Transmyocardial laser revascularization combined with intramyocardial endothelial progenitor cell transplantation in patients with intractable ischemic heart disease ineligible for conventional revascularization: preliminary results in a highly selected small patient cohort.

OBJECTIVE: Transmyocardial laser revascularization for angina relief and intramyocardial autologous endothelial progenitor cell injection for neoangiogenesis may offer a new treatment strategy for patients with intractable ischemic heart disease. METHODS: Transmyocardial laser revascularization and intramyocardial injection of bone marrow-derived CD133+ cells was performed in six highly symptomatic patients. Transmyocardial laser channels were created and isolated CD133+ cells were injected intramyocardially. All patients were followed up for a minimum of 6 months postoperatively. RESULTS: One patient died shortly after the operation due to refractory heart failure. In the five survivors, CCS class improved as well as left ventricular ejection fraction. Left ventricular end-diastolic volume and myocardial perfusion varied between the patients. All patients described a considerable improvement in quality of life postoperatively. Repeated 24-hour Holter monitoring revealed no significant arrhythmias. CONCLUSIONS: In this small patient cohort, intramyocardial CD 133+ cell injection combined with transmyocardial laser revascularization led to an improvement in clinical symptomatology in all patients and in left ventricular function in 4 out of 5 patients, with an unclear effect on myocardial perfusion. Caution is advised when employing this therapy in patients with severely depressed left ventricular function.

An observational study of pre-operative transcranial Doppler examinations to predict cerebral hyperperfusion following carotid endarterectomies.

The objective of this observational study was to determine whether pre-operative transcranial Doppler measurements could identify patients at risk for early cerebral hyperperfusion following carotid endarterectomies. Fifty-five patients (mean age 64.4 years) with symptomatic internal carotid artery stenosis were included. Pre-operative transcranial Doppler measurements included middle cerebral artery blood flow velocities at normocapnia, pulsatility indices and estimation of the cerebro-vascular reserve capacity ipsilateral to the internal carotid artery stenosis. The percentage change in blood flow velocities before and at the end of the procedure was calculated. Early cerebral hyperperfusion was defined as an increase of mean blood flow velocity of more than 100% at the end of the carotid endarterectomy. Early cerebral hyperperfusion was observed in 9.2%. Cerebral hyperperfusion was seen in patients with a subtotal carotid artery stenosis in combination with reduced pre-operative blood flow velocity and pulsatility. The post-operative stroke incidence in patients with an early cerebral hyperperfusion was tenfold higher compared to patients who did not experience early hyperperfusion. A prospective clinical trial is warranted to determine whether transcranial Doppler parameters can be used to indicate patients at risk for reperfusion strokes following carotid endarterectomies.

New issues in geriatric care.

The rapid growth of the elderly population has increased the need for improved geriatric care and prevention of disability. For example, the prevalence and severity of osteoporosis can be reduced significantly by the use of estrogen, with or without added progestin, in postmenopausal women. A common and devastating problem of frail elderly persons is urinary incontinence, most cases of which can be classified without referral for urologic services. Appropriate treatment can improve nearly half of all cases of persistent incontinence. Comprehensive geriatric assessment is effective in guiding the treatment of frail elderly patients and leads to significantly improved outcomes under appropriate conditions. The advent of the teaching nursing home has shed light on the medical problems of elderly residents of nursing homes, including malnutrition, dysregulation of water and electrolyte balance, falling, cognitive and affective illnesses, behavior disturbances, infections, and pathogenic drug use. The future application of advanced technology may revolutionize nursing home care.

Urinary incontinence among geriatric patients in an acute-care hospital.

The prevalence, time course, and factors associated with urinary incontinence were examined among 363 patients aged 65 years or older admitted to the acute medical and surgical services of a university hospital. Overall, 35% were incontinent of urine at some time during their hospital stay; incontinence was more common among women and among those older than 75 years. Indwelling catheters were used in 50% of the incontinent patients and 25% of the patients who were otherwise continent while in the hospital. Incontinence was associated with impaired cognitive and physical functioning and with treatment for urinary tract infections. In most of the patients who were incontinent while hospitalized, incontinence was a persistent phenomenon and had been present before hospitalization and was present afterward. Only 5% had "transient" or "nosocomial" incontinence. These data suggest that the acute-care hospital may provide a good opportunity for physicians to identify the often-ignored problem of incontinence, and to then initiate an appropriate diagnostic evaluation of this condition if it persists after hospital discharge.

Drug therapy for geriatric urinary incontinence.

This article summarizes drugs currently available to treat the different types of geriatric urinary incontinence. Practical aspects of using these drugs and evidence in the literature for their efficacy are reviewed. Directions for further research on drug treatment of this condition are also discussed.