Insulin resistance and inflammatory activation in older patients with systolic and diastolic heart failure

OBJECTIVE

To evaluate insulin resistance and systemic inflammation in older patients with systolic (SHF) or diastolic heart failure (DHF).

PATIENTS

52 non-diabetic patients (> 70 and < 90 years old) with chronic heart failure (CHF) and hospitalised within the previous six months for heart failure were studied, together with a control group of older healthy volunteers (n = 26). On the basis of Doppler echocardiographic criteria patients were classed as having SHF (n = 27) or DHF (n = 25).

MAIN OUTCOME MEASURES

Fasting glucose, insulin, C reactive protein, interleukin 6, and tumour necrosis factor alpha soluble receptor II (TNF-alphaSRII) concentrations were determined. Insulin resistance was estimated by the homeostasis model assessment (HOMA).

RESULTS

HOMA index (median, interquartile range) was higher in patients with DHF (1.77, 1.06-2.26) than in patients with SHF (0.97, 0.81-1.85) or healthy volunteers (1.04, 0.76-1.44; p = 0.01). After adjustment for body mass index, age, and use of angiotensin converting enzyme inhibitors, both groups of patients with CHF were more insulin resistant than were healthy volunteers (p = 0.02). C reactive protein, interleukin 6, and TNF-alphaSRII were all significantly (p < 0.001) higher in patients with DHF and SHF than in healthy volunteers. All markers of systemic inflammation were independently associated with the presence of clinical CHF.

CONCLUSION

Insulin resistance and inflammatory activation are present in older patients with SHF and DHF.

Does diastolic function evaluated with radionuclide ventriculography predict mortality, hospitalization and the development of new onset heart failure?

Left ventricular systolic dysfunction (LVSD) in asymptomatic patients is associated with the development of heart failure (HF) and the degree of LVSD predicts prognosis. Whether left ventricular diastolic dysfunction (LVDD) predicts the development of HF or mortality is not known. Our objective was to investigate the predictive value of LVDD evaluated by radionuclide ventriculography (RN). All patients referred for RN during a 12 month period were included. Medical records were reviewed to determine characteristics of the patients at the time of RN and events occurring during a 5 year follow-up. Data from 195 patients were analysed. During the follow-up period 49 patients (25.1%) died, 41 (21.0%) were admitted to hospital and 25 (12.3%) developed HF. An ejection fraction (EF) <40% was associated with mortality (relative risk (RR), 2.04; P=0.001) and hospital admissions (RR, 1.33; P=0.002). Patients who developed subsequent HF had, on average, lower EF at baseline. In a multivariate analysis the lower the EF the more likely patients were to develop new onset HF (odds ratio, 0.92; 95% CI 0.88-0.97; P=0.003). LVDD evaluated with peak filling rate and time to peak filling rate was not associated with any of the outcomes. However, a higher proportion of patients with pre-existing HF at the time of the RN had abnormal LVDD than patients with no HF. LVDD evaluated by RN is associated with symptoms of HF at the time of assessment but is not a good predictor of mortality, hospitalization or new onset HF. EF remains a better predictor of outcomes.

Autonomic function in elderly patients with chronic heart failure

AIMS

Autonomic function (AF) is attenuated by heart failure (HF). Reports have been based on studies of young patients with systolic heart failure (SHF). However, HF is a disease of older patients who are more likely to have diastolic heart failure (DHF). We investigated whether age alters AF in elderly HF patients and whether the haemodynamic type of HF influences AF.

METHOD AND RESULTS

Thirty-six elderly HF (Framingham criteria) patients (11 with SHF, 25 with DHF) and 21 matched healthy subjects underwent simple bedside AF tests. Compared with the reference values for healthy adults, the mean E:I ratios and the median 30:15 ratios standing were all essentially normal. The median 30:15 ratios tilt and the mean Valsalva ratios were all significantly below the reference value (P for all cases <<0.050). Comparing three groups, there were no significant differences for mean E:I ratio (P=0.111), 30:15 tilt (P=0.619) and 30:15 standing (P=0.167), whereas there were significant differences for the mean Valsalva ratios (P=0.001). The mean Valsalva ratio of the SHF patients was significantly lower than that for the DHF patients (P<0.001) which in turn was significantly lower than the result of the healthy subjects (P<0.001).

CONCLUSION

There is an age-related impairment in AF with further impairment occurring in patients with HF. However, the severity of autonomic dysfunction is less in patients with DHF compared with patients with SHF.

A proton magnetic resonance spectroscopy study of age-related changes in frontal lobe metabolite concentrations

Ageing is associated with reduction of grey matter volume and it is reported that the frontal lobes are preferentially affected. We have applied quantitative magnetic resonance spectroscopy (MRS), incorporating measurement of brain tissue water content and metabolite T(2) relaxation times, to determine absolute concentrations of the putative neuronal marker N-acetylaspartate (NAA), creatine (Cr) and choline (Cho) compounds in the frontal lobe of 50 male subjects aged between 20 and 70 years (10 per decade). The fractional brain water content (beta(MR)) did not change significantly as a function of age (r = 0.07, P = 0.65) and had a mean value of 81% (CV = 2%). The concentration (in millimoles per litre brain tissue) of NAA decreased significantly with age (r = -0.42, P = 0.003), with an overall decrease of 12% between the third and seventh decades. The concentrations of Cr and Cho did not change significantly with age. The interpretation of the age-dependent decrease in NAA concentration as reflecting either a reduction in neuronal volume, number or function is discussed.

Role of carotid sinus syndrome and neurocardiogenic syncope in recurrent syncope and falls in patients referred to an outpatient clinic in a district general hospital

Carotid sinus syndrome (CSS) and neurocardiogenic syncope (NCS) are recognised as important causes of recurrent syncope and falls in the elderly. In this study the role of CSS (diagnosed with carotid sinus massage) and NCS (diagnosed with prolonged head-up tilt) in a district general hospital were investigated. Over 27 consecutive months carotid sinus massage was performed in 139 patients. Of these 29 (20.8%) patients (mean (SD) age of 78 (9) years) showed a positive response. Of these 18 (62%) patients showed a positive response only when carotid sinus massage was performed with 70( degrees ) head-up tilt. Thirteen (8.7%) of the 149 patients who had prolonged head-up tilt testing were found to have NCS. The mean (SD) age for patients with NCS was 59 (26) years and the mean (SD) time required to produce a positive response during prolonged head-up tilt was 12 (5) minutes. It is concluded that carotid sinus massage and head-up tilt testing are useful in patients presenting with unexplained syncope and falls in a district general hospital setting. Carotid sinus massage should be repeated upon head-up tilt if a negative response is obtained in the supine position.

Perindopril for elderly people with chronic heart failure: the PEP-CHF study. The PEP investigators

BACKGROUND

The prevalence of chronic heart failure (CHF) rises with increasing age, from < 1% in those below 65 years of age to > 5% in those over 65 years of age and is a major cause of morbidity and mortality in older people. Recent European guidelines point to a major deficiency in our knowledge of how to treat diastolic chronic heart failure, and a lack of information on treatment for heart failure in the elderly in general.

AIMS

The aims of this trial are to assess the potential benefits of the ACE inhibitor perindopril to treat chronic heart failure in elderly people, in the absence of any major left ventricular systolic dysfunction.

SUBJECTS

One thousand people over the age of 70 years will be recruited into this study. Evidence of chronic heart failure will be confirmed by clinical criteria and echocardiography.

METHODS

Once a diagnosis of chronic heart failure has been confirmed, the patient will receive either perindopril or placebo in addition to their usual treatment. Death, and unplanned heart failure related hospitalisations, are the primary outcomes. Quality of life, as measured by the Guyatt questionnaire will be assessed at the beginning of the study and at 1 year. Sub-studies of this trial include a 6-min walking test and more detailed evaluation of ventricular function (as assessed by echocardiography). Both parameters will be measured at 8 weeks and 1 year, and analysed against baseline data. Cognitive function in this group of patients will also be evaluated at baseline and 1 year. This trial is due to report in the year 2001.

Elderly patients with hypercholesterolaemia: a double-blind study of the efficacy, safety and tolerability of fluvastatin

BACKGROUND

Coronary heart disease is a major cause of morbidity and mortality in the elderly, a rapidly growing section of the population. Elderly patients have been excluded from most preventative risk factor trials.

METHODS

We evaluated fluvastatin, a fully synthetic hydroxymethyl glutaryl coenzyme A reductase inhibitor, in white patients older than 60 years, in seven hospital centres. After an 8-week cholesterol-decreasing diet phase, patients were allocated to groups to receive fluvastatin 40 mg daily (n = 33) or placebo (n = 36) given for 12 weeks. All patients had low-density lipoprotein cholesterol concentrations > or = 4.1 mmol/l 1 week before they were allocated to a treatment at random. After receiving randomised treatment for 12 weeks, 50 patients then received fluvastatin 40 mg daily on an open basis for a further 12 weeks.

RESULTS

Mean +/- SD age was 70.7 +/- 5.2 years for fluvastatin patients and 68.3 +/- 5.6 years for placebo. Mean +/- SD percentage changes in lipid concentrations from randomisation to the end of 12 weeks were calculated (n = 63) by intent-to-treat analysis. Total cholesterol decreased by 21.64 +/- 8.7% in the fluvastatin group and by 2.91 +/- 7.25% in the placebo group (P < 0.01); high-density lipoprotein cholesterol increased by 4.98 +/- 10.84% in the fluvastatin group and decreased by 0.05 +/- 8.68% in the placebo group (P = 0.05); low-density lipoprotein cholesterol decreased by 27.14 +/- 8.45% in the fluvastatin group and by 2.16 +/- 9.68% in the placebo group (P < 0.01); very-low-density lipoprotein cholesterol decreased by 30.70 +/- 30.65% in the fluvastatin group and by 9.80 +/- 28.6% in the placebo group (P < 0.01); triglyceride decreased by 18.13 +/- 17.35% in the fluvastatin group and by 2.97 +/- 21.85% in the placebo group (P < 0.01). There were no statistically significant differences between treatment groups for any other biochemical or haematological parameters. Adverse events were mainly mild, diminishing with continued treatment, and no event was serious by standard criteria. Patient-assessed tolerability after randomised treatment was 'very good' for 18 fluvastatin patients and for 26 placebo patients (P = 0.79). Seven patients withdrew from the 12-week follow-up (four from the fluvastatin group and three from the placebo group).

CONCLUSIONS

We conclude that fluvastatin decreases lipid concentrations effectively and safely in elderly patients, producing clinically significant decreases in total cholesterol, low-density lipoprotein cholesterol, triglyceride and, especially, very-low-density lipoprotein cholesterol, while increasing high-density lipoprotein cholesterol moderately.

Reproducibility and responsiveness of quality of life assessment and six minute walk test in elderly heart failure patients

OBJECTIVE

To examine the reproducibility and responsiveness to change of a six minute walk test and a quality of life measure in elderly patients with heart failure.

DESIGN

Longitudinal within patient study.

SUBJECTS

60 patients with heart failure (mean age 82 years) attending a geriatric outpatient clinic, 45 of whom underwent a repeat assessment three to eight weeks later.

MAIN OUTCOME MEASURES

Subjects underwent a standardised six minute walk test and completed the chronic heart failure questionnaire (CHQ), a heart failure specific quality of life questionnaire. Intraclass correlation coefficients (ICC) were calculated using a random effects one way analysis of variance as a measure of reproducibility. Guyatt's responsiveness coefficient and effect sizes were calculated as measures of responsiveness to change.

RESULTS

24 patients reported no major change in cardiac status, while seven had deteriorated and 14 had improved between the two clinic visits. Reproducibility was satisfactory (ICC > 0.75) for the six minute walk test, for the total CHQ score, and for the dyspnoea, fatigue, and emotion domains of the CHQ. Effect sizes for all measures were large (> 0.8), and responsiveness coefficients were very satisfactory (> 0.7). Effect sizes for detecting deterioration were greater than those for detecting improvement.

CONCLUSIONS

Quality of life assessment and a six minute walk test are reproducible and responsive measures of cardiac status in frail, very elderly patients with heart failure.

Haemodynamic responses in young and elderly, healthy subjects during ambient and warm head-up tilt

1. Postural hypotension is common in elderly people and is usually multifactorial in origin. In young subjects increased ambient temperature is associated with postural symptoms. We hypothesized that such increases in skin temperature due to the use of bed clothes might contribute to nocturnal postural hypotension in the elderly. We therefore studied haemodynamic responses to head-up tilt in healthy elderly and young subjects, with and without passive heating induced by covering with blankets. 2. Nine young (28.7 +/- 1.5 years; mean +/- S.E.M.) and nine elderly (71.9 +/- 1.8 years) subjects were studied. All had been carefully screened to exclude factors likely to affect responses to tilt. All subjects underwent a standard head-up tilt procedure at ambient room temperature while haemodynamic responses were monitored. The subjects were then covered in blankets for 55 min and the tilt repeated. Skin temperature before the second tilt had increased from approximately 32.5 degrees C to approximately 35.2 degrees C (P < 0.001). 3. The elderly subjects maintained higher blood pressures throughout both tilts (P < 0.001) and both groups showed similar qualitative responses to tilt. Supine heart rates were higher in the elderly group (P < 0.01) with a tendency to increase more in the young group in response to tilt, especially while warm (P = 0.370). Stroke volumes and cardiac indices were consistently higher in the young group who showed larger changes during both head-up tilts. In both groups the haemodynamic responses to ambient and warm tilt were essentially the same. 4. Healthy elderly subjects, who are carefully screened to exclude individuals with cardiovascular pathology, respond to head-up tilt in the same qualitative fashion as young subjects. Quantitative responses in older subjects are 'damped'. Short-term natural body warming does not impair the reflexes in young or old subjects.

Treatment of depression in the elderly: effect of physical illness on response

OBJECTIVES

To determine the response to treatment of different subgroups within a sample of physically ill elderly depressed patients.

DESIGN

Acute geriatric medical inpatients with depression, randomly assigned to an 8-week double-blind placebo-controlled trial of fluoxetine.

MAIN OUTCOME MEASURE

Response rate as defined by the 17-item Hamilton Depression Rating Scale.

RESULTS

Data were analysed in subgroups according to diagnosed physical problems and concomitant medication. A logistic regression analysis was performed to identify subgroups valid for separate analysis. Those reaching at least 5 weeks of treatment showed a significant improvement compared with the placebo group if they had serious life-threatening disease, cerebrovascular disease, were not demented, or were either on no analgesics or on analgesics stronger than paracetamol.

CONCLUSION

While the response to treatment in these subgroups was encouraging, general physicians must not be led to believe that the answer to depression lies only in pharmacological intervention, just as the belief that the risk-benefit ratio of such treatment where indicated is too high must be discouraged.

Chronic heart failure--mechanisms and management

Over 80% of patients with chronic heart failure are over the age of 65 years. A number of community based studies over the years have indicated that up to half of elderly patients with heart failure are undiagnosed and therefore untreated. The high proportion of elderly patients with heart failure who are undiagnosed is probably due to the non-specific presentation of the condition, heart failure symptoms being over shadowed by co-morbid conditions and the haemodynamic presentation of diastolic dysfunction, vide infra. Measurement of plasma atrial natriuretic peptide levels may be helpful in identifying elderly patients at risk of, or in the early stages of heart failure. Paradoxically, there are also a number of elderly patients who are being treated for heart failure who do not have the condition. Even with the secular changes occurring in lifestyles (smoking, diet, exercise) the prevalence of heart failure will continue to increase well into the next century because of the continuing increase in the number of older people. Difficulties with diagnosis of heart failure may be related to the observation that cardiologists tend to concentrate on young cardiac patients.

Surgery for lung cancer: age alone is not a contraindication

A retrospective analysis of the clinical features, operative procedures, postoperative complications and subsequent survival of 70 (50 male) elderly patients undergoing surgery for lung cancer compared with 74 (53 male) younger patients treated at the same hospital during the same period was performed, to determine if elderly people with lung cancer are less likely to benefit from and/or tolerate surgery. The elderly group had to wait longer for operation (p = 0.001) and were more likely to have pre-existing disease (p = 0.019). In contrast, they had fewer recognised postoperative complications (p = 0.032) and there was no difference between the two groups in perioperative mortality and subsequent survival. Surgical treatment of localised lung cancer represents the best chance for cure and this study suggests that age should not be a consideration in the decision to operate or not. The patient's general state of health should be assessed and management decisions based on individual status rather than on age.

Placebo-controlled treatment trial of depression in elderly physically ill patients

OBJECTIVES

To determine the response of physically ill elderly depressed patients to treatment.

DESIGN

Acute geriatric medical inpatients with depression, randomly assigned to an 8-week double-blind placebo-controlled trial of fluoxetine.

MAIN OUTCOME MEASURE

Response rate as defined by the 17-item Hamilton Depression Rating Scale.

RESULTS

Eighty-two patients entered the trial; 62 patients (all those who had completed at least 3 weeks of treatment) were included in the efficacy analysis. Forty-two completed the full 8 weeks (21 in each group) with response rates of 67% in the fluoxetine group and 38% in the placebo group. No significant difference was found between the responses of the two groups (p = 0.12). There was a trend for results in the fluoxetine group to continue to improve with time. On secondary analysis those patients with serious physical illness who completed 5 or more weeks (N = 37) showed a significant improvement in mood if treated with fluoxetine (p = 0.02).

CONCLUSIONS

The main benefit of antidepressants is to approximately double the chances of recovery. This trial showed the response rate of the fluoxetine treated group was increased by a factor of 1.8 over the placebo group in an 8-week period. The presence of physical illness, often severe and/or multiple, did not reduce the effectiveness of the medication, which was well tolerated overall. Those with serious physical disease responded significantly better to drug treatment; this will require further work. Psychological support was also considered to be important.

Use of restraints and bedrails in a British hospital

OBJECTIVE

To determine the prevalence of restraint and bedrail use in a British hospital.

DESIGN

Cross-sectional observational study.

SUBJECTS

Six hundred sixty-eight patients in the acute medical, surgical, and geriatric beds of a large British teaching hospital on a single night.

MEASUREMENTS

Observed use of restraints and bedrails. Reasons for restraint use were determined by interviews with nursing staff and examination of the case notes.

RESULTS

Fifty-six (8.4%) patients had bedrails raised. No other restraints were in use. Reported indications for bedrail use were: prevention of falls (52 patients), prevention of wandering (1), and patient request (3). In stepwise logistic regression analysis, bedrail use was associated significantly with agitated confusion, age 70 years or more, and stroke, while patients on the acute geriatric wards were significantly less likely to have bedrails raised.

CONCLUSIONS

Restraint use is relatively uncommon in Britain. Nevertheless, inappropriate use of bedrails is a reason for concern.

Gait disturbance in Alzheimer's disease: a clinical study

Gait disturbance is common in patients with Alzheimer's disease (AD). The aim of this study was to analyse the clinical gait syndromes of patients with AD using Nutt's classification. Fifty-five patients who satisfied the NINCDS-ADRDA criteria for probable AD and 55 controls were recruited from a geriatric and a psychogeriatric unit. Patients with classical musculoskeletal or neurological syndromes causing gait disturbance were excluded. A standardized neurological examination was carried out in all subjects. Twenty-two (40%) patients and ten (18%) controls had a higher level gait disorder (p < 0.01). The pattern of gait disturbance in AD patients varied according to the stage of the disease. Cautious gait was the commonest gait disorder in AD patients with mild dementia, while frontal gait disorder was the commonest disturbance in patients with severe dementia. The prevalence of frontal release signs (gegenhalten or any primitive reflex) was highest among patients with frontal gait disorder.

Gastro-intestinal protein loss in elderly patients with cardiac cachexia

Undernutrition resulting from chronic congestive heart failure (cardiac cachexia, CC) increases morbidity and mortality particularly in elderly people. The aetiology of CC is thought to be multifactorial. We have assessed the presence of gastro-intestinal protein loss in a group of patients with CC and a group of healthy age-and sex-matched controls. Gastro-intestinal protein loss was measured using the chromic chloride test in 29 patients with CC [mean age 76.1 (SD4.4) years] and 29 healthy controls [mean age 74.9 (SD 4.8) years]. The patients were undernourished in terms of anthropometric measurements compared to controls. The patients had a significantly lower mean ejection fraction [41.5(18.3)% vs. 65.5(2. 2)%] and higher mean pulmonary artery pressure [89.4(19.9)mmHg vs. 19.3(8.1) mmHg]. The recovery of radioactivity in a 5-day stool collection was similar in the two groups [patients vs. controls: 1. 0(0.7)% vs. 0.98(0.6)%, p=0.9]. These values are within the expected normal range. We conclude that gastro-intestinal protein loss is not a significant factor in the production of cardiac cachexia.

Fat malabsorption in elderly patients with cardiac cachexia

Malnutrition resulting from chronic congestive heart failure (cardiac cachexia, CC) is not uncommon and contributes to mortality and morbidity especially of elderly people. The aetiology of cardiac cachexia is probably multifactorial. We have assessed whether malabsorption of fat is associated with CC and if so whether it is due to small-bowel bacterial overgrowth. Three groups of subjects were studied: 29 (20 women) patients (mean age 76.1 years) with controlled congestive heart failure and weight loss (CC); 14 (seven women) patients (mean age 74.0 years) with controlled congestive heart failure and no weight loss (non-cachexia, NON-CC); and 29 (20 women) healthy controls (mean age 74.9 years). Fast absorption was quantified using the cumulative 6 h 14CO2 exhalation in the 14C-triolein breath test and small-bowel bacterial overgrowth was quantified using the cumulative 8 h 14CO2 exhalation in the 14C-glycocholic acid breath test. The cumulative 6 h 14CO2 exhalation in the triolein breath test was reduced in the CC group (p = 0.001) implying impaired fat absorption. There was no evidence of small-bowel bacterial overgrowth in any group. Impaired absorption of fat was related to the clinical severity of heart failure and its duration. Impaired fat absorption is associated with cardiac cachexia. It is not due to small-bowel bacterial overgrowth. The aetiology of fat malabsorption in heart failure requires further studies.

Legionnaires' disease--a potential hazard of rationalisation

The cases of two elderly patients who complained of general malaise after they had undergone ward transfer (due to rationalisation of the rehabilitation service) are discussed. Both were pyrexial and had signs of pneumonic consolidation. Subsequent investigation revealed that their symptoms were due to infection with Legionella pneumophila. Their cases highlight the problems associated with ward closures and the hazards of stagnant water.

Asthma in the elderly patient

Asthma is common in old age and carries significant morbidity and mortality. Most deaths due to asthma occur in old people. Often the diagnosis of asthma is overshadowed by other medical problems such as heart failure and emphysema, and thus elderly people may not receive optimal treatment. The treatment of an elderly patient with asthma is further complicated by concomitant disease and pharmacological interactions.

Orthostatic hypotension and vasodilatory peptides in bronchial carcinoma

AIM

To determine whether inappropriately secreted vasodilatory peptides have a role in the pathogenesis of orthostatic (postural) hypotension, a recognised paraneoplastic effect of bronchial malignancies usually attributed to immune mediated destruction of autonomic ganglia.

METHODS

Serum concentrations of three vasodilatory peptides, atrial natriuretic peptide (ANP), vasoactive intestinal polypeptide (VIP) and calcitonin gene related peptide (CGRP), were measured in 111 patients with bronchial carcinoma and 35 controls prospectively screened for orthostatic hypotension (> 20 mmHg drop in systolic blood pressure on repeated occasions on standing from the supine position) and in whom other causes of this condition were excluded.

RESULTS

Twenty two (20%) patients with carcinoma and two (6%) controls had orthostatic hypotension according to the criteria used. Serum concentrations of ANP, VIP and CGRP were elevated above normal in, respectively, 25 (23%), 10 (9%) and eight (7%) patients with carcinoma and in six (18%), zero and three (9%) controls. There was no correlation between orthostatic hypotension and concentrations of any of the vasodilatory peptides.

CONCLUSION

Elevated serum concentrations of ANP and CGRP were no more frequent in subjects with bronchial carcinoma than in controls and could not be attributed to the tumour, although there was a possible association for VIP. Orthostatic hypotension was more common in patients with carcinoma, but there was no evidence that the peptides measured played a role in its pathogenesis.

Heart failure in the elderly patient

Both prevalence and incidence of heart failure rise with age. Diagnosis of heart failure in the older patient may be difficult because of atypical symptoms or the acceptance of symptoms as manifestations of old age. Heart failure is not a diagnosis but a syndrome. Echocardiograms should be obtained in most elderly patients to aid diagnosis and assessment. Loop diuretics, taking into account the altered homoeostasis of old age and presence of co-morbidity, are the mainstay of symptomatic treatment. ACE inhibitors are likely to benefit survival, although formal trials have failed to include many older patients. Digoxin and direct vasodilators are less well tolerated in elderly patients.

An intrathoracic lipoma impairing left ventricular function

Images

The use of expandable metal stents for large airway obstruction in older patients

OBJECTIVE

To review the indications, management, and outcome of 30 older patients who had expandable metal stents inserted for large airway obstruction.

DESIGN

Information was collected retrospectively from case notes about presentation, radiographic appearances, pulmonary function, including arterial oxygen tension, and histology. Survival data were collected by reviewing hospital or General Practice records.

MEASUREMENTS

Spirometry, peak expiratory flow rate, and blood gases were recorded before and after stent insertion.

MAIN RESULTS

There was a significant improvement in the patient's mean forced expiratory volume in 1-second (FEV1) and mean peak expiratory flow rate (PEFR). The arterial oxygen tension (pO2) increased from 8.6 Kpa to 10.6 Kpa. The mean length of survival for the whole group was just under 5 months.

CONCLUSIONS

Airway stenting for obstruction provides palliative and functional benefits in these severely disabled patients and a consequent improvement in quality of remaining life.

Reliability of commercially available immunocytochemical markers for identification of neuroendocrine differentiation in bronchoscopic biopsies of bronchial carcinoma

BACKGROUND

Although neuroendocrine differentiation occurs quite commonly in non-small cell bronchial malignancies, its biological significance and implications for management remain uncertain. Determining these facts requires its recognition early, ideally at diagnosis, which is usually made on tissue from bronchoscopy, but the best means of its detection in such material is unclear. A prospective comparative study was performed of 10 commercially available antisera to a series of markers of neuroendocrine differentiation, to test their efficacy when applied to fibreoptic bronchoscopy biopsy specimens.

METHODS

Expression of chromogranin A, synaptophysin, neurone-specific enolase, protein gene product 9.5, the BB isoenzyme of creatine kinase, gastrin releasing peptide, adrenocorticotrophic hormone, calcitonin, calcitonin gene related peptide, and leucine enkephalin was sought by immunolabelling of bronchoscopic biopsy tissue from 83 primary bronchial carcinomas, 22 of them of small cell type.

RESULTS

Only synaptophysin and chromogranin were sensitive and specific enough for neuroendocrine differentiation to discriminate between small cell and non-small cell lesions, whereas protein gene product 9.5 and creatine kinase were neither particularly sensitive nor specific and neurone-specific enolase actually labelled more non-small cell tumours than small cell lesions. Of the five secretory products sought, only gastrin releasing peptide was detectable in just one tumour. Three squamous and two morphologically undifferentiated tumours immunolabelled for synaptophysin and chromogranin, almost certainly indicating neuroendocrine differentiation in the absence of small cell morphology.

CONCLUSIONS

Of the markers studied, only synaptophysin and chromogranin were sufficiently specific and sensitive for neuroendocrine differentiation to justify their inclusion in any panel of antibodies used in its detection in tissue obtained at fibreoptic brochoscopy.

Prevalence of low vision in elderly patients admitted to an acute geriatric unit in Liverpool: elderly people who fall are more likely to have low vision

The prevalence of visual impairment among elderly patients admitted to hospital is unknown. This group of patients may be particularly at risk from poor vision which could jeopardise their independence. A prospective study of visual imapairment and its aetiology in acute geriatric admissions assessed after the acute illness had settled was performed. Subjects were all patients aged 65 years or over, excluding those chronically confused, admitted to the Department of Geriatric Medicine at the Royal Liverpool University Hospital with an acute medical illness. After the acute illness had settled visual impairment, as defined by the American criteria (best acuity 6/18), was assessed on the ward with a Snellen chart read at 6 m using binocular vision and current glasses. Those patients identified with impaired vision on initial screening were formally assessed in the ophthalmology department to identify the cause. 200 patients were examined. 101 patients (50.5%) had impaired vision. In these patients, correctable refractive errors were present in 40%, cataract in 37% and senile macular degeneration in 14%. Of the 101 patients with impaired vision 79% had a reversible cause. Comparing these results with a recent study in the community showed a much higher incidence for patients admitted to hospital. There was a particularly high prevalence in those elderly patients who were admitted with falls (76%, p = 0.0003). In conclusion, elderly patients, especially those presenting with falls, admitted to hospital have a high prevalence of visual impairment. Visual impairment may be compounding or causing falls.(ABSTRACT TRUNCATED AT 250 WORDS)