Severe delayed postpolypectomy bleeding in elder patient with post-polycythemia myelofibrosis.

BACKGROUND: The interest of the case lies in an unexpected delayed bleeding following an endoscopic procedure in a patient with post-polycythemia myelofibrosis. The case gives the opportunity to discuss the medical management and monitoring of patients with myeloproliferative disorders undergoing minimally invasive surgery interventions. CASE PRESENTATION: A 75 years old woman affected by post-polycythemia myelofibrosis underwent endoscopy polypectomy followed by a delayed major local bleeding. At the time of the endoscopy followed by bleeding, the platelet count was 837 × 109/L, haemoglobin 113 g/L, PCV 35,2% and WBC 20.22 × 106/L. No antithrombotic prophylaxis with low molecular weight heparin was used. Antiplatelet drug was withdraw seven days before endoscopy and restarted one week after the procedure. Polyp size was 11 x 19 mm and it was located on right side of the colon. CONCLUSION: There are some patients in whom current guidelines do not apply and our case stress the importance of myeloproliferative neoplasms as a risk factor for complications of endoscopic polypectomy. The delayed haemorrhage we observed suggest to strictly control the patient for a period longer than only one week also in case of antithrombotic treatment with antiplatelet drugs.

Association between serum 25-hydroxyvitamin d levels, bone geometry, and bone mineral density in healthy older adults.

PURPOSE: The association between serum 25-hydroxyvitamin D values and cortical/trabecular bone parameters in older adults has been incompletely explored. This study was designed to investigate the relationship between serum 25-hydroxyvitamin D levels and bone parameters for the tibia and radius using peripheral quantitative computed tomography in free-living healthy older adults. METHODS: The study involved 134 older adults attending a twice-weekly low-intensity fitness program. In addition to clinical history and serum parameters, we assessed fat-free mass using dual-energy X-ray absorptiometry, total bone and cortical bone cross-sectional areas, and trabecular and cortical bone mineral density for the tibia and radius by peripheral quantitative computed tomography. RESULTS: After applying multivariate linear regression models, adjusting for sex, age, body mass index, fat mass and fat-free mass, and creatinine, the association between 25-hydroxyvitamin D and bone parameters was significant for total bone and cortical bone cross-sectional areas in the radius (partial R (2) = 0.05 and 0.09, respectively) and for trabecular bone mineral density and cortical bone cross-sectional area in the tibia (partial R (2) = 0.11 and 0.02, respectively). CONCLUSION: These findings support the idea that serum 25-hydroxyvitamin D levels and bone parameters are linked in older adults. Longitudinal studies are needed to establish whether vitamin D levels over time are associated with changes in these parameters.

Effects of 21 months of cholinesterase inhibitors on cognitive and functional decline in demented patients.

AIMS: The aim of this study was to assess, in a natural setting, the development of cognitive, behavioral and functional performance of elderly dementia patients treated with cholinesterase inhibitors (ChEIs) during a 21-month follow-up. Another aim was to compare patterns of clinical changes in relation to patients' level of cognitive impairment at the beginning of therapy. METHOD: Of the 1987 elderly demented patients seen at our unit, 143 met the inclusion/ exclusion criteria, were followed for at least 21 months, and were thus included in the study. At baseline and each control point (up to 21 months), patients were scored for Mini Mental State Examination (MMSE), Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). RESULTS: After 21 months' treatment with ChEIs, patients showed a significant reduction in MMSE, ADL and IADL values. The MMSE score decreased by 1.7 points/year (95% CI -2.1; -1.3), irrespective of initial cognitive level, and was lower than that expected in non-treated patients (-3/-4 points/year). CONCLUSION: ChEI therapy is effective in slowing the progression of dementia, even in the long term, irrespective of baseline cognitive level.

A rare case of sepsis due to Corynebacterium macginleyi from central venous catheter in an elderly woman.

Corynebacterium macginleyi is a gram positive rod that causes especially ocular infections: since now only six elderly cases of extraocular infection are described. A 76 years old bedridden woman with a central venous catheter was hospitalized for 10 days of persistent fever. She was treated before with vancomicin and then with imipenem. The clinical conditions improved and the patient was discharged after two weeks of hospitalization. Among recognised risk factors for this infection the advanced age, indwelling devices and immunosuppression seem the most important. On the other hand, the antibiotics of choice are glycopeptides while the association of another antibiotic is recommended in our opinion only in severe clinical manifestation.

Chronic pain in the elderly with advanced dementia. Are we doing our best for their suffering?

Elderly subjects with advanced dementia are exposed, like all aging individuals, to a wide range of chronic degenerative and progressive medical conditions which can cause pain and discomfort, both physical and psychological. Pain is defined as an unpleasant subjective experience, generally assessed with verbal self-reporting methods. The inability to report pain verbally - a common occurrence in advanced stages of dementia - is widely recognized as the main confounding factor in identifying these patients' pain. As several previous studies on pain assessment in cognitively impaired elderly subjects systematically eliminated non-communicative demented patients, it is hard to estimate the prevalence of their pain. The lack of pain assessment methods which do not rely on self-reporting contributes to under-estimation of the prevalence of pain, particularly among institutionalized patients, the majority of whom suffer from some degree of dementia. Assessing chronic pain in these frail elderly patients requires careful monitoring of any changes in their behavior which may be due to a new source of discomfort, rather than an aggravation of their cognitive impairment. Although some currently available tools for pain assessment in non-verbal older adults seem promising, no single tool has yet been sufficiently validated as reliable for widespread adoption in clinical practice. Prior research has documented a significantly lower prescription of analgesic medications in demented patients than in cognitively intact peers: as untreated or under-treated pain can have adverse physical and psychological consequences, there is an urgent need for appropriate pain assessment methods in elderly patients with advanced dementia, since too many of them continue to suffer needlessly. The purpose of this review is to discuss the main tools developed in the last decade for pain assessment in non-communicative older individuals, highlighting the strengths and weaknesses of each, and providing a guide for their use in clinical practice, particularly in geriatric settings.

A case of naturally evolving gout in an elderly man.

Gout is a common disorder in adults that can lead to severe organ decline, disability and impaired quality of life due to the formation of periarticular tophi. We report a case of massive tophaceous gout in a 78-year-old man with a 16-year-long history of untreated disease. The patient gradually became disabled, his renal function deteriorated, and he finally died of sepsis. Our case demonstrates that chronic gout not only affects the joints, but is also associated with organ function decline and can, even nowadays, lead to death.

Changes in healthy elderly women's physical performance: a 3-year follow-up.

BACKGROUND: Inflammatory states, hypovitaminosis D and secondary hyperparathyroidism may have a role in the age-related loss of muscle mass, and physical performance in healthy old people. The aim of this study is to investigate changes in muscle mass, strength and physical performance in healthy, active elderly females over a 3-year follow-up, correlating them with any inflammatory states and PTH and 25-hydroxyvitamin D (25-OHD) levels. METHODS: One hundred healthy females over 65 years of age routinely attending a twice-weekly mild fitness program were eligible for the study. Clinical history, serum parameters, body composition by DEXA, handgrip strength, knee extensor isometric/isotonic strength and functional performance measured using the Short Physical Performance Battery (SPPB) were evaluated at the baseline and after 3 years. RESULTS: After 3 years, the women had a significant decrease in weight (∆:-0.8±3.1 kg; p<0.05) and height (∆:-0.4±0,6 cm; p<0.001), while their BMI and body composition parameters did not change. Only IL-6 (∆: 0.6±2.0; p<0.01) and PTH (∆: 30.7±29.2 ng/L; p<0.001) increased significantly, while there were no changes in 25-OHD levels. There was a significant decrease in all the SPPB results and in muscle strength. ∆ PTH only correlated with the variation in 4-meter walking speed (r: 0.41; p<0.01). CONCLUSIONS: With advancing age, physical performance declines even in healthy, active females despite a spare of muscle mass. The increase in PTH seems to have a role in this decline, that could be clarified by further investigations.

Predictors of low bone mineral density in elderly males with chronic obstructive pulmonary disease: the role of body mass index.

OBJECTIVE: The aim of this study was to investigate the relationships between nutritional indices (Body mass index (BMI), serum albumin), sarcopenia, bone mineral density (BMD) and the severity of their pulmonary obstruction in elderly patients with chronic obstructive pulmonary disease (COPD). METHODS: The method involved was a prospective transversal study; 82 males >65 years old, 41 stable patients with COPD and 41 healthy elderly individuals (controls). All subjects underwent spirometry, biochemical analyses and dual energy X-ray absorptiometry. The significance of the differences between mean values and prevalence rates was tested. The relationships between BMD and independent predictors were analysed by multiple linear regressions. Logistic regression models were applied on dichotomised variables. RESULTS: In patients with COPD, the prevalence of osteoporosis was higher in subjects with sarcopenia (46% vs. 0%; p < 0.05) and with BMI < 25.1 kg/m(2) (58% vs. 15%; p < 0.02). Multiple regression analysis indicated that BMI, appendicular skeletal muscle mass (ASMM), albumin, and forced expiration volume after 1 s (FEV1) explained the 70% of BMD variability at the hip and 56% at the spine. Logistic regression showed that a BMI < 25.1 kg/m(2) was independently associated with osteoporosis risk (OR = 10.0; 95%CI 1.3-76); no independent effect emerged for FEV1% (

Ischemic colitis in the elderly: predictors of the disease and prognostic factors to negative outcome.

OBJECTIVE: Ischemic colitis (IC) poses a challenge for physicians, especially in elderly patients. The aim of this study was to identify predictors of the disease and to assess the factors predicting its evolution in elderly people. MATERIAL AND METHODS: A retrospective study was undertaken in patients with IC admitted to Padua General Hospital between 2003 and 2008. Only patients with biopsy-proven IC were considered. Fifty control subjects were randomly selected from those seen at our units for acute geriatric disease during the same interval. Patients with IC were classified as having either a positive or negative outcome. RESULTS: A total of 46 patients were considered. The risk factors for IC identified from univariate analysis were analyzed in a multivariate logistic regression model and constipation [adjusted odds ratio (OR) 4.8; 95% confidence interval (CI) 1.1-20.1], vasculopathy (OR 4.9; 95% CI 1.4-16.6), hepatitis C virus (HCV) (OR 9.9; 95% CI 1.1-92.9) and cancer (OR 7.5; 95% CI 2.1-26.9) confirmed their independent significance as risk factors. Hematochezia was predictive of a positive outcome (OR 0.07; 95% CI 0.02-0.40), while cancer (OR 3.2; 95% CI 1.2-11.9), HCV positivity (OR 9.6; 95% CI 1.6-56.5), signs of peritonism (OR 4.7; 95% CI 1.2-18.4), localization in the right colon (OR 5.75; 95% CI 1.5-21.9) and increased levels of lactate dehydrogenase (LDH) and urea were independently predictive of a negative outcome. CONCLUSIONS: Elderly patients with IC are characterized by significant comorbidities. The absence of hematochezia and the presence of a concomitant malignancy, HCV, a marked increase in urea and LDH and disease involving only the right colon are factors that may predict a negative outcome in elderly patients.