Warfarin-associated thoracic aortic dissection in an elderly woman.

BACKGROUND: The risk/benefit ratio of warfarin therapy changes in the over 75s, when haemorrhagic side-effects become more common. These may not always be reported in the literature. CASE REPORT: A woman of 80 years, on long-term warfarin therapy presented with an acute dissecting thoracic aortic aneurysm; on investigation the only precipitating factor found was an international normalised ratio of 4.8. This patient, who also had an abdominal aortic aneurysm, survived, on discontinuation of her anticoagulant therapy. CONCLUSIONS: We describe a previously unreported complication of warfarin therapy in a patient over 75 years of age, to add to the cautions in prescribing this drug in patients of this age group.

Osteoporosis en el anciano / Osteoporosis in the elderly

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[Air pollution and mortality and hospital admission for respiratory disease in Parma on 1992-2001 period]. / Studio sulle associazioni tra inquinamento atmosferico, mortalità e ricoveri nella città di Parma. Periodo 1992-2001.

A study into the effects of atmospheric pollution on the health of people living in the city of Parma (population 170,000) shows motor vehicle traffic of average density and light industrial activities that have little impact on air pollution. General mortality and hospitalisation for all causes and for DRG specific were considered as sanitary events. The day values of the total PT, PM10, SO2 and NO2, CO and benzene were analysed. In addition, atmospheric conditions and outbreaks of flu were considered. The study results for the period 1992-2001 show quite moderate pollution levels with the sole exception of PM10 that shows average values often higher than 40 microg/l. An analysis of the associations between mortality and climatic parameters shows the role of temperature with RR equal to 1.0064 (CI95% 1.0046-1.0082) and epidemics of influenza with RR 1.042 (CI95% 1.0219-1.0671). As regards the pollution parameters, the total PT and SO2 turned out to be related to increases in mortality of respectively 0.6% for 100 microg/m3 of PT and 1.72% for 50 microg/m3 of SO2 while the NO2 turned out to be related to an increase in hospitalisations of 1.9% for 10 microg/m3 of NO2.

Reliability of an Italian standardized and expanded Brief Psychiatric Rating Scale (BPRS 4.0) in raters with high vs. low clinical experience.

OBJECTIVE: The aims of this study were (i) to assess the inter-rater reliability of the latest Italian expanded 24-item version of the Brief Psychiatric Rating Scale, BPRS version 4.0 and (ii) to assess the feasibility of obtaining reliable BPRS 4.0 ratings by reliability training of clinically less experienced trainees (medical and rehabilitation students). METHOD: A videotape-training procedure was used, and the inter-rater agreement scores of three different groups of raters, namely psychiatrists and psychologists (n=28), psychosocial rehabilitation students (n=27) and medical students (n=54) were calculated and compared. RESULTS: The results indicated that both experienced raters (psychiatrists and psychologists) and inexperienced raters (medical and psychosocial rehabilitation students) were able to achieve high levels of inter-rater reliability. CONCLUSION: Our results are of particular interest in view of the increasing need to draw upon professionals, other than psychiatrists and psychologists, for cost-effective and standardized evaluation of rehabilitation interventions.

The Italian version of the Family Assessment Device.

The aim of the study was to evaluate in a heterogeneous. Italian sample (n = 340) the psychometric properties of the Italian version of the Family Assessment Device (FAD), a 60-item questionnaire assessing family functioning. The questionnaire was administered to psychiatric (n = 116), medical (n = 114) and non-clinical samples (n = 110). In a sample of 30 non-clinical subjects the temporal stability of the FAD was investigated. The results showed a good temporal stability for Problem Solving, General Functioning. Communication, and Affective Responsiveness scales, and a good internal reliability of the scale. Factor analysis of the Italian version provided discrepancies with the hypothesized structure of the instrument, leading to the identification of seven slightly different dimensions. The proposed seven-factor model of the instrument did not provide a good fit to our data. The results of our study suggest the need for a major improvement in the adaptation of the FAD in the Italian setting.

Performance evaluation of tests used for tuberculin screening in adults: randomised comparison between Tine and Mono.

Between February 1993 and December 1994, 875 adults underwent tuberculin screening by the Public Health Service of Parma. The adults were randomly assigned to a multipuncture test, Tine or Mono, and contemporarily, as a reference test, received the intradermal Mantoux (IM) in the opposite arm. The tests were then read 72 hours later by two different trained nurses. The error quota due to IM was estimated by repeating both the tests done initially in patients with discordant results. The Mono test revealed a sensitivity of 95%, which was the same as that observed for the Mantoux test. As an 'operative index' of the screening, the number of false positives subsequently tested for every 10 correctly identified was used. The authors retain that the results obtained indicate the validity of the Mono test for screening in the adult population with a prevalence of tuberculous infection above 10%.

Hospital-acquired Clostridium difficile diarrhoea and herd immunity.

Clostridium difficile diarrhoea represents a significant health-service burden. We recently experienced an outbreak of C difficile diarrhoea associated with increased use of cefotaxime. The question we pose in this paper is how did the introduction and withdrawal of a single antibiotic so greatly affect rates of C difficile diarrhoea? Other antibiotics had nearly as high a risk of causing diarrhoea as cefotaxime, and the majority of patients never received cefotaxime. We believe that such outbreaks of C difficile diarrhoea are best understood in terms of a population model, and that taking antibiotics like cefotaxime should be thought of as a population rather than an individual risk factor. We postulate a herd-immunity model of C difficile diarrhoea, and examine the implications of this hypothesis.

Risk of diarrhoea, Clostridium difficile and cefotaxime in the elderly.

Clostridium difficile diarrhoea is an increasingly important nosocomial infection. Clostridium difficile infection is associated with antibiotic use. The elderly are at greatest risk. We reported an outbreak associated with the use of cefotaxime, a third-generation cephalosporin. We review the extent of this association, putative causal mechanisms and suggest an integrated approach to the control of C difficile infection which focuses on both limiting environmental contamination and reducing patient susceptibility. Future developments are also considered, especially the potential for vaccination.

Effects of aging on neuroendocrine activation in subjects and patients in the presence and absence of heart failure with left ventricular systolic dysfunction.

The neuroendocrine profile and echocardiographic features of 40 patients (81 +/- 1 years, means +/- standard error) with heart failure and impaired left ventricular systolic function were compared with those of an age-matched group of healthy subjects, 20 younger patients with heart failure (aged 58 +/- 1 years) and 15 younger healthy subjects. Normal elderly subjects had a neuroendocrine profile similar to that of healthy younger subjects apart from elevated plasma norepinephrine (958 +/- 84 vs 302 +/- 118 pg/ml; p< 0.001) and atrial natriuretic peptide ( 40 +/- 6 vs 28 +/- 5 pg/ml; p<0.05). Despite a similar severity of heart failure, elderly patients had smaller ventricular dimensions (left ventricular internal dimension in diastole 51 +/- 2 vs 69 +/- 3 mm;p<0.0001 and greater impairment of ventricular compliance using Doppler indexes. Plasma norepinephrine was higher (1,191 +/- 80 vs 620 +/- 67 ppg/ml; p<0.01), and plasma atrial natriuretic peptide, plasma active renin, and angiotensin II were lower in elderly patients than in the younger patients with heart failure. As functional capacity declines with age, elderly patients may have less severe cardiac dysfunction for any given level of functional impairment, and this may account for most of the differences in neuroendocrine activity with age. Age appears to be an important determinant of plasma norepinephrine and may be a confounding factor in interpreting the prognostic significance of this hormone.

Stability of plasma concentrations of N and C terminal atrial natriuretic peptides at room temperature.

BACKGROUND: Plasma concentrations of atrial natriuretic peptide (ANP) are increased in patients with ventricular dysfunction and could have a diagnostic role in heart failure. ANP may be unstable after collection, however, limiting any practical diagnostic role. METHODS: Blood samples were obtained from 18 patients with various conditions. Aliquots were either processed optimally or kept as blood or plasma at room temperature for 6-72 h before processing. RESULTS: Concentrations of C-terminal ANP were lower in specimens kept as blood for 24 and 72 h (mean difference from control -43% and -76%, respectively, (P < 0.001) but N-terminal ANP (extracted) seemed to be stable under all conditions studied (-2% at 24 h and -7% at 72 h, not significant). CONCLUSIONS: N-terminal ANP (extracted) is stable and potentially has a role in the diagnosis of heart failure in routine clinical practice.

Effect of aging on myocardial perfusion reserve.

UNLABELLED: Myocardial perfusion reserve (hyperemic divided by basal myocardial blood flow) describes vasodilator responsiveness of coronary-resistive vessels. The effect of aging and gender on myocardial perfusion reserve remains controversial. METHODS: We studied 56 normal volunteers (21 women, 35 men; aged 50 +/- 20 yr, range 21-86 yr) with 15O-water PET to measure myocardial blood flow during basal and hyperemic states with intravenous dipyridamole (0.56 mg/kg, n = 46) or adenosine (140 micrograms/kg/min, n = 10). For comparative analysis, patients were grouped according to age: < 30 yr (n = 11), 30-49 yr (n = 18), 50-69 yr (n = 15) and > or = 70 yr (n = 12). RESULTS: Overall, basal flow was 1.00 +/- 0.26 ml/min/g and hyperemic flow was 3.31 +/- 1.38 ml/min/g, resulting in a myocardial perfusion reserve of 3.38 +/- 1.35. There was an increase in basal flow with age (r = 0.45, p < 0.025), although hyperemic flow was only lower in patients > or = 70 yr, causing a significant reduction in myocardial perfusion reserve: 3.54 +/- 0.96 in < 30 yr, 4.23 +/- 1.35 in 30-49 yr, 3.51 +/- 1.21 in 50-69 yr and 1.94 +/- 0.46 in > or = 70 yr (p < 0.05 versus all groups < 70 yr). CONCLUSION: Myocardial blood flow during basal and hyperemia conditions are roughly comparable up to 60 yr of age. Above this age, there is significant increase in basal flow associated with an increase in systolic blood pressure. Above 70 yr, there is a significant reduction in hyperemic flow, and thus myocardial perfusion reserve independent of hemodynamic response to vasodilator stress.

Plasma neuro-endocrine activity in very elderly subjects and patients with and without heart failure.

Marked neuro-endocrine activation in patients with heart failure indicates a worse prognosis and a greater prognostic benefit from the use of ACE inhibitors. However, although the incidence of heart failure rises rapidly with age, relatively little is known about activation of the renin-angiotensin and sympathetic nervous system in patients with heart failure over the age of 75 years. This study was undertaken to investigate plasma concentrations of neurohormonal variables in elderly patients referred to the cardiac clinic with a presumptive, but unconfirmed, diagnosis of heart failure, and to compare these values to plasma concentrations found in age-matched normal subjects. Fifty patients referred with a diagnosis of heart failure were studied. All were receiving a diuretic but not an ACE inhibitor. Patients with renal, haematological and valve disease were excluded. Routine biochemistry and neurohormonal measurements were performed at their first visit, together with an electrocardiogram, chest X-ray and a full clinical examination by an experienced cardiologist. An echocardiogram and Doppler study was also performed and the diagnosis of heart failure either confirmed or refuted. Plasma concentrations of neuro-endocrine variables in healthy elderly subjects were similar to our normal laboratory range in younger subjects with the exception of atrial natriuretic peptide (ANP) (40 +/- 6 pg.ml-1, normal range < 40) and noradrenaline (5.7 +/- 0.7 nmol.l-1, normal range < 2.8). Impairment of left ventricular systolic function was confirmed in 38 of the 50 symptomatic patients (76%) and was associated with increases in plasma concentrations of active renin (58 +/- 8 IU.mol-1, P < 0.001 compared to healthy elderly subjects), angiotensin II (23 +/- 5 pg.ml-1, P < 0.008), noradrenaline (7.7 +/- 1.2 nmol.l-1, P < 0.01) and atrial natriuretic peptide (121 +/- 18 pg.ml-1, P < 0.002). Plasma concentrations were similar in normal subjects and those receiving treatment for heart failure but in whom the diagnosis was not confirmed. A weak relationship between plasma atrial natriuretic peptide (ANP) and left ventricular fractional shortening was demonstrated (r = -0.5, P < 0.001). Using an upper limit of ANP in the healthy elderly subjects of 62 pmol.ml-1 (mean + SD), plasma concentrations of ANP in the population with suspected heart failure had a sensitivity of 74% and specificity of 66% for the diagnosis of heart failure among elderly patients in the community or where access to echocardiography is limited. Left ventricular diastolic filling (assessed by Doppler) was abnormal in healthy elderly subjects and patients with heart failure, and appeared of limited value in the diagnosis of heart failure secondary to diastolic dysfunction. This study confirms that the renin-angiotensin system is activated in elderly patients with heart failure treated with diuretics. ANP may be helpful in diagnosing heart failure where it appears to have a complimentary role to echocardiography.

The changing face of community and institutional care for the elderly.

BACKGROUND: The NHS and Community Care Act 1990, implemented from 1 April 1993, was expected to alter profoundly the provision of domiciliary services to old people. This change needs to be compared with what would have happened if no action had taken place. We sought to identify trends in community and residential care before and after 1993 to facilitate this comparison. METHODS: Statistics were collated from diverse government publications and other authoritative sources. RESULTS: Between 1985 and 1993 there was a progressive contraction of public community and residential services, as well as hospital beds available to the elderly. The concomitant huge increase in places publicly funded in private old people's and nursing homes appears to have been little affected by the implementation of the NHS and Community Care Act. CONCLUSIONS: The NHS and Community Care Act has had little effect in curbing the institutionalization of old people, which has reached now the highest percentage this century at 7 per cent. A considerable expansion of community services would be required to return to the per capita provision of the early 1980s.

Inositol-specific phospholipase D activity in health and disease.

1. We report the first demonstration of the pathophysiological importance and clinical applications of the relatively recently discovered circulating enzyme, phosphoinositol-specific phospholipase D. This enzyme is known to cleave the large variety of important cell-surface molecules linked to the cell membrane by glycan-phosphatidylinositol linkages (glycan-phosphatidylinositol anchors). 2. When measured in the sera of healthy individuals, phosphoinositol-specific phospholipase D activity was found to show a strong negative correlation with age, the degree of depreciation being greater than that measured for most other analytes. 3. Serum phosphoinositol-specific phospholipase D activity was considerably depressed in patients presenting with conditions leading to reduced liver synthetic reserve, such as hepatocellular carcinoma or liver cirrhosis caused by chronic viral hepatitis, and correlated with reduced albumin levels in these conditions, indicating that the liver is the site of phosphoinositol-specific phospholipase D synthesis and that phosphoinositol-specific phospholipase D may be used as an additional marker of liver synthetic reserve. 4. When measured in patients with acute liver disease, such as acute viral hepatitis, or in patients with bronchopneumonia, phosphoinositol-specific phospholipase D activity was found to be significantly raised, demonstrating features characteristic of an acute-phase reactant. 5. These findings indicate that, besides its pathophysiological importance, phosphoinositol-specific phospholipase D and the measurement of its activity in serum may have a useful place in the investigation of a range of clinical conditions, including tissue injury and inflammation.

Do acute diseases transiently impair anterior pituitary function in patients over the age of 75? A longitudinal study of the TRH test and basal gonadotrophin levels.

Several studies have shown that anterior pituitary function is affected by the ageing process. Little is known, however, about the effect acute diseases have on the anterior pituitary. Should they be associated with a disturbance of anterior pituitary hormone production, they might make anterior pituitary function tests difficult to interpret when they are most needed. To test this hypothesis, we studied the thyrotrophin (TSH) releasing hormone (TRH) test and basal plasma gonadotrophins, taken as indicators of anterior pituitary function and reserve, in 74 consecutive patients (49 women) mean age 82 +/- 5.1 suffering from acute diseases soon after admission to hospital. A total of 44 (30 women) were followed up and retested after 3 disease-free months following recovery and discharge home. Seventy-one age- and sex-matched healthy controls (47 women), mean age 82 +/- 5.0 living in the community were also studied. The mean peak TSH increment after TRH (mean delta max TSH) increased from 5.7 soon after admission, to 7.7 U/l at follow-up (P = 0.01). The mean plasma LH increased from 25 to 35 U/l in women (P = 0.0004) and from 9.7 to 14 U/l in men (P = 0.03). The mean plasma FSH increased from 21 to 25 U/l in women (P = 0.04) and from 7.5 to 9.4 U/l in men (P = 0.01). Controls had greater TSH responses to TRH and higher plasma gonadotrophins levels when compared with acute patients (LH women P = 0.17, for all other tests P < 0.05). We conclude that a transient reduction of anterior pituitary function is a common occurrence in patients over the age of 75 suffering from acute diseases. This has diagnostic relevance and therapeutic implications.