High lipoprotein(a) level promotes both coronary atherosclerosis and myocardial infarction: a path analysis using a large number of autopsy cases.

OBJECTIVE: To investigate whether hyper-lipoproteinaemia(a) (Lp(a)) promotes coronary atherosclerosis, acute thrombosis resulting in myocardial infarction (MI), or both. DESIGN: Retrospective chart review. SETTING: A community-based general geriatric hospital. PATIENTS: 1062 consecutive autopsy cases (609 men, 453 women). The mean age at the time of death was 80 years. MAIN OUTCOME MEASURES: A semiquantitative evaluation of the coronary stenosis on cut sections and pathological definition of MI. Lp(a) levels of fresh serum taken antemortem, measured by a latex-enhanced turbidimetric immunoassay. RESULTS: The prevalence of severe coronary stenosis and pathological MI increased linearly with increasing Lp(a) levels with no apparent threshold. The odds ratios (95% CI) of hyper-Lp(a) (2.99 (1.70 to 5.28) for 200-299 mg/l and 3.25 (1.90 to 5.54) for >300 mg/l) for severe coronary stenosis were larger than those of hypertension (2.61 (1.88 to 3.63)), diabetes mellitus (2.09 (1.41 to 3.11)) and hypercholesterolaemia (2.05 (1.31 to 3.21)). The severe coronary sclerosis was much stronger risk of MI (6.28 (4.33 to 9.11)) than hyper-Lp(a), hypertension and diabetes mellitus. A path analysis showed that the Lp(a) levels affected both coronary sclerosis and MI, with path coefficients of 0.15 and 0.07 (direct effect), respectively. In cases with severe coronary sclerosis Lp(a) affected only MI (0.15). CONCLUSIONS: Lp(a) levels have distinct effects on coronary sclerosis and MI, with about half of the overall effect on MI being via coronary sclerosis. This result supports the prothrombotic and a probable proinflammatory role of Lp(a) in coronary events.

Spread of a large plasmid carrying the cpe gene and the tcp locus amongst Clostridium perfringens isolates from nosocomial outbreaks and sporadic cases of gastroenteritis in a geriatric hospital.

SUMMARYTo investigate two clusters of diarrhoea cases observed in our geriatric hospital wards, the faecal specimens were analysed. Reversed passive latex agglutination assay revealed that 63.2% and 41.7% of the faecal specimens from each cluster were positive for Clostridium perfringens enterotoxin. PCR assay revealed that 71.4% and 68.8% of C. perfringens isolates from each cluster were positive for the enterotoxin gene (cpe). These observations suggested that both the clusters were outbreaks caused by enterotoxigenic C. perfringens. Subsequent pulsed-field gel electrophoresis analysis revealed that the two outbreaks were caused by different C. perfringens isolates. However, these outbreak isolates as well as other sporadic diarrhoea isolates shared a 75-kb plasmid on which the cpe gene and the tcp locus were located. The 75-kb plasmid had horizontally spread to various C. perfringens isolates and had caused outbreaks and sporadic infections. However, the site and time of the plasmid transfer are unclear.

Survey of antibiotic resistance in Pseudomonas aeruginosa by The Tokyo Johoku Association of Pseudomonas Studies.

Pseudomonas aeruginosa resistance (minimum inhibitory concentration [MIC], > or =16 microg/ml defined as resistant) to meropenem, imipenem, panipenem, piperacillin, ceftazidime, cefozopran, cefoperazone, sulbactam/cefoperazone, amikacin, and tobramycin, as well as cross-resistance profiles, were investigated in P. aeruginosa strains isolated at eight hospitals in the Johoku area, Tokyo, during November 1998. Overall, 8.3% of isolates were imipenem-resistant and 4.6% were ceftazidime-resistant. However, the incidence of antibiotic-resistant P. aeruginosa was distinctly different at each hospital. P. aeruginosa resistance to imipenem ranged from (MIC) 1 to 64 microg/ml (MIC90 32 microg/ml), and its resistance to ceftazidime ranged from 2 to more than 128 microg/ml (MIC90, 64 microg/ml). Meropenem (MIC range, < or =0.25 to 16 microg/ml) was more active than panipenem (MIC range, 2 to 64 microg/ml). Cefozopran was more active than piperacillin, cefoperazone, or sulbactam/cefoperazone, but many strains were resistant to cefoperazone (17/57). Our analysis found cross-resistance to many beta-lactams, but the degree of cross-resistance was very variable.

High incidence of acute myositis with type A influenza virus infection in the elderly.

We describe six elderly cases of acute myositis with type A influenza virus infection (Sydney) during the 1998-1999 outbreak. All six cases suffered from myalgia or muscle weakness especially in the lower extremities and the serum creatine kinase (CK) values were elevated above 1,000 IU/l without MB isoenzymes or electrocardiogram abnormalities. There have been a few case reports of acute myositis associated with influenza virus infection in the elderly. However, we noticed a high incidence of acute myositis among elderly patients with type A influenza virus infection. This complication may occur more commonly in elderly patients than has previously been thought.

Insertion/deletion polymorphism in the angiotensin-converting enzyme gene affects heart weight.

BACKGROUND: Angiotensin (Ang) II, a major regulatory factor for left ventricular mass, is generated from Ang I by ACE. ACE levels are associated with an insertion/deletion (I/D) polymorphism in the ACE gene. The ACE polymorphism should result in varied Ang II concentrations and hence affect left ventricular mass. We therefore investigated whether ACE genotype is a predictor of heart weight. METHODS AND RESULTS: From 693 consecutive patients autopsied between 1994 and 1998 in our hospital, patients with valvular disease, myocardial infarction, or cardiomyopathy were excluded. The remaining 443 autopsy patients were the subjects of our study. The heart weight at autopsy was corrected for body surface area. Genomic DNA was purified from the kidney, and ACE genotype was determined by polymerase chain reaction. Heart weight in the DD genotype (249. 9+/-49.9 g/m(2)) was significantly higher than that in the ID (230. 0+/-51.2 g/m(2); P<0.05) and II (226.8+/-49.8 g/m(2); P<0.01) genotypes. Heart weight was also positively related to age (r=0.145, P<0.0001) and coronary stenosis index (r=0.147, P=0.0019). Multiple regression analysis showed that a history of hypertension (P<0.0001), age (P=0.0001), and DD genotype (P=0.0154) were independent predictors of heart weight. CONCLUSIONS: ACE genotype predicts cardiac mass; however, it was less effective than epigenetic factors such as hypertension or age.

[Susceptibilities of Enterococcus faecium, PRSP and MRSA to RP59500 and their correlations with those to other drugs].

Investigations on emergence of vancomycin-resistant Enterococcus faecium (VREF) which has recently been attracting attention, especially in the Western countries, have been conducted in Japan. A total of 1,239 isolates of E. faecium were collected from 19 institutions during the period of April 1995 and June 1996, in the purpose of evaluating susceptibilities to variety of antimicrobial agents, including RP59500 and vancomycin (VCM), and detecting vancomycin-resistant genes (van genes). Susceptibilities of penicillin-resistant Streptococcus pneumoniae (PRSP) and methicillin-resistant Staphylococcus aureus (MRSA) were also studied. As a result, 2 isolates of E. faecium were found to be moderately resistant to VCM showing MIC of 8 micrograms/ml though the final identification in species level and the detection of van genes by PCR method have not been completed. On the other hand there detected no MRSA nor PRSP showing moderately resistant or resistant to VCM. It was concluded that RP59500 and VCM possessed favorable activity against clinically isolated E. faecium, PRSP and MRSA. Among other species of enterococci, moderately resistant strains to VCM showing MIC of 8 micrograms/ml were detected; 10 isolates of E. gallinarum, 4 of E. casseliflavus and 2 of E. flavescens. In those isolates, vanC1 and vanC2 were detected by PCR, and vanB was also detected in a isolates of E. gallinarum simultaneously.

[Levofloxacin-induced neurological adverse effects such as convulsion, involuntary movement (tremor, myoclonus and chorea like), visual hallucination in two elderly patients].

Levofloxacin-induced-neurological adverse events such as convulsion, involuntary movement (tremor, myoclonus and chorea-like) and visual hallucination in two elderly patients are reported. A 67-year-old man with minor alcoholism and a past-history of gastrectomy and cholecystectomy was given 300 mg/day of oral levofloxacin and fulfenamic acid for an upper respiratory infection. On the 4th day, he reported gradual exacerbation of hand tremor which resembled chorea-like involuntary movement and gait disturbance. He also experienced visual hallucinations. On the 7th day, he suffered generalized convulsions and was admitted. Serum concentration of levofloxacin at this time (3 hours after last administration of a 100 mg tablet of levofloxacin) was 3.6 micrograms/ml. Cessation of the agents promoted complete recovery of these neurological adverse effects within a week. Another 85-year-old man with chronic bronchitis and slight renal impairment received long term administration of 200 mg/day of levofloxacin. On the 68th day of administration, gradual exacerbation of gait disturbance, dysarthria and chorea-like involuntary movement occurred. On the day of admission, 76 days after the start of administration, the serum level of levofloxacin was 2.55 micrograms/ml and that of spinal fluid was 1.12 micrograms/ml (3 hours after the last administration of a 100 mg tablet of levofloxacin). Cessation of the agents promoted complete recovery of these neurological adverse effects within the next two weeks. Both patients had no apparent neurological disorders except age-related brain atrophy. Age-related renal and brain impairment might have contributed to the neurological adverse effects of levofloxacin.

[Elderly outpatients' attitudes toward care in terminal stage disease].

Responses to a questionnaire regarding 1) dying at home, 2) being told of a diagnosis of cancer, and 3) hydration and nutrition, uses of narcotics for pain and dyspnea, oxygen treatment, antibiotics, transfusion and surgery in a near-vegetative state was obtained from 562 outpatients (73.4 +/- 8.6 years:mean +/- SD, men:women = 1.0:1.7). Dying at home was preferred by 64% and hospital death by 24%. Sixty and 65% of patients chose to be told of the diagnosis either in the last 3 months or at the early curable stage of the disease respectively, while only 53% wanted to be told precisely about their remaining estimated survival. If their spouse had terminal stage disease, 42% chose to inform the spouse of the diagnosis. Eighty percent chose palliative care, while 9.3% wished for intensive life-sustaining treatment. In a near vegetative state, tube feeding was desired by 8.7% and intravenous drip infusion by 39%; narcotics for pain or dyspnea were desired by 40 and 52%; oxygen or tracheostomy plus a respirator for dyspnea was chosen in 56 and 11% respectively; antibiotics for treatment of infection was desired by 38%; surgery for intestinal obstruction by 36 percent; transfusion for bleeding by 29%; and no treatment in any situation by 21%. Commonly expressed wishes were for a natural death, dying at home, and being told of the status of their disease, while details of palliative care were not well recognized.

[Evaluation of a multi-hospital cooperative study on the efficacy and safety of panipenem/betamipron (PAPM/BP) on elderly patients of respiratory infections].

The efficacy and safety of Panipenem/Betamipron (PAPM/BP) on elderly patients of respiratory infections was examined at 17 hospitals in a cooperative study. Among the 95 case, we examined the efficacy of the medication in 86 cases, and the safety in all 95 cases. Efficacy was confirmed in 81.3% of pneumonia patients, 57.7% of secondary-infection patients of chronic respiratory diseases, and 74.4% of the total. No significant difference was observed among each group according to age, comparing patients > or = 65 years old grouped by 5 years, or when broadly comparing groups < 75 years and > or = 75 years of age. The microbiological efficacy was 100% for Streptococcus pneumoniae, 80% for Staphylococcus aureus, 80% in Klebsiella pneumoniae; therefore, a very good disappearance rate of symptoms could be obtained in all major respiratory etiologic agents except Pseudomonas aeruginosa. In this study, we also examined other factors considered to affect the course of treatment for elderly patients of infectious diseases, namely the presence of absence of underlying diseases, the distinctness of infectious symptoms, the patient's condition before the appearance of infectious symptoms, and previous history of treatment with antimicrobial agents. For safety, the incidence rate of side effects was 14.7%, which was similar to the 16.9% in the developmental study. These two findings were also similar in content. No significant difference was observed among each age group, comparing patients > or = 65 years old grouped by 5 years, or comparing groups < 75 years and > or = 75 years of age. From the above evaluation, we consider PAPM/BP to be an effective drug for normal adult patients as well as elderly patients of respiratory infections.

[Clinical study on penicillin insusceptible/resistant Streptococcus pneumoniae in the elderly patients].

Clinical features of respiratory infection in the elderly with penicillin insusceptible (31 cases) and resistant (7 cases) Streptococcus pneumonia (PSSP/PRSP) are compared to those with penicillin sensitive S. pneumoniae (PSSP) (29 cases). Incidence of bacteremia and pneumonia was higher in the PSSP group. PISP/PRSP tend to be isolated from patients with bronchitis underlaid with chronic pulmonary disease without statistic significance. Efficacy of the penicillins and 1st and 2nd generation cephem was satisfactory except in only one case of pneumonia with PISP which needed an alternative choice to the 3rd generation cephem. Now a day the degree of resistance is not so high and the available antibiotics are sufficient for the treatment of pneumococcal infection in the elderly patients. However, the wide use of oral cephems and certain new quinolones which do not have enough activity against Streptococcus pneumoniae may increase resistance. In which case, continuous surveillance and clinical caution against this resistant strain is necessary.

Nosocomial diarrhoea in the elderly due to enterotoxigenic Clostridium perfringens.

To diagnose sporadic diarrhoea due to Clostridium perfringens infection, faecal specimens from elderly patients were examined directly for C.perfringens enterotoxin using reverse passive latex agglutination assay, and then cultured for this organism. C.perfringens isolates from those samples were grouped by slide agglutination and by pulsed-field gel electrophoresis (PFGE). Fifty of the 60 isolates agglutinated with newly raised antiserum WX2 and 38 shared the same genomic PFGE pattern. Characteristics of the epidemics and experimental data suggest that the diarrhoea was caused by a nosocomial spread of C.perfringens, and not by a food-borne outbreak.

[An analysis of 41 elderly patients with urosepsis].

We performed a clinical evaluation in 41 patients with urosepsis at Tokyo Metropolitan Geriatric Hospital from July 1992 through March 1993. The most common organism isolated from the patients was Escherichia coli (46.3%), followed by Pseudomonas aeruginosa (9.8%), Methicillin-resistant staphylococcus aureus (7.3%), and mycetes (7.3%). The most frequent underlying disease was cerebrovascular disease (34.1%) and malignancies were observed 29.2% of all cases. Twenty-six patients (63.4%) had indwelling urethral catheters. Indwelling catheters were suspected to be related to the onset of urosepsis in 16 cases. Total mortality of urosepsis was 4.9% (2/41) in this study. We speculate that the main cause of urosepsis is a long-term use of urethral catheterization, especially in elderly patients with severe complications who are vulnerable to infections. It is important to assess and correct the conditions of dysuria of individual patients before placing indwelling urethral catheters.