Tony Sabatini

Impact of Prosthesis-Patient Mismatch on Cardiac Events and Midterm Mortality After Aortic Valve Replacement in Patients With Pure Aortic Stenosis

Background— Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthesis being implanted is too small in relation to body size, thus causing abnormally high transvalvular pressure gradients. The objective of this study was to examine the midterm impact of PPM on overall mortality and cardiac events after aortic valve replacement in patients with pure aortic stenosis. Methods and Results— The indexed EOA (EOAi) was estimated for each type and size of prosthesis being implanted in 315 consecutive patients with pure aortic stenosis. PPM was defined as an EOAi ≤0.80 cm2/m2 and was correlated with overall mortality and cardiac events. PPM was present in 47% of patients. The 5-year overall survival and cardiac event-free survival were 82±3% and 75±4%, respectively, in patients with PPM compared with 93±3% and 87±4% in patients with no PPM (P≤0.01). In multivariate analysis, PPM was associated with a 4.2-fold (95% CI, 1.6 to 11.3) increase in the risk of overall mortality and 3.2-fold (95% CI, 1.5 to 6.8) increase in the risk of cardiac events. The other independent risk factors were history of heart failure, NHYA class III-IV, severe left ventricular hypertrophy, and absence of normal sinus rhythm before operation. Conclusions— PPM is an independent predictor of cardiac events and midterm mortality in patients with pure aortic stenosis undergoing aortic valve replacement. As opposed to other risk factors, PPM may be avoided or its severity may be reduced with the use of a preventive strategy at the time of operation.

Atrial fibrillation and cognitive disorders in older people

OBJECTIVES: To find a correlation between chronic non‐rheumatic atrial fibrillation (CNRAF) and cognitive impairment in a group of older, nondemented patients.

Hyperglycemia as a Predictor of In-Hospital Mortality in Elderly Patients without Diabetes Mellitus Admitted to a Sub-Intensive Care Unit

OBJECTIVES: To investigate the association between hyperglycemia and in‐hospital and 45‐day mortality in acutely ill elderly patients.

Dementia is a major predictor of death among the Italian elderly

To the Editor: We read with interest the article by Baldereschi et al. on the effect of dementia in predicting death among Italian elderly.1 We have pertinent data on 24 and 60 months’ mortality rate obtained in a multidimensional study conducted in Italy in 1992 on a community-dwelling population 70 years of age and older.2 All institutionalized subjects were excluded. At baseline (1992), valid questionnaires assessing demographics, mental status, chronic conditions, and functional and social status were available for 549 persons (89.6% of the eligible population). Vital status and time of death 2 (1994) and 5 years (1997) after the baseline evaluation was ascertained by telephoning patients and caregivers. The mean age of the 549 persons (179 men and 370 women) was 76.9 ± 5.4 years. They had 4.6 ± 2.0 years of education; they were affected by 3.5 …

Delirium in a Sub-Intensive Care Unit for the elderly: occurrence and risk factors

Background and aims: The objective was to study occurrence and risk factors of delirium in a new model of care, the Sub-Intensive Care Unit for the elderly (SICU), which is a level of care between that offered by ordinary wards and intensive care. Methods: A prospective observational study of 401 consecutively admitted patients, 60+ years, in a four-bed SICU in the geriatric ward of a general hospital. Delirium was detected by the Confusion Assessment Method (CAM) at admission (prevalent) and during SICU stay (incident). Impaired function (Barthel Index) and/or IADL two weeks prior to admission identified disability, and additional Mini-Mental State Examination (MMSE) <18 at discharge identified probable dementia. Results: Delirium was detected in 117 patients (29.2%). Of these 62 (15.5%) had delirium at admission and a further 55 developed delirium during their time in the SICU. Delirium occurred in 19(11.4%) of the “robust” (no dementia or disability), 28 (24.1%) of the disabled and 70 (58.4%) of the demented patients (p<0.001). Prevalent delirium was found in 8 (4.8%), 11 (9.5%) and 43 (36.1%) (p<0.001) and incident in 11 (6.6%), 17 (14.7%) and 27 (22.7%) (p<0.001) of the robust, disabled, and demented patients respectively. Heavy alcohol use, maximum intake of 7 or more drugs, and the use of a bladder catheter were independently associated with delirium. Conclusions: Delirium was common in the SICU, and patients with probable dementia had the highest risk. They tended to have delirium at admission, whereas patients without dementia, although less at risk, were more prone to developing delirium during their stay in the SICU.

Subintensive care unit for the elderly: a new model of care for critically ill frail elderly medical patients

ObjectiveAn increasing number of elderly patients are admitted to the hospital for critical diseases and the gap between supply and demand of intensive care resources is a growing problem. To meet this challenge, 4 beds in a 24-bed acute care for the elderly (ACE) medical unit were dedicated to a subintensive care unit (SICU). Severely ill elderly medical patients, requiring a higher level of care than provided in ordinary wards, are admitted. The aim of the study was to describe the characteristics of the setting and to discuss its usefulness based on data obtained after the first period of implementation.MethodsThis article describes the development, management, economics and patient characteristics of the SICU. Patient care combines the ACE model with a highly specialised medical care. Patients admitted to the SICU are compared with patients treated in the ordinary ACE unit before the SICU opened. All patients received a multidimensional evaluation, including demographics, main diagnosis, number of chronic somatic diseases, Charlson index, APACHE II score, APACHE-APS subscore, number of currently administered drugs, serum albumin, cognitive status (Mini-Mental State Examination), depression (Geriatric Depression Scale) and functional status (basic and instrumental activities of daily living). Ward physicians performed assessment and collection of data.ResultsDuring the first 16 months, 489 patients were admitted, 401 according to the selection criteria (60± years and APACHE II score≥5 and/or APACHE-APS score ≥3). Mean age was 78.1 years, mean APACHE II score 14.5 (moderate severity) and non-invasive mechanical ventilation was received by 87 (21.7%). The most common diagnoses were respiratory failure, cardiac disease and stroke. Mean length of stay in the SICU was 61.8 h, and 6.0 days in the hospital. Compared with ACE-unit patients admitted during 2002 (n=1380), SICU patients were obviously more seriously ill (APACHE II score 14.5 vs 6.7). When comparing patients of same illness severity (APACHE-APS score ⩾=3) (n=125), patients treated in the SICU had lower in-hospital mortality than those treated in the ordinary ACE ward (12.5 vs 19.2%). Only a few patients (3.5%) were transferred to the intensive care unit as a consequence of increased severity of illness.ConclusionsThe SICU is an innovative method to treat frail elderly patients with more severe conditions. Low hospital mortality compared with that of severe patients in the ACE unit supports the usefulness of this model. It could be implemented in medical units of large hospitals in order to give optimal care and advanced interventions to the frail elderly and to avoid intensive care unit overcrowding.

Chronic Atrial Fibrillation and Low Cognitive Function

To the Editor: We read with great interest the article by Kilander et al1 recently published in Stroke . We would like to support their conclusions by presenting data obtained from our clinical experience. We analyzed the relationship between atrial fibrillation and cognitive function in the elderly patients admitted to our Medical Unit for the Acute Care of the Elderly (Poliambulanza Hospital, Brescia, Italy). During the period from November 1997 through July 1998, 600 patients were consecutively admitted. For the aim of the study we excluded 331 patients: those aged <70 years with previous cerebrovascular events (TIA and minor or major stroke); with terminal, wasting diseases or severe metabolic …

ASSESSMENT OF PNEUMONIA IN ELDERLY PATIENTS

To the Editor: We read with great interest the article by Mody et al. on assessment of pneumonia in elderly patients, and we would like to contribute to this topic, presenting data obtained on 125 elderly patients consecutively admitted with a diagnosis of pneumonia to our Acute Care for the Elderly Medical Unit (ACE-MU) in Brescia, Italy, during a 14-month period. Admission to the ACE-MU is mainly through the emergency department (82%). We have compared the characteristics and the survival at 6 months of pneumonia inpatients admitted with and without functional impairment. A trained staff of geriatricians performed a multidimensional evaluation, including information on demographics (age, sex, education, living site before admission and after discharge, living conditions, and caregiver or formal support availability), cognitive and affective status, physical health, functional abilities, and social support, on the first day after admission using a standard protocol. Cognitive status was evaluated using the Mini-Mental State Examination and depressive symptoms using the Geriatric Depression Scale. Self-reported disability was assessed using the Barthel Index (the lower the score, the higher the degree of disability) and the Lawton and Brody instrumental activity of daily living scale. A premorbid Barthel Index score (2 weeks before admission) of less than 90 was considered to be a marker of disability. Somatic health was evaluated by the detection of single symptomatic diseases uncontrolled by therapy and comorbidity (computed using the Charlson index). Severity of pneumonia was measured according to Acute Physiology And Chronic Health Evaluation (APACHE) II score and APACHE II acute physiologic subscore (the higher the score, the higher the severity). The number of currently administered drugs was also recorded. Pneumonia was diagnosed according to clinical signs and chest radiography, and treatment was performed according to the American Thoracic Society guidelines. Six-month mortality was the outcome measure of the analysis. Table 1 gives the demographic, functional, and clinical characteristics of the population affected by pneumonia according to their premorbid functional status. As expected, severity of somatic, biological, psychological, and functional conditions was higher in patients with pneumonia with premorbid functional impairment than in those without functional impairment; 6-month mortality was significantly higher in patients with functional impairment (34.4%) than in independent patients (14.1%). We have reasons to agree and disagree with the results of Mody et al. Our patients with pneumonia had similar

BATHING DISABILITY IN OLDER PATIENTS

To the Editor: We read with great interest the paper by Gill and colleagues on bathing disability recently published in the Journal of the American Geriatrics Society; we would like to confirm their statement that disability in bathing is a ‘‘sentinel’’ event in the natural history of an elderly person undergoing progressive loss of autonomy, discuss this topic, and present data of a study in an aging community-based population in Italy. The data were obtained in a multidimensional study carried out in a population aged 70 and older living in the rural city of Ospitaletto, Brescia, Italy. Of a total number of 613 subjects aged 70 and older recorded in the local registry office, 37 refused to participate, and 27 were contacted but did not complete the interview. Valid questionnaires were available for 549 (89.6% of the eligible population). Trained community researchers collected the data in the subjects’ homes. In addition to demographics (sex, age, years of education), social interaction, mood (using the short version of the Geriatric Depression Scale (GDS)), cognitive performance (using the Mini-Mental State Examination (MMSE)), physical health (number of chronic conditions), and disability (using the Katz activity of daily living (ADL) scale) were assessed. Persons (n 5 20) with severe disability (incontinent and unable to eat) and with MMSE scores lower than 14 were excluded from the study, leaving 529 for further analysis. Cognitive impairment was defined as a MMSE score between 14 and 23, depression as a GDS score higher than 5. Cox proportional hazards models were used to control for potentially confounding variables. The mean age standard deviation of the 529 elderly subjects (174 men, 355 women) was 76.7 5.3. They had 4.6 1.9 years of education and were affected by 3.5 2.2 chronic conditions; 197 (37.2%) lived alone. MMSE and GDS mean scores were 25.8 3.9 and 3.7 3.0, respectively. Patients were divided into three mutually exclusive groups based on functional disability: 406 (76.7%) with no functional ADL impairments; 67 (12.7%) disabled only in bathing; and 56 (10.6%) disabled in dressing, toileting or transferring. One hundred thirty-three (25.1%) died during the 60-month follow-up period. As reported in Table 1, 60-month risk of death is 2.8 times as high in those with impairment in bathing as in subjects able to bathe themselves. The rate was independent from and comparable with that of more-disabled subjects. These results are confirmed also after controlling for cognitive and depressive status. We may argue from these data that bathing disability is the first step down a slippery slope ending with death, reflecting a biological status of elderly persons independent from conditions such as depression or cognitive impairment. Bathing is related to some still-unknown events that increase the risk of mortality, even after controlling for other disabilities. From this perspective, it is possible to answer the pivotal question ‘‘Is the crucial element the lack of a bath or the inability to bathe?’’ In fact, the inability to bathe is a marker of frailty that providing more-intensive care does not change, and interventions aimed at supporting this specific disability only marginally affect outcomes such as nursing home placement and death. In this framework, analytically studying bathing, as Gill and colleagues did, is extremely important in clarifying the mechanisms underlying the development of disability and the correlations with other domains controlling the health of older people.

Primary carcinoid tumor of the ovary: report of an unusual case.

Carcinoid tumors are endocrine malignancies that are often associated with a characteristic syndrome, the malignant carcinoid syndrome, which is most common in patients with small bowel tumors and liver metastases. In the rare instances when the syndrome is present without liver metastases the primary tumor is usually localized to the bronchus or ovary and secretes hormones directly into the systemic circulation. About two thirds of patients with carcinoid syndrome have evidence of carcinoid heart disease. We report on a case of a primary ovarian carcinoid tumor with an unusual clinical presentation.