Silvestro Canonico

The role of blood pressure in cognitive impairment in an elderly population

Objective The aim of this study was to investigate the cross-sectional relationship between arterial blood pressure and cognitive impairment in a group of elderly subjects, controlling for such confounding variables as age, education, depression, drug use and antihypertensive treatment. Design and setting A cross-sectional survey in Campania, a region in southern Italy. Subjects and methods A random sample of 1339 elderly subjects aged 65–95 years (mean 73.9 ± 6.2 years) selected from the electoral rolls was interviewed by trained physicians. Sociodemographic characteristics, results of Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), blood pressure and whether antihypertensive treatment was being administered were recorded. When subjects with neurological diseases and those under psychotropic therapy were excluded from the analyses, the population numbered 1106. Results The MMSE score was less than 24 for 27.9% of the subjects and the mean GDS score was 10.8 ± 6.3. The mean systolic blood pressure (SBP) was 145.3 ± 19.0 mmHg and the mean diastolic blood pressure (DBP) was 82.0 ± 9.2 mmHg. Logistic regression analysis showed that female sex, age, GDS score and DBP but not SBP were predictive of cognitive impairment. Educational level and antihypertensive treatment, on the contrary, play a protective role. DBP was associated with cognitive impairment in subjects aged 75 years (odds ratio 1.62, 95% confidence interval 1.16–2.25) and over (odds ratio 5.16, 95% confidence interval 1.50–17.71) but not in those aged 65–74 years. Conclusion DBP but not SBP is predictive of cognitive impairment in subjects aged 75 years and over without neurological disorders independently from sex, age, education, GDS and antihypertensive treatment.

Relationships Between Daily Acute Glucose Fluctuations and Cognitive Performance Among Aged Type 2 Diabetic Patients

OBJECTIVE The mean amplitude of glycemic excursions (MAGE) is a significant determinant of overall metabolic control as well as increased risk for diabetes complications. Older individuals with type 2 diabetes are more likely to have moderate cognitive deficits and structural changes in brain tissue. Considering that poor metabolic control is considered a deranging factor for cognitive performance in diabetic patients, we evaluated whether the contributions of MAGE to cognitive status in older patients with type 2 diabetes were independent from the main markers of glycemic control, such as sustained chronic hyperglycemia (A1C), postprandial glycemia (PPG), and fasting plasma glucose (FPG). RESEARCH DESIGN AND METHODS In 121 older patients with type 2 diabetes, 48-h continuous subcutaneous glucose monitoring (CSGM) were assessed. MAGE and PPG were evaluated during CSGM. The relationship of MAGE to performance on cognitive tests was assessed, with adjustment for age, glycemic control markers, and other determinants of cognitive status. The cognitive tests were a composite score of executive and attention functioning and the Mini Mental Status Examination (MMSE). RESULTS MAGE was significantly correlated with MMSE (r = 0.83; P < 0.001) and with cognition composite score (r = 0.68; P < 0.001). Moreover, MAGE was associated with the MMSE (P < 0.001) and cognition composite score (P < 0.001) independently of age, sex, BMI, waist-to-hip (WHR) ratio, drug intake, physical activity, mean arterial blood pressure, FPG, PPG, and A1C. CONCLUSIONS MAGE during a daily period was associated with an impairment of cognitive functioning independent of A1C, FPG, and PPG. The present data suggest that interventional trials in older patients with type 2 diabetes should target not only A1C, PPG, and FPG but also daily acute glucose swings.

Prevalence of Varicose Veins in an Italian Elderly Population

The prevalence of varicose veins (VV) in the elderly population of the Campania Region, in Southern Italy, was estimated. A random sample of the people aged more than 65 years was drawn by means of a stratified multistage sampling design warranting that observed percentages were direct estimates of population percentages. The investigation covered 1319 subjects, 560 (42.5%) men and 759 (57.5%) women, their ages ranging from 66 to 96 years with an average value of 74.2 years, who were interviewed and visited by trained physicians. W were defined as any reticular or truncal visible vari cosities of the lower limbs, and investigated symptoms were heaviness, pain, nightly cramps, edema, eczema, hyperpigmentation, and ulceration. Some variables were studied as risk factors: age, sex, lifetime occupation, smoking, alcohol, hypertension, diabetes, and obesity; previous treatment and use of elastic stockings were also studied. Statistical associations were evaluated by Chi-square test, a two-tailed P value of 0.05 being assumed as significance level. In total, 391 (29.6%) subjects were reported to be affected by W, but the clinical examination was positive in only 362 (27.4%) with a good corre- spondence between answers and clinical findings. Prevalence was greatly affected by sex, the percentage being two times higher in women (35.2%) than in men (17%). W developed after a pregnancy in 40.5% of women, but a high percentage of women (38.2%) also reported menopause as a time starting point. No significant association between reported risk factors and W was found among men, whereas obesity was strongly related to W in women. One or more symptoms were reported in 92.1% of persons affected by W, but no previous therapy was reported by 58.9% of subjects. Only 16.9% of patients used elastic stockings with a significant difference between men (7.4%) and women (20.2%).

Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly

BackgroundRestorative proctocolectomy with ileopouch-anal anastomosis (IPAA) is the treatment of choice for intractable or complicated ulcerative colitis (UC). Debate exists concerning outcomes of IPAA in the elderly and literature data are scarce. We report our experience of IPAA in older population.MethodsWe gathered data on a prospective database of patients undergoing IPAA for UC over 70 years of age in our Unit from January 1990 through January 2010. Patients were compared with randomly selected younger controls on a 1:3 ratio. Patients underwent IPAA in 2 or 3 stages. Demographical data, disease characteristics, comorbidities, concomitant medications, peri-operative management, intra- and post-operative complications were analyzed. Function and quality of life were assessed by clinical visit and Inflammatory Bowel Disease Questionnaire 1 and 3 years after ileostomy takedown.ResultsTwenty-seven elderly patients underwent IPAA for UC in the study period; these were compared with 81 younger controls. The former had more comorbidities and higher ASA score. All patients underwent loop-ileostomy closure. There were no differences between groups concerning the rate of major complications, but elderly patients more frequently had nuisances due to stoma output. Younger patients experienced significantly more episodes of small bowel obstruction. No significant differences in bowel control and health-related quality of life was observed, except for an higher rate of elderly patients taking antidiarrhoeals at 1-year follow-up; this observation was not confirmed at 3-year follow-up. A minimal decrease in continence was observed, but this did not affect overall satisfaction.ConclusionsIPAA can be safely offered to selected elderly UC patients who are strongly motivated and with no clinical disturbances of continence. In experienced hands no differences are likely to be expected concerning complications, quality of life and function. Results are stable with time and comparable to those of younger patients.

Systematic review of cuff and pouch cancer in patients with ileal pelvic pouch for ulcerative colitis.

Background:Ileal pouch–anal anastomosis (IPAA) is the procedure of choice for refractory or complicated ulcerative colitis (UC). Since 1990, pouch-related adenocarcinomas have been described. The aim of this study was to review the literature to evaluate the burden of this complication, seeking for risk factors, prevention, and ideal management. Methods:We performed a systematic review of the literature to identify all described pouch-related adenocarcinoma in patients operated on with IPAA for UC. Studies were thoroughly evaluated to select authentic de novo pouch carcinomas. Some authors were contacted for additional information. Data of patients were pooled. Meta-analyses of suitable studies were attempted to identify risk factors. Results:Thirty-four articles reported on 49 patients (2:1, male:female) who developed unequivocal pouch-related adenocarcinoma, 14 (28.6%) and 33 (67.3%) arising from the pouch and anorectal mucosa, respectively. Origin was not reported in 2 (4%). Pooled cumulative incidence of pouch-related adenocarcinoma was 0.33% (95% confidence interval [CI], 0.31–0.34) 50 years after the diagnosis and 0.35% (95% CI, 0.34–0.36) 20 years after IPAA. Primary pouch cancer incidence was below 0.02% 20 years after IPAA. Neoplasia on colectomy specimen was the strongest risk factor (odds ratio, 8.8; 95% CI, 4.61–16.80). Mucosectomy did not abolish the risk of subsequent cancer but avoiding it increased 8 times the risk of cancer arising from the residual anorectal mucosa (odds ratio, 8; 95% CI, 1.3–48.7; P = 0.02). Surveillance is currently performed yearly starting 10 years since diagnosis, but cancers escaping this pathway are reported. In patients receiving mucosectomy, a 5-year delay for surveillance could be proposed. Conclusions:Pouch-related adenocarcinomas are rare. Diagnosis of Crohns disease in the long term may further decrease the rates in UC. Presumed evolution from dysplasia might offer a time window for cancer prevention. Abdominoperineal excision should be recommended for pouch-related adenocarcinomas.

Inguinal hernia repair in patients with coagulation problems: Prevention of postoperative bleeding with human fibrin glue

BACKGROUND Our purpose was to establish the efficacy of human fibrin glue (HFG) in preventing coagulative complications after inguinal hernia repair in patients with coagulation disorders. METHODS A randomized controlled trial of 50 patients with coagulation disorders undergoing hernia repair was performed. Patients had concurrent coagulopathies as a consequence of liver disease or long-term treatment with anticoagulants. Coagulopathies were defined according to the following criteria: prothrombin time < 10.5 seconds, activated partial thromboplastin time < 21 seconds, and fibrinogen < 230 mg/dL. Patients were randomized in a 1:1 ratio with (group A) or without (control group B) use of HFG. RESULTS Postoperative hemorrhagic complications were significantly reduced in group A (4%) compared with group B (24%). CONCLUSION This study shows that HFG is effective in preventing local hemorrhagic complications after herniorrhaphy in patients with concurrent coagulation disorders. This implies that the use of HFG reduces the costs of prolonged hospitalization related to such complications.

Morbidity patterns in aged population in southern Italy. A survey sampling

The goal of the study was to investigated the prevalence of disability, cognitive impairment, depressive symptomatology and chronic diseases in a sample of the elderly population. A cross-sectional study was carried out on a random sample from the general population of elderly located in a geographically well defined Mediterranean area of Southern Italy. We examined 1339 subjects. Investigated diseases were: chronic obstructive lung disease, hypertension, arthrosis, diabetes mellitus, neurological disease, myocardial infarction, angina, atrial fibrillation, peripheral artery disease and congestive heart failure. Cognitive status was assessed by means of the Mini-Mental State Examination (MMSE), depression symptomatology was evaluated by Geriatric Depression Scale (GDS) and disability by means of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). This methodological study showed that 27.9% had a MMSE score <24 and the score decreased with age in both sexes. A total of 9.8% of the subjects had severe depression (GDS score >20). Comorbidity was evaluated from the past medical history and confirmed by a clinical exam by a physician. Only 8.7% of subjects were found without chronic illness. Median number of diseases was two, with 26.6% declaring four diseases or more. Comorbidity increased with age, an overall slight decrease of the number of diseases being observed in the subjects >85 years old. Subjects disabled in ADL were 7%, while disabled in IADL were 46.7%. The disability prevalence increased with age, affecting more female than male.

Randomized, controlled trial to compare the J-pouch and W-pouch configurations for ulcerative colitis in the maturation period.

PURPOSE: Proctocolectomy with ileal pouch-anal anastomosis has become the procedure of choice for the treatment of ulcerative colitis. Functional results may differ with different pouch designs. This randomized study aimed to evaluate the relative effectiveness of two-limb J and four-limb W reservoir designs in the so-called maturation period after ileostomy closure. METHODS: Twenty-four patients underwent ileal pouch-anal anastomosis for ulcerative colitis. Eleven were randomly assigned to the J-pouch group and 13 to the W-pouch group. Frequency of defecation and other functional data were collected at 4, 8, and 12 months after ileostomy closure. Maximum tolerated volume was assessed in the same period by a latex balloon inflated with water. Maximum resting anal pressure, maximum voluntary contraction, and the rectoanal inhibitory reflex were assessed in the preoperative period and at 4, 8, and 12 months after ileostomy closure. RESULTS: Frequency of defecation decreased from 4 to 12 months after ileostomy closure in both groups (P=0.04), but patients with a W-pouch had significantly lower values than patients with J-pouches (P<0.01). Night-time defecation (P=0.04) and use of antidiarrheals (P=0.04) were significantly lower for patients with a W-pouch. Maximum tolerated volume was greater in the W-pouch group throughout the whole period (P=0.01). Maximum resting anal pressure, maximum voluntary contraction, and rectoanal inhibitory reflex did not differ between the study arms CONCLUSION: Patients with W-pouch have better functional results than those with J-pouches in the “maturation period” after ileostomy closure.

Dipeptidyl Peptidase 4 Inhibition May Facilitate Healing of Chronic Foot Ulcers in Patients with Type 2 Diabetes

The pathophysiology of chronic diabetic ulcers is complex and still incompletely understood, both micro- and macroangiopathy strongly contribute to the development and delayed healing of diabetic wounds, through an impaired tissue feeding and response to ischemia. With adequate treatment, some ulcers may last only weeks; however, many ulcers are difficult to treat and may last months, in certain cases years; 19–35% of ulcers are reported as nonhealing. As no efficient therapy is available, it is a high priority to develop new strategies for treatment of this devastating complication. Because experimental and pathological studies suggest that incretin hormone glucagon-like peptide-1 may improves VEGF generation and promote the upregulation of HIF-1α through a reduction of oxidative stress, the study evaluated the effect of the augmentation of GLP-1, by inhibitors of the dipeptidyl peptidase-4, such as vildagliptin, on angiogenesis process and wound healing in diabetic chronic ulcers. Although elucidation of the pathophysiologic importance of these aspects awaits further confirmations, the present study evidences an additional aspect of how DPP-4 inhibition might contribute to improved ulcer outcome.

Effects of a new pocket device for negative pressure wound therapy on surgical wounds of patients affected with Crohn's disease: a pilot trial.

Introduction. Surgical site infections (SSIs) affect costs of care and prolong length of stay. Crohn’s disease (CD) represents an independent risk factor for SSI. The risk can be further increased by concomitant administration of immunosuppressive drugs and poor performance status at the time of surgery. Patients suffering from CD often need more than one surgical intervention during life, sometimes requiring fashioning of a stoma. The aim of this pilot study was to compare a portable device for negative pressure wound therapy (PICO, Smith & Nephew, London, UK) to conventional gauze dressings in patients undergoing surgery for stricturing CD. Methods. Between January 2010 and November 2011, this controlled trial enrolled 30 patients, who were assigned to treatment with either PICO (n = 13) or conventional dressings (n = 17). Each patient completed a 3-month follow-up. Results. Patients receiving PICO experienced significantly less postoperative wound complications (P = .001) and SSI (P = .017) compared with those who received conventional dressings. This resulted in shorter hospital stay (P = .0007). No significant differences in cosmetic results were found. Conclusion. These data suggest that PICO allows faster and safe discharge by reducing the incidence of SSI and wound-related complications in selected patients undergoing surgical intervention for stricturing CD. This could be particularly useful in patients receiving steroids.