Aim
Myocardial infarction without chest pain misleads the clinician, resulting in a diagnosis delay and an increase of mortality. The main objective of the present study was to determine the risk ...factors of atypical presentation in older patients with myocardial infarction.
Methods
All consecutive patients aged ≥75 years presenting with myocardial infarction and hospitalized in the cardiology intensive care unit were included in the present prospective multicenter observational study. All patients benefited from both specialized cardiac management and geriatric assessment.
Results
A total of 215 consecutive patients were included. The mean age was 85 ± 6 years. A total of 142 patients (66%) had a typical presentation (i.e. chest pain) and 73 patients (34%) had an atypical clinical presentation (i.e. no chest pain). A total of 29 (13.5%) patients died within 30 days of the index hospitalization. Higher Cumulative Illness Rating Score‐Geriatric severity index score (P = 0.019) and initial atrial fibrillation (P = 0.022) were predictive of 30‐day all‐cause mortality. Typical presentation (P = 0.010) was a protective factor of 30‐day all‐cause mortality. A Cumulative Illness Rating Score for Geriatrics total score increase (P = 0.0003) and residing in a nursing home (P = 0.024) emerged as independent risk factors for atypical presentation.
Conclusions
In “real‐life” elderly patients, comorbidities influence the prognosis of myocardial infarction, but also clinical presentation. Identification of patients at risk of atypical presentation; that is, patients with multiple comorbid conditions, might help refine the prognostic value in older patients with myocardial infarction. Geriatr Gerontol Int 2018; 18: 1591–1596.
Abstract Background The Emergency Department (ED) is an environment at risk for medical errors. Objective Our aim was to determine the factors associated with the adverse events resulting from ...medical errors in the ED among patients who were admitted. Methods This was a prospective observational study. For a 1-month period, we included all ED patients who were subsequently admitted to the medical ward. Detection of medical errors was made by the admitting physician and then validated by two experts who reviewed all available data and medical charts pertaining to the patient’s hospital stay, including the first review from the ward physician. Related adverse events resulting from medical errors were then classified by type and severity. Adverse events were defined as medical errors that needed an intervention or caused harm to the patient. Univariate analysis examined relationships between characteristics of both patients and physicians and the risk of adverse events. Results From 197 analyzed patients, 130 errors were detected, of these, 34 were categorized as adverse events among 19 patients (10%). Seventy-six percent of these were categorized as proficiency errors. The only factors associated with a lower risk of adverse events were the transition of care involving a handoff within the ED (0% vs. 19%; p = 0.03) and the involvement of a resident (junior doctor) in addition to the senior physician (37% vs. 67%; p < 0.01). Conclusions In our study, the involvement of more than one physician was associated with a lower risk of adverse events.
Hip fracture has devastating consequences in elderly patients with comorbidities. The two main objectives to improve outcome are the needs for early surgery and for a multidisciplinary approach, ...known as the orthogeriatric concept..
Objectives: Differentiating cardiogenic pulmonary edema (CPE) from respiratory causes of dyspnea is difficult in elderly patients. The aim of this study was to compare the usefulness of B‐type ...natriuretic peptide (BNP) and amino‐terminal fragment BNP (proBNP), to diagnose CPE in patients aged 65 and older.
Design: Prospective study.
Setting: Medical emergency department of a 2,000‐bed urban teaching hospital.
Participants: Patients aged 65 and older presenting with acute dyspnea and a respiratory rate of 25 breaths/min or greater, a partial pressure of oxygen of 70 mmHg or less, or an oxygen saturation of 92% or less were included.
Measurements: Rapid BNP and proBNP assays, performed blind at admission, were compared with the final diagnosis (CPE or no CPE) as defined by an expert team.
Results: Two hundred two patients (mean age±standard deviation 80±9) were included; 88 (44%) had CPE. There was a strong correlation between proBNP and BNP values (correlation coefficient=0.91, P<.001). The median BNP and proBNP were higher in the group of patients with CPE (377 vs 74 pg/mL, P<.001, and 3,851 vs 495 pg/mL, P<.001, respectively). The best threshold values of BNP and proBNP were 250 pg/mL and 1,500 pg/mL, respectively. The area under the receiver operating characteristic curve was greater with BNP than with proBNP (0.85 vs 0.80, P<.05). BNP assay was more accurate in diagnosis than the emergency physician, whereas proBNP was not. Higher values of BNP and proBNP were associated with greater in‐hospital mortality.
Conclusion: BNP assay is a more useful diagnostic indicator for CPE than proBNP in patients aged 65 and older.
Background Knowledge gaps across literature prevent current guidelines from providing the profile of elderly patients most likely to derive benefit fi~om invasive strategy （IS） in non ST-elevation ...myocardial infarction （NSTEMI）. Furthermore, the benefit of IS in a real-world elderly population with NSTEMI remains unclear. The aims of this study were to determine factors that lead the cardiologist to opt for an IS in elderly patients with NSTEMI, and to assess the impact of IS on the 6-month all-cause mortality. Methods This multicenter prospective study enrolled all consecutive patients aged 〉 75 years old who presented a NSTEMI and were hospitalized in cardiology intensive care unit between February 2014 and February 2015. Patients were compared on the basis of reperfusion strategy （invasive or conservative） and living status at six months, in order to determine multivariate predictors of the realization of an IS and multivariate predictors of 6-month mor- tality. Results A total of 141 patients were included; 87 （62%） underwent an IS. The strongest independent determinants of IS were younger age odds ratio （OR）： 0.85, 95%-confidence interval （CI）： 0.78-0.92; P 〈 0.001） and lower ＂Cumulative Illness Rating Scale-Geriatric＂ number of categories score （OR： 0.83, 95%CI： 0.73-0.95; P = 0.002）. IS was not significantly associated with 6-month survival （OR： 0.80, 95%CI： 0.27-2.38; P = 0.69）. Conclusions In real-world elderly patients with NSTEMI, younger patients with fewer comorbidities profited more often from an IS. However, IS did not modify 6-month all-cause mortality.
Cardiac asthma is common, but has been poorly investigated. The objective was to compare the characteristics and outcome of cardiac asthma with that of classical congestive heart failure (CHF) in ...elderly patients.
Prospective study in an 1,800-bed teaching hospital.
Two hundred and twelve consecutive patients aged > or = 65 years presenting with dyspnea due to CHF (mean age of 82 +/- 8 years) were included. Findings of cardiac echocardiography and natriuretic peptides levels were used to confirm CHF. Cardiac asthma patients were defined as a patient with CHF and wheezing reported by attending physician upon admission to the emergency department. The CHF group (n = 137) and the cardiac asthma group (n = 75), differed for tobacco use (34% vs. 59%, p < 0.05), history of chronic obstructive pulmonary disease (16% vs. 47%, p < 0.05), peripheral arterial disease (10% vs. 24%, p < 0.05). Patients with cardiac asthma had a significantly lower pH (7.38 +/- 0.08 vs. 7.43 +/- 0.06, p < 0.05), and a higher PaCO2 (47 +/- 15 vs. 41 +/- 11 mmHg, p < 0.05) at admission. In the cardiac asthma group, patients had greater distal airway obstruction: forced expiratory volume in 1 second of 1.09 vs. 1.33 Liter (p < 0.05), and a forced expiratory flow at 25% to 75% of vital capacity of 0.76 vs. 0.99 Liter (p < 0.05). The in-hospital (23% vs. 19%) and one year mortality (48% vs. 43%) rates were similar.
Patients with cardiac asthma represented one third of CHF in elderly patients. They were more hypercapnic and experienced more distal airway obstruction. However, outcomes were similar.
αβ CD8
, γδ, and NK lymphocytes are fundamental effector cells against viruses and tumors. These cells can be divided into multiple subsets according to their phenotype. Based on progressive telomere ...attrition from naive to late effector memory cells, human CD8
T cell subsets have been positioned along a pathway of differentiation, which is also considered as a process of lymphocyte aging or senescence. A similar categorization has not been clearly established for γδ and NK cell populations. Moreover, the distinction between the aging of these populations due to cellular differentiation or due to the chronological age of the donor has not been formally considered. In this study, we performed systematic measurements of telomere length and telomerase activity in human αβ CD8
, γδ, and NK lymphocytes based on subset division and across age to address these points and better understand the dichotomy between differentiation and temporal aging. This approach enables us to position phenotypically distinct γδ or NK subsets along a putative pathway of differentiation, such as for CD8
T cells. Moreover, our data show that both cellular differentiation and donor aging have profound but independent effects on telomere length and telomerase activity of lymphocyte subpopulations, implying distinct mechanisms and consequences on the immune system.
HIV infection has become a chronic disease, with a lower mortality, but a consequent increase in age-related noninfectious comorbidities. Metabolic disorders have been linked to the effect of cART as ...well to the effects of immune activation and chronic inflammation. Whereas it is known that aging is intrinsically associated with hyperinflammation and immune system deterioration, the relative impact of chronic HIV infection on such inflammatory and immune activation has not yet been studied focusing on an elderly HIV-infected population.The objectives of the study were to assess 29 blood markers of immune activation and inflammation using an ultrasensitive technique, in HIV-infected patients aged ≥75 years with no or 1 comorbidity (among hypertension, renal disease, neoplasia, diabetes mellitus, cardiovascular disease, stroke, dyslipidemia, and osteoporosis), in comparison with age-adjusted HIV-uninfected individuals to identify whether biomarkers were associated with comorbidities. Wilcoxon nonparametric tests were used to compare the levels of each marker between control and HIV groups; logistic regression to identify biomarkers associated to comorbidity in the HIV group and principal component analysis (PCA) to determine clusters associated with a group or a specific comorbidity.A total of 111 HIV-infected subjects were included from the Dat'AIDS cohort and compared to 63 HIV-uninfected controls. In the HIV-infected group, 4 biomarkers were associated with the risk of developing a comorbidity: monocyte chemoattractant protein-1 (MCP-1), neurofilament light chain (NF-L), neopterin, and soluble CD14. Six biomarkers (interleukin IL-1B, IL-7, IL-18, neopterin, sCD14, and fatty acid-binding protein) were significantly higher in the HIV-infected group compared to the control group, 11 biomarkers (myeloperoxydase, interleukin-1 receptor antagonist, tumor necrosis factor receptor 1, interferon-gamma, MCP-1, tumor necrosis factor receptor 2, IL-22, ultra sensitivity C-reactive protein, fibrinogen, IL-6, and NF-L) were lower. Despite those differences, PCA to determine clusters associated with a group or a specific comorbidity did not reveal clustering nor between healthy control and HIV-infected patients neither between the presence of comorbidity within HIV-infected group.In this highly selected geriatric HIV population, HIV infection does not seem to have an additional impact on age-related inflammation and immune disorder. Close monitoring could have led to optimize prevention and treatment of comorbidities, and have limited both immune activation and inflammation in the aging HIV population.
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