Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very elderly patients

BACKGROUND： Acute cholangitis in old people is a cause of mortality and prolonged hospital stay. We evaluated the effects of methods and timing of biliary drainage on the outcomes of acute cholangitis in elderly and very elderly patients. METHODS： We analyzed 331 patients who were older than 75 years and were diagnosed with acute calculous cholangitis. They were admitted to our hospital from 2009 to 2014. Patients＇ demographics, severity grading, methods and timing of biliary drainage, mortality, and hospital stay were retrospectively obtained from medical records. Clinical parameters and outcomes were compared between elderly （75-80 years, n= 156） and very elderly （≥81 years, n=175） patients. We analyzed the effects of methods [none, endoscopic retrograde cholangio- pancreatography （ERCP）, percutaneous transhepatic biliary drainage, or failure] and timing （urgent or early） of biliary drainage on mortality and hospital stay in these patients. RESULTS： Acute cholangitis in older patients manifested as atypical symptoms characterized as infrequent Charcot＇s triad （4.2%） and comorbidity in one-third of the patients. Patients were graded as mild, moderate, and severe cholangitis in 104 （31.4%）, 175 （52.9%）, and 52 （15.7%）, respectively. Urgent bili-ary drainage （≤24 hours） was performed for 80.5% （247/307） of patients. Very elderly patients tended to have more severe grades and were treated with sequential procedures of transient hiliary drainage and stone removal at different sessions. Hospital stay was related to methods and timing of biliary drainage. Mortality was very low （1.5%） and not related to patient age but rather to the success or failure of biliary drainage and severity grading of the acute cholangitis. CONCLUSIONS： The methods and timing used for biliary drainage and severity of cholangitis are the major determinants of mortality and hospital stay in elderly and very elderly patients with acute cholangitis. Urgent successful ERCP is mandatory for favorable prognosis in these patients.

Prevalence and Associated Factors of Diabetes Mellitus in a Very Elderly Chinese Population: A Cross-sectional Study

Objectives This paper aimed to investigate the prevalence of diabetes mellitus(DM)and explore the associated risk factors in a very elderly southwest Chinese population.Methods From September 2015 to June 2016,a cross-sectional survey was conducted to obtain a representative sample of 1,326 participants over 80 years old living in Chengdu.The presence of DM was based on fasting plasma glucose(FPG)and 2-h plasma glucose(2-h PG)levels during an oral glucose tolerance test(OGTT).A logistic regression model was used to calculate the odds ratios(ORs)and 95%confidence intervals(CIs)of the potential associated factors.Results The participants’mean age was 83.5±3.1 years.The overall prevalence of DM was 27.4%.The prevalence was higher in males(30.2%)than females(24.7%)(P=0.02).The prevalence of DM increased with body mass index(BMI)and decreased with aging.The multivariate analysis suggested that male sex(OR=1.433;95%CI,1.116–1.843),hypertension(OR=1.439;95%CI,1.079–1.936),overweight or obesity(OR=1.371;95%CI,1.023–1.834),high heart rate(≥75 beats/min;OR=1.362;95%CI,1.063–1.746),and abdominal obesity(OR=1.615;95%CI,1.216–2.149)were all significantly positively correlated with DM.However,age was negatively correlated with DM(OR=0.952;95%CI,0.916–0.989).Conclusions The prevalence of DM and newly diagnosed DM in a very elderly southwest Chinese population was high.OGTT screening should be performed regularly in people aged≥80 years to ensure timely diagnosis of DM.

Transcatheter aortic valve implantation in very elderly patients： immediate results and medium term follow-up

Objective To evaluate immediate transcatheter aortic valve implantation （TAVI） results and medium-term follow-up in very elderly pa- tients with severe and symptomatic aortic stenosis （AS）. Methods This multicenter, observational and prospective study was carried out in three hospitals. We included consecutive very elderly （〉 85 years） patients with severe AS treated by TAVI. The primary endpoint was to evaluate death rotes from any cause at two years. Results The study included 160 consecutive patients with a mean age of 87 ± 2.1 years （range from 85 to 94 years） and a mean logistic EuroSCORE of 18.8% ± 11.2% with 57 （35.6%） patients scoring 〉 20%. Procedural success rate was 97.5%, with 25 （15.6%） patients experiencing acute complications with major bleeding （the most frequent）. Global mortality rate during hospitalization was 8.8% （n = 14） and 30-day mortality rate was 10% （n = 16）. Median follow up period was 252.24± 232.17 days. During the follow-up period, 28 （17.5%） patients died （17 of them due to cardiac causes）. The estimated two year overall and cardiac survival rates using the Kaplan-Meier method were 71% and 86.4%, respectively. Cox proportional hazard regression showed that the variable EuroSCORE ≥ 20 was the unique vari- able associated with overall mortality. Conclusions TAVI is safe and effective in a selected population of very elderly patients. Our findings support the adoption of this new procedure in this complex group of patients.

Diabetes Mellitus in Very Elderly Russian Patients with Coronary Artery Disease

Background: Conflicting data are available on prevalence and characteristics of diabetes mellitus in very elderly patients and centenarians;therefore, we evaluated features of this pathology in patients with coronary artery disease (CAD) over 75 years old. Material and Methods: 580 patients with CAD over 75 years old were enrolled in the study on the prevalence of diabetes mellitus. 190 patients with CAD and diabetes mellitus were included in the cross-sectional study of the diabetes mellitus characteristics in old age: 153 very elderly patients (mean age—85.7 ± 4.7 years)—in the main group, 37 patients < 70 years old—in the comparison group. Toassess the condition of patients, standard clinical and laboratory methods for coronary artery disease and diabetes mellitus were used. 24-hour plasma glucose profile and hemoglobin A1c (HbA1c) level were evaluated in all patients with diabetes mellitus. Results: Diabetes mellitus or impaired glucose tolerance was found in 22.2% of very elderly patients with CAD. Glucose levels in very elderly diabetic patients were lower at all time points than in patients < 70 years old. The largest differences were recorded for the blood glucose concentration at 6 a.m. (p = 0.00005). Glucosuria was registered in 29.7% of patients aged 51 - 69 years, while among elderly patients—in 11.1% (p = 0.004). The mean levels of HbA1c were 7.3% and 8.7%, respectively (p = 0.01). Correlation analysis revealed negative correlation between the age of patients and the glucose level (r = ?0.4, p = 0.00002—for 6 AM glucose). The mean body mass in-dex in very elderly patients was 30.8 ± 5.8 kg/m2, in patients < 70 years old—33.9 ± 6.5 kg/m2 (p = 0.03). Significant differences between the groups of very elderly and younger patients were registered in terms of triglycerides (1.65 and 3.57 mmol/L, respectively, p < 0.00001), HDL-cholesterol (1.16 and 0.87 mmol/L, respectively, p = 0.03) and ath-erogenic index (3.45 and 6.73, respectively, p = 0.002). Conclusion: The study results indicate that diabetes mellitus is often diagnosed in very elderly patients with CAD. In very elderly patients, lower values of blood glucose, hemoglobin A1c and glucosuria are recorded, compared with younger patients with diabetes mellitus.

Intervention study of finger-movement exercises and finger weight-lift training for improvement of handgrip strength among the very elderly

Objectives:To examine the effects of finger-movement exercises and finger weight-lift training on handgrip strength and Activities of Daily Living Scale(ADLS)values.Methods:A total of 80 very elderly adults(aged
80 years)were assigned to either an intervention group(n?40)or a control group(n?40).Subjects in the intervention group performed finger-movement exercises and weight-lift training for a period of 3 months,while subjects in the control group received no intervention,and were unaware of the interventions received in the other group.Results:After completing 3 months of finger-movement exercises and weight-lift training,the average handgrip strength of the 40 participants in the intervention group had increased by 2.1 kg,whereas that in the control group decreased by 0.27 kg(P<0.05).After receiving intervention,the number of subjects in the intervention group with an ADLS score>22 points decreased by 7.5%(P<0.05,vs.pre-intervention).Conclusions:The combined use interventionwith finger-movement exercises and proper finger weight-lift training improved the handgrip strength andADLS values of very elderly individuals.These rehabilitation exercisesmay be used to help the elderlymaintain their self-care abilities.

The duration of acute kidney injury is an additional parameter to predict1-year survival in very elderly patients

Background:Acute kidney injury(AKI)is primarily defined and classified according to the magnitude of theelevation of serum creatinine(Scr).We aimed to determine whether the duration of AKI adds prognostic valuein addition to that obtained from the magnitude of injury alone.Methods:This retrospective study enrolled very elderly inpatients(≥75 years)in the Chinese PLA General Hospitalfrom January 2007 to December 2018.AKI was stratified by magnitude according to KDIGO stage(1,2,and 3)andduration(1–2 days,3–4 days,5–7 days,and>7 days).The primary outcome was the 1-year mortality after AKI.Multivariable Cox regression analysis was performed to identify covariates associated with the 1-year mortality.The probability of survival was estimated using the Kaplan–Meier method,and curves were compared using thelog-rank test.Results:In total,688 patients were enrolled,with the median age was 88(84–91)years,and the majority(652,94.8%)were male.According to the KDIGO criteria,317 patients(46.1%)had Stage 1 AKI,169(24.6%)hadStage 2 AKI,and 202(29.3%)had Stage 3 AKI.Of the 688 study subjects,61(8.9%)with a duration of AKIlasted 1–2 days,104(15.1%)with a duration of AKI lasted 3–4 days,140(20.3%)with a duration of AKI lasted5–7 days,and 383(55.7%)with a duration of AKI lasted>7 days.Within each stage,a longer duration of AKIwas slightly associated with a higher rate of 1-year mortality.However,within each of the duration categories,the stage of AKI was significantly associated with 1-year mortality.When considered separately in multivariateanalyses,both the duration of AKI(3–4 days:HR=3.184;95%CI:1.733–5.853;P<0.001,5–7 days:HR=1.915;95%CI:1.073–3.416;P=0.028;>7 days:HR=1.766;95%CI:1.017–3.065;P=0.043)and more advanced AKIstage(Stage 2:HR=3.063;95%CI:2.207–4.252;P<0.001;Stage 3:HR=7.333;95%CI:5.274–10.197;P<0.001)were independently associated with an increased risk of 1-year mortality.Conclusions:In very elderly AKI patients,both a higher stage and duration were independently associated withan increased risk of 1-year mortality.Hence,the duration of AKI adds additional information to predict long-termmortality.

Individualized Treatment and Palliative Care for A90-Year-Old Patient with Primary Gastric Diffuse Large-B Cell Lymphoma:4 Year Follow-up and Inspiration

A 90-year-old man was diagnosed with primary gastric diffuse large B-cell lymphoma(PGDLBL)by PET/CT examination,gastroscopy,biopsy and histopathological analysis at a regular physical check in April,2016.The patient received R-CO chemotherapy(rituximab,cyclophosphamide,and vincristine)and radiotherapy subsequently,with enteral nutritional treatment through 3-cavity nasogastric tube due to development of pyloric obstruction.To satisfy patient's strong desire of eating by himself,we performed surgery of exploratory laparotomy and Roux-en-Y gastric bypass(RGB)to relieve pylorus obstruction.Postoperatively,the patient resumed oral feeding,supplemented by nasogastric tube feeding at 1350-1550 Kcal daily.He is now 94 years old with fairly well nutrition and normal communication.The outcome of 4 year follow-up suggests that nutritional treatment and palliative medicine are important for improving prognosis and life-quality of very elderly patients with end-stage tumors apart from the effective chemotherapy,radiotherapy,and surgery.