[Is transcatheter aortic valve implantation superior to surgical valve replacement?] / Is TAVI beter dan chirurgische aortaklepvervanging?

Severe aortic valve stenosis is treated traditionally with surgical valve replacement. Transcatheter aortic valve implantation (TAVI) has experienced a rapid development in the last decade. Indications for TAVI have been broadened from inoperable and high surgical risk patients to intermediate-risk patients. Mortality rates are identical after TAVI compared with surgical valve replacement in intermediate-risk patients. However, mortality is not an appropriate outcome measure for a frail older person. Quality of life, autonomy and functioning independently are probably more suitable outcomes in this frail older population. Moreover, TAVI costs are high. TAVI is not appropriate for all elderly patients but depends on the individual patients' criteria and wishes.

Gait speed as a test for monitoring frailty in community-dwelling older people has the highest diagnostic value compared to step length and chair rise time.

BACKGROUND: Frailty reflects a state of increased risk of negative health outcomes, such as falls and mortality. Self-management in recognition and monitoring of frailty is a prerequisite for effective and efficient care for the elderly. Mobility may be self-monitored with simple reliable tests, such as maximum step length (MSL) test, gait speed (GS) test, or chair rise test (CR). AIM: The aim was to investigate whether a complex frailty assessment may be replaced by simple stand alone mobility tests as a prerequisite for self-monitoring of frailty. DESIGN: This was an observational cross-sectional study. SETTING: The study was performed in an outpatient clinic. POPULATION: The study subjects were community-dwelling older people aged 70 years or older. METHODS: In all subjects, frailty status was assessed using a standardised geriatric assessment that included Fried's frailty phenotype and the Frailty Index (FI). Mobility was assessed with the MSL, GS and CR. RESULTS: A total of 593 subjects with mean age of 76.8 years (±4.8 [SD]), 56% female, participated in the study. GS showed a correlation of r=-0.60 with both the Fried score and the FI. The MSL correlated best with the Fried score: r=-0.52, and the CR correlated best with the FI: r=0.51. The GS had an area under the curve of 0.92 for assessing the dichotomised frailty state. CONCLUSION: Compared with step length and chair rise time, gait speed has the strongest correlation with frailty, the highest diagnostic value, and it is the simplest single measure that can replace the complex frailty assessment as a self-test for monitoring frailty at home. CLINICAL REHABILITATION IMPACT: THE self-monitoring of frailty is likely to be possible with GS, which may be a valuable tool for empowering older individuals.

Comparison of different strategies of referral to a fall clinic: how to achieve an optimal casemix?

UNLABELLED: OBJECTIVE To study the potential differences in patient characteristics between two referral methods to a fall clinic, specifically: case-finding of patients admitted to an emergency department because of a fall, compared to direct referral to the fall clinic via the general practitioner. DESIGN: Cross-sectional study. SETTING: Fall clinics in two university teaching hospitals in the Netherlands. PARTICIPANTS: Three hundred community-dwelling older people aged 65 years or over currently attending the fall clinics in Nijmegen (Group 1, n=154) and in Amsterdam (Group 2, n=146). MEASUREMENTS: Patients were referred by a general practitioner (Group 1) or were selected using the Carefall Triage Instrument (CTI) after visiting the emergency department (Group 2). In all patients, modifiable risk factors for recurrent falls were assessed. RESULTS: Group 1 had less modifiable risk factors for falling (a mean of 4 (SD 1.6) vs. a mean of 5 (SD 1.5) in Group 2, p < 0.001). Compared to Group 2, Group 1 had more prevalent " recurrent falling (≥ 2 falls)" (p=0.001) and "assisted living in homes for the aged" (p=0.037). "Fear of falling", "mobility and balance problems", "home hazards" and "osteoporosis" were significantly less prevalent in Group 1. CONCLUSION: This study suggests that patients referred to a multidisciplinary fall prevention clinic by their general practitioner have a different risk profile than those selected by case finding using the CTI. These differences have consequences for the reach of secondary care for fall-preventive interventions and will probably influence the effectiveness and efficiency of a fall prevention program.

[Tuberculosis spondylodiscitis in three older patients]. / Spondylodiscitis door tuberculose bij 3 oudere patiënten.

Three patients, two women aged 78 and 70 years, respectively, and a man aged 71 years, had back pain for months. Fever was absent. Blood parameters of infection were slightly or highly elevated. The diagnosis of spondylodiscitis was confirmed by MRI in all three patients. In one patient tuberculosis was confirmed by culture. One patient was from Turkey and the other two patients had been exposed professionally to tuberculosis. On two occasions, spondylodiscitis was complicated by compression of the spinal cord, and surgical intervention was necessary on one occasion because of neurological deficit. Initial treatment consisted of long-term bed rest and antituberculous therapy. All three patients recovered successfully. Tuberculous spondylodiscitis is a rare cause of back pain, but should be included in the differential diagnosis, particularly if there is an increased risk based on the medical history or if the patient comes from an endemic region or has an increased risk due to his or her profession.

Aortic graft infection by Lactobacillus casei: a case report.

A 65-year-old man with an abdominal aortic endoprosthesis presented with fever without other symptoms. Investigations revealed Lactobacillus casei bacteraemia. The Lactobacillus graft infection was at first successfully treated by antibiotic therapy. However, during follow-up a relapse occurred, and after surgical replacement of the graft the patient was cured. At surgery an aortoenteric fistula was found as source of the infection.

Venous compliance and the venodilatory effect of nitroglycerin in insulin-dependent diabetic patients with and without (incipient) nephropathy.

The venous system plays a pivotal role in volume and blood pressure homeostasis. We tested the hypothesis that the visco-elastic properties of the peripheral venous system are reduced in patients with (incipient) diabetic nephropathy. Twenty-two normotensive patients with long-term insulin-dependent diabetes mellitus (IDDM), 11 without and 11 with (incipient) nephropathy (eight microalbuminuria and three proteinuria, serum creatinine below 100 mumol l-1), and 14 healthy age/sex matched controls were studied. Forearm venous compliance (VENCOMP) was determined using strain gauge plethysmography and direct intravenous pressure measurements. Furthermore, the venodilatory effect of 0.4 mg sublingual nitroglycerin (NTG) was studied. In comparison with healthy controls, VENCOMP was decreased in patients without and with (incipient) nephropathy, without any differences between the two diabetic groups: 0.059 (0.052-0.066), 0.044 (0.038-0.059) and 0.049 (0.046-0.058) ml 100 ml-1 mmHg-1, respectively (medians and interquartile ranges) (P < 0.05). No differences in the increase of forearm volume after NTG were observed: 0.34 (0.11-0.51), 0.37 (0.19-0.50) and 0.39 (0.20-0.55) ml 100 ml-1, respectively. In conclusion, the visco-elastic properties of the peripheral venous system are reduced in patients with long-term IDDM. This reduction is not related to the presence of nephropathy. No major differences were observed in NTG-induced venodilation between diabetic patients and healthy subjects.