GOLD classes may stratify mortality risk better than quartiles of FEV1/Ht3, whereas the second seems to be more suited to stratify the risk of clinical outcomes. Concerns about the use of externally developed reference values to calculate FEV1PP do not seem confirmed, at least for GOLD classification.

Ultrasound estimation of pleural effusion in geriatric patients

The pleural fluid is a viscous substance between the two pleural layers of the lungs, important in the respiratory mechanics. A pleural effusion (PE) is an excess of pleural fluid in the pleural cavity, caused by several pathologies (e.g., pulmonary embolism, cancer, and infections). Because of its incidence, PE identification and quantification are important to lead the clinician in the selection of the optimal therapeutic strategy. PE volume can be estimated by invasive (quantitative) and non-invasive (qualitative) approaches. Invasive methods provide accurate measurement of PE volume and utilize Computed Tomography (CT) imaging and thoracentesis. Non-invasive methods are based on Ultrasound (US) imaging and are able to identify the PE, but do not quantify its volume. Aiming to spare the patients from risks due to X-ray exposure and invasiveness of thoracentesis, a non-invasive approach for the estimation of PE is coveted. The aim of this study is the feasibility assessment of a simple and affordable model for the quantification of PE through US images. Two US scans are performed to measure: the height of PE column (hPEUS) and the area of the effusion (aPEUS) in correspondence of half hPEUS. The proposed model estimates the PE volume (PEVUS) by multiplying hPEUS and aPEUS, based on cylindrical approximation. PEVUS are compared with PE volumes estimated by CT scans (PEVct), achieved within 24 h from the US exam. The model was successfully tested on 7 patients for PE volumes ranging from 70 mL to 550 mL. The good agreement between PEVus and PEVct volumes is witnessed by the slope of the best fitting line (0.988) and the high correlation coefficient (R=0.99). The two measurements are also compared by Bland-Altman plot, which provides a mean of difference of 1.7 mL and limits of agreement of -32.5 mL and +36.0 mL. The findings of this work show that the proposed model can be a valid tool for the estimation of PE volume by means of US exam. An important advantage of this model is the possibility to quantify PE by the measurements of only two parameters. This approach is not time consuming, hence it can be easily implemented in clinical routine.

An Unusual Cause of Hematuria: Primary Bladder Melanoma in an Older Man

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Composite Mantle-Cell Lymphoma and Classical Hodgkin Lymphoma in a Very Old Adult

because of atypical presentation, limited history, and presence of multiple pathologies. Abdominal pain and hematuria are typical symptoms of EC, but they are present in only 80% and 50% of cases, respectively. The symptoms are not uncommon in elderly adults, but they are often treated for uncomplicated UTIs. Plain abdominal radiograph is highly sensitive (90%), and computed tomography is the most sensitive and specific diagnostic tool. Abdominal radiographs are not routinely performed in elderly adults with UTI. The mechanism of gas formation is not exactly known. Given its prevalence in individuals with diabetes mellitus and those with urinary retention, several theories have suggested fermentation of glucose or albumin in urine as plausible mechanism for the gas formation within the affected tissue. Escherichia coli and Klebsiella pneumoniae have been the commonest pathogens associated. EC is usually treatable with medical therapy alone, but bladder irrigation may be needed if blood clots are present, as in the woman described herein. Rarely, bladder debridement and partial or total cystectomy are required. Overall mortality is 9%. In conclusion, UTI and cystitis are common diagnoses in elderly adults, and plain abdominal X-ray is not routinely ordered unless there is suspicion of renal calculi. This woman with diabetes mellitus presented with typical symptoms of EC, namely abdominal pain and hematuria, but diagnosis of EC was incidentally revealed on plain film ordered to look for renal calculus. Geriatricians and internists should consider this rare condition, and with early imaging, timely diagnosis and treatment will lower morbidity and mortality.