Peptic ulcers in the elderly is a surgical disease.

BACKGROUND: Operative management for peptic ulcer disease (PUD) has changed significantly over the last 30 years. METHODS: For a 15-year period, records of patients undergoing operative management for peptic ulcer disease were stratified into age groups and examined with respect to presentation, type of operation, and risk factors. RESULTS: In all, 154 patients underwent surgery for PUD during the 1990s. Elderly patients were more likely to require an emergent operation (91%, P = 0.005), present with hemodynamic instability (25%, P = 0.025), and have a longer hospital stay (21 days, P = 0.012). Among the elderly in the 1990s as compared with the 1980s, there was increased use of nonsteroidal anti-inflammatory drugs ([NSAIDs] (49%, P = 0.005), decreased tobacco use (22%, P = 0.014), and less likelihood of postoperative renal failure (6%, P = 0.014). CONCLUSIONS: Elderly patients in the 1990s comprise the majority of cases presenting in a more unstable condition as compared with patients <60 years old, but show similar rates of morbidity and mortality. Elderly patients undergoing surgery for PUD have shown an increase in use of NSAIDs over the last 15 years. The types of procedures have not changed, but operations are more likely to be an emergent basis.

Torsemide: a new loop diuretic.

The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and dosage and administration of torsemide are reviewed. Torsemide belongs to the pyridine-sulfonylurea class of loop diuretics. Its primary site of activity is the thick ascending limb of the loop of Henle, where it blocks active reabsorption of sodium and chloride, resulting in diuresis, natriuresis, and other effects. Torsemide has high bioavailability, a relatively long half-life, and a prolonged duration of activity. It is highly protein bound. Clinical trials indicate that torsemide is effective in the treatment of hypertension and of edema and other symptoms in patients with chronic renal failure (CRF), hepatic dysfunction, or congestive heart failure (CHF). Torsemide has infrequent, mild, and transient adverse effects; among the most common are orthostatic hypotension, fatigue, dizziness, and nervousness. The recommended initial oral dosages of torsemide are 10-20 mg/day for CHF, 20 mg/day for CRF, 5 mg/day for hypertension, and 5-10 mg/day (in combination with a potassium-sparing diuretic or aldosterone antagonist) for hepatic cirrhosis. In most patients, the pharmacokinetic advantages of torsemide over other loop diuretics are unlikely to translate into a substantial edge in clinical outcomes, and in practice there may be no cost advantages. Although torsemide does not offer major advantages over other loop diuretics, it may be of benefit in patients who do not respond to or cannot tolerate other agents.

The effect of aspirin on niacin-induced cutaneous reactions.

BACKGROUND: Niacin (nicotinic acid) is one of the first-line agents recommended for the treatment of hyperlipidemia. Bothersome cutaneous reactions (flushing, feeling of warmth, itching, and tingling), however, often limit patient acceptability and tolerability. The National Cholesterol Education Program recommends giving aspirin or another nonsteroidal anti-inflammatory drug before administering niacin. Lack of scientific data supporting this recommendation, however, led to this randomized, double-blind, placebo-controlled trial to evaluate the efficacy of 80 mg of aspirin and 325 mg of aspirin in reducing these cutaneous reactions. METHODS: Thirty-one healthy subjects were randomized into one of four groups. Each group completed four different treatment regimens (placebo-placebo; 80 mg of aspirin-500 mg of niacin; 325 mg of aspirin-500 mg of niacin; and placebo-500 mg of niacin). Subjects received one of each of the four treatment regimens on separate visits that were at least 24 hours apart. Intensity and tolerability of cutaneous reactions were evaluated by an intensity rating scale and a visual analog scale. RESULTS: Results indicate that 325 mg of aspirin is significantly better than 80 mg of aspirin in decreasing intolerability to niacin. Aspirin reduced the incidence of warmth and flushing associated with niacin, but not the itching and tingling. CONCLUSIONS: It appears from this pilot study that preceding niacin with 325 mg of aspirin will decrease the warmth and flushing associated with niacin.