Favorable results of implantable cardioverter-defibrillator implantation in patients older than 70 years

BACKGROUND: The clinical results of implantable cardioverter-defibrillator (ICD) implantation in the elderly have received limited documentation. As the longevity of the U.S. population has increased, so has the need for ICD implantation in the elderly. We evaluated the efficacy and outcome of ICD implantation in elderly patients (>70 years) compared with younger patients. METHODS: The case records of all consecutive patients who underwent ICD implantation at our institution between 1986 and 1994 were reviewed. Of a total of 238 patients, 78 patients were 70 years of age or older and 160 patients were younger than 70 years of age. RESULTS: The mean age of the younger group was 58 years and that of the elderly group was 74 years. There were no statistical differences in the presence of coronary artery disease, left ventricular systolic function, the inducibility of arrhythmias, or the history of sudden cardiac death. The hospital morbidity rate was similar in both groups (6.9% in the younger group and 7.7% in the elderly group; p = not significant). The operative mortality rate was 1.9% for the younger group and 1.3% for the elderly group (p = not significant). At a mean follow-up of 33 +/- 26 months, Kaplan-Meier survival curves demonstrated similar survival rates, with 93%, 82%, and 65% of the patients alive at 1, 3, and 6 years, respectively. CONCLUSIONS: Implantable cardioverter-defibrillator implantation was equally effective in the treatment of patients older than 70 years as in younger patients. No differences in theoretic survival or morbidity were observed.     

Long-term prognosis of young patients after myocardial infarction in the thrombolytic era

BACKGROUND: Myocardial infarction (MI) in young adults is a rare event. In the Framingham study, the 10-year incidence rate of MI per 1,000 was 12.9 in men 30-34 years old. Overall, 4-8% of patients with acute MI are < or = 40 years old. HYPOTHESIS: It was the purpose of this study to assess the in-hospital and long-term morbidity and mortality in patients < or = 40 years old with acute myocardial infarction compared with older patients in the thrombolytic era. METHODS: A consecutive series of 75 patients aged < or = 40 years (mean 35.0 +/- 4.8) with acute myocardial infarction was compared with an equally sized group of patients aged > 40 years (mean 65.1 +/- 9.8). RESULTS: Thrombolysis or direct percutaneous transluminal coronary angioplasty was performed in 52 versus 24% (p = 0.0004) and 5.3 versus 2.7% (p = NS) in younger and older patients, respectively. Significantly fewer young patients had multivessel disease (28 vs. 64%, p < 0.004). No in-hospital mortality was observed in patients with reperfusion therapy irrespective of age. After a mean followup time of 47 +/- 35 months, cardiac mortality was 0 and 11% (p < 0.03), respectively, in young and older patients with, and 3 versus 24% (p < 0.02) without reperfusion therapy, respectively. In addition, significantly fewer patients in the younger age group developed recurrent angina pectoris (12 vs. 39%, p = 0.0004) or congestive heart failure (9 vs. 34%, p = 0.0005) irrespective of reperfusion therapy. CONCLUSION: Our observations demonstrate that long-term prognosis after myocardial infarction in young patients is excellent in the thrombolytic era.     

Does aqueous humor secretion decrease with age?

Aqueous humor flow was calculated during day-time in 148 healthy volunteers and 75 older patients using the Fluorotron Master II anterior chamber protocol (Coherent, Palo Alto, USA). Healthy volunteers as well as patients had no history of ocular pathology, surgery or laser treatment. Slitlamp examination revealed no ocular pathology. Hypertension, diabetes, local and systemic drug therapy, neoplasia, kidney or liver disease, contact lens and ocular trauma were excluded. Mean age of volunteers was 26.5 +/- 3.8 years; age of patients: 65.5 +/- 10.5 years. Aqueous humor flow during day-time in healthy volunteers in the OD: (mean +/- s.d.) 2.26 +/- 1.0 microliters/min, in the OS: 2.17 +/- 1.0 microliters/min, OS: 1.86 +/- 1.1 Ml/min. Correlation coefficient: r = 0.8. The mean aqueous humor flow in the older patients during day-time: OD: 1.91 +/- 1.1 microliters/min. Correlation coefficient: r = 0.54. The Mann-Whitney-U-test revealed a significant difference when comparing the right eyes of healthy volunteers with the right eyes of patients (p < 0.01). When comparing all left eyes the difference is also significant (p = 0.01). The results of the study underline, that the mean aqueous humor secretion does significantly decrease with age. However, the data show that there is only a slight decrease of flow of approximately 2.5% per decade. From the clinical point of view it should be concluded, that although the aqueous humor secretion does decrease with age, this is not of clinical importance, even in cases of glaucoma surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Determinants of survival in pulmonary Langerhans' cell granulomatosis (histiocytosis X). Groupe d'Etude en Pathologie Interstitielle de la Société de Pathologie Thoracique du Nord

The course of pulmonary Langerhans' cell granulomatosis (pulmonary LCG) is variable, difficult to predict and ranges from spontaneous remission to progressive respiratory insufficiency and death. To identify the determinants of survival, we performed a survival analysis on 45 patients with pulmonary LCG. The patients were aged 28 +/- 10 yrs (mean +/- SD) (range 12-62 yrs), 32 males and 13 females, almost exclusively current smokers (96%), and 78% presented symptoms at the time of diagnosis. Diagnosis was made by lung biopsy in 25 patients (56%) and by bronchoalveolar lavage (BAL) analysis in 20 patients (44%). The patients were followed for a median period of 6 yrs (range 1-29 yrs) after the diagnosis. During the period of observation, 33 (73%) patients survived (median follow-up period = 5.8 yrs; range, 1-29 yrs) and 12 (27%) died or underwent lung transplantation (median follow-up period = 8.4 yrs; range 1.4 - 16.1 yrs). The median survival was approximately 13 years. A univariate analysis demonstrated that diminished survival was significantly associated with: an older age at diagnosis (p = 0.0001); a lower forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio at diagnosis (p = 0.005); a higher residual volume/total lung volume (RV/TLC) ratio at diagnosis (p = 0.02); and steroid therapy during follow-up (p = 0.03). Additional predictive information on mortality was: age > 26 yrs (sensitivity 83%, specificity 64%); FEV1/FVC ratio < 0.66 (sensitivity 75%, specificity 86%); and a RV/TLC ratio > 0.33 (sensitivity 75%, specificity 63%). In multivariate Cox analysis, the combination of factors which gave the best prognostic value was FEV1/FVC ratio and age (p < 0.01). The present findings suggest that adverse prognosis factors at diagnosis in pulmonary Langerhans' cell granulomatosis include older age, lower FEV1/FVC ratio and higher RV/TLC ratio, with additional predictive information on mortality if aged > 26 yrs, FEV1/FVC ratio < 0.66, and RV/TLC ratio > 0.33.     

Heart transplantation in patients over 54 years of age. Mortality, morbidity and quality of life

AIMS: As a consequence of recent advances in heart transplantation, upper age limits for the procedure have been liberalized in many centres. It was the purpose of this study to compare post-transplant mortality, morbidity and quality of life in a consecutive series of 72 patients > 54 years (mean age, 57.6 +/- 2.7 years) with a control group of 72 adult patients < or = 54 years (mean age, 42.4 +/- 9.5 years) transplanted at one centre between 1985 and 1991. METHODS AND RESULTS: Patients were followed for 41 +/- 27 months post-transplant. Actuarial 1-, 5- and 7-year survival rates were 78 +/- 5%, vs 81 +/- 5%, 52 +/- 7% vs 66 +/- 6% and 46 +/- 8% vs 63 +/- 6% in patients > 54 years and < or = 54 years, respectively (P = ns). Causes of death were not significantly different between the groups. Patients > 54 years experienced significantly fewer rejection episodes after the 6th month post-transplant (0.5 +/- 0.9 vs 0.9 +/- 1.0, P < 0.04), and incidence and treatment of rejection episodes as well as incidence of infection was comparable between the groups. Non-lymphoid malignancies, mainly skin cancer, occurred more often in the older age group (27% vs 13%, P < 0.05). Quality of life, as assessed by the Nottingham Health Profile, was better in 5/6 dimensions of social functioning in older patients and the difference reached statistical significance for the dimensions of emotional reactions (P = 0.005) and sleep (P = 0.0005). CONCLUSION: In conclusion, carefully selected patients > 54 years can undergo heart transplantation with mortality and morbidity comparable to younger patients. Quality of life post-transplant seems even to be slightly better in the older age group.     

Changes in visual acuity in a population. The Beaver Dam Eye Study

PURPOSE: To describe the change in visual acuity over a 5-year period in persons participating in a large population-based study. METHODS: Best-corrected visual acuity was measured, after refraction, with logMAR charts using a modification of the Early Treatment Diabetic Retinopathy Study protocol in 3684 persons living in Beaver Dam, Wisconsin, who ranged in age from 43 to 86 years at the time of a baseline examination from 1988 to 1990, and at a follow-up examination from 1993 to 1995. RESULTS: The change in the number of letters read correctly over the 5-year period varied from 0.4 +/- 4.9 (mean +/- standard deviation) in people between 43 and 54 years of age to -5.2 +/- 15.4 in people 75 years of age or older at baseline. Over the 5-year period, vision became impaired (20/40 or worse in the better eye) in 2.9% of the population and severely impaired (20/200 or worse in the better eye) in 0.3%. The visual angle doubled in 1.7% of the population, and 2.4% had improved vision. People 75 years of age or older at baseline were 12.5 times (95% confidence interval [Cl], 8.6-18.2; P < 0.001) more likely to have impaired vision, 9.7 times (95% Cl, 5.9-16.0; P < 0.001) more likely to have doubling of the visual angle, and 78 times more likely (95% Cl, 9.9-614.1; P < 0.001) to have severe visual impairment than people younger than 75 years of age at baseline. People 75 years of age or older who were living in nursing homes or group homes were 3.8 times more likely to have impaired vision, 3.3 times more likely to have severely impaired vision, and 5.7 times more likely to have a doubling of the visual angle than those not residing in a nursing home or a group home. CONCLUSION: These data provide precise population-based estimates of incidence of visual loss over a wide spectrum of ages and show that decreased visual acuity in people 75 years of age is a common finding, especially in those who are in nursing homes or group homes.     

Four-year follow-up of patients undergoing percutaneous balloon mitral commissurotomy. A report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry

OBJECTIVES: This study reports the long-term outcome of patients undergoing percutaneous balloon mitral commissurotomy who were enrolled in the National Heart, Lung, and Blood Institute (NHLBI) Balloon Valvuloplasty Registry. BACKGROUND: The NHLBI established the multicenter Balloon Valvuloplasty Registry in November 1987 to assess both short- and long-term safety and efficiency of percutaneous balloon mitral commissurotomy. METHODS: Between November 1987 and October 1989, 736 patients > or = 18 years old underwent percutaneous balloon mitral commissurotomy at 23 registry sites in North America. The maximal follow-up period was 5.2 years. RESULTS: The actuarial survival rate was 93 +/- 1% (mean +/- SD), 90 +/- 1.2%, 87 +/- 1.4% and 84 +/- 1.6% at 1, 2, 3 and 4 years, respectively. Eighty percent of the patients were alive and free of mitral surgery or repeat balloon mitral commissurotomy at 1 year. The event-free survival rate was 80 +/- 1.5% at 1 year, 71 +/- 1.7% at 2 years, 66 +/- 1.8% at 3 years and 60 +/- 2.0% at 4 years. Important univariable predictors of actuarial mortality at 4 years included age > 70 years (51% survival), New York Heart Association functional class IV (41% survival) and baseline echocardiographic score > 12 (24% survival). Multivariable predictors of mortality included functional class IV, higher echocardiographic score and higher postprocedural pulmonary artery systolic and left ventricular end-diastolic pressures (p < 0.01). CONCLUSIONS: Percutaneous balloon mitral commissurotomy has a favorable effect on the hemodynamic variables of mitral stenosis, and long-term follow-up data suggest that it is a viable alternative with respect to surgical commissurotomy in selected patients.     

Urodynamic assessment of patients with acute urinary retention: is treatment failure after prostatectomy predictable?

PURPOSE: Some patients with acute urinary retention due to benign prostatic hyperplasia do not have successful outcome after prostatectomy and require either a chronic indwelling urethral catheter or clean intermittent catheterization. Urodynamic and clinical parameters were examined preoperatively in 81 men 56 to 93 years old (mean age 72 years) in search of an outcome predictor after prostatectomy. MATERIALS AND METHODS: International Prostate Symptom Score, prostate volume, retention episodes, retention volume and urodynamic parameters from a multichannel pressure-flow study were analyzed preoperatively and postoperatively. All patients underwent transurethral prostatectomy and were reexamined 2, 4, 12 and 24 weeks after surgery. A multichannel pressure-flow study was performed preoperatively and 12 weeks postoperatively. RESULTS: At 24 weeks postoperatively 11 patients (13%) were unable to void and therefore classified as treatment failures while the remaining patients voided spontaneously and were classified as treatment successes. There were statistically significant differences (p < 0.005) between treatment failure and treatment success regarding age (83.5 +/- 7 versus 70.1 +/- 8 years), preoperative volume of retention (1,780 versus 1,080 ml.), and maximal detrusor pressure (24.4 versus 73.5 cm. water), but not to International Prostate Symptom Score, episodes of retention and prostate volume. The ability to void during preoperative pressure flow study and the presence of detrusor instability predicted good outcome. In treatment success patients postoperative urodynamic data showed significant decrease in detrusor pressure at maximum flow rate (from 80.8 +/- 33 to 34.6 +/- 10 cm. water). Those with treatment failure had an increase in maximal detrusor pressure (from 26 +/- 12 to 42.6 +/- 13 cm. water), suggesting detrusor recovery. CONCLUSIONS: Patients with acute urinary retention, age 80 years or older, with retention volume greater than 1,500 ml., no evidence of instability and maximal detrusor pressure less than 28 cm. water are at high risk of treatment failure. However, despite treatment failure the detrusor may recover in patients younger than 80. Therefore, prostatectomy should still be performed in this group (less than 80 years old) even if preoperative urodynamics suggest an unfavorable outcome.     

Isolation of a pentraxin-like protein from rainbow trout serum

To investigate the outcome of Graves' thyrotoxicosis after antithyroid drug management, data from 81 patients, treated in Chang Gung Memorial Hospital at Taipei and Linkou from October 1981 to March 1990, were analyzed. The gender ratio of female to male was 59:22. The mean age of onset was 33.1 +/- 10.5(15-60) year-old. All the patients were treated with antithyroid drug (Thionamide group) for a duration of 11 to 63 months (mean +/- SD = 28.1 +/- 9.8 months). Forty of 81 patients (49.4%) were remained remission after up to 2 years of follow-up. Those patients relapse usually occurred within 2 years after discontinuation of treatment (34/41), and only one exceptional case relapsed after 3 years. Three conditions affected the relapse rate. Patients with larger goiter (grade II-III) and shorter duration of treatment (< 23 months) had a higher relapse rate than those-with smaller goiter (grade O-I) [29/46 vs. 12/35; chi 2 = 6.576, p = 0.010; p = 0.015 in stepwise logistic regression (LR)] and longer duration of treatment (> or = 23 months) (15/20 vs. 26/61; chi 2 = 6.316, p = 0.012; p = 0.020 in LR). Patients with higher pre-treated serum triiodothyronine (T3) level (T3 > or = 300 ng/dl) had a higher relapse rate than those with lower T3 level (T3 < 300 ng/dl) in univariate analysis (30/50 vs. 11/31, chi 2 = 4.601, p = 0.032), but no significant difference by LR (P = 0.094). Other clinical parameters including age, sex, past history, family history, thyroxine (T4) level, T3/T4 ratio, thyroid autoantibodies, staging of ophthalmopathy, responsiveness to thyrotropin-releasing hormone stimulation test at the end of treatment, and whether combined treatment with thyroxine had no significant difference between the relapse and remission groups. These data suggest: (a) patients with larger goiter (grade II-III had higher relapse rate; (b) most of the recurrent thyrotoxicosis patients relapsed within two years after drug withdrawal; (c) continuing treatment for more than twenty-three months produces better outcome; (d) patients with Graves' thyrotoxicosis should be followed up for at least three years after withdrawal of antithyroid drug.     

The medtronic intact porcine valve: ten-year clinical review

OBJECTIVE: Our objective was to assess the long-term mortality and morbidity associated with the Medtronic Intact valve (Medtronic, Inc, Minneapolis, Minn). METHOD: Between 1983 and 1996, 447 patients (280 men and 167 women) received 466 Intact valves: 280 aortic, 156 mitral, and 30 tricuspid. The mean age was 57 years (median 63 years), with 45% younger than 60 years. The mean New York Heart Association class was 3.1. The follow-up was 98% complete and extended for 39 months (1-154 months) and 1324 patient-years. There were 32 valves at risk at 10 years after implantation. Doppler echocardiography was performed whenever possible in patients followed up for longer than 4 years (mean 8 years) after implantation. RESULTS: Ten-year overall actuarial survival was 30% +/- 6% (14% +/- 7% for New York Heart Association classes IV-V and 39% +/- 8% for classes I-III). At 10 years freedom from infective endocarditis was 92% +/- 3%, freedom from thromboembolism was 80% +/- 5%, and freedom from nonstructural valve deterioration was 95% +/- 2%. Ten-year freedom from explantation was 64% +/- 6%, freedom from valve-related events was 51% +/- 6%, and freedom from valve-related death was 88% +/- 3%. There were 26 examples of structural valve deterioration, mainly caused by leaflet calcification (in 17 cases) and by buttress detachment (in 6 cases). In the aortic position at 10 years freedom from structural valve deterioration was 81% +/- 9%, but with only 1 event in patients older than 40 years (freedom 92% +/- 8%) and 100% freedom in patients older than 60 years. There was also 100% freedom from structural valve deterioration in the tricuspid position. In the mitral position freedom was 65% +/- 8%, with no significant difference between age groups. CONCLUSION: The Intact valve provides superior results in the aortic position in patients older than 40 years and in the tricuspid position at all ages.     

Hemi-arthroplasty--primary or secondary measure for 3- and 4-fragment fractures of the proximal humerus in the elderly?

Successful treatment of three- and four-part proximal humerus fractures is a therapeutic challenge to the surgeon, particularly in the case of elderly patients. Open reduction and internal fixation have been advocated, but have not consistently produced acceptable results. The results of humeral head replacement as a salvage procedure after non-union or failed open reduction and internal fixation are less predictable. The outcome of hemiarthroplasty (Neer II) performed for three- and four-part proximal humerus fractures in elderly patients was studied. The average patient follow-up was 42.9 months (range 5-98). Eighteen women and eight men with an average age of 64.5 years were evaluated according to the UCLA. Constant-Murley and HSS Score. A Visual Score (0-100 points) was also used. Hemiarthroplasty was performed in 11 patients within 4 weeks of trauma and in 15 patients after 4 weeks. Fair, good, or excellent results were achieved in 80% (UCLA and Visual), 73% (HSS) and 46% (Constant-Murley) of the patients, respectively. Ninety-six percent of the patients reported only slight or no pain. The range of motion was limited in almost all cases. The outcome was not significantly influenced by age, sex and follow-up time. However, there was a significant correlation between the outcome and the length of time between injury and humeral head replacement (r = -0.5). The outcome after early hemiarthroplasty was better than after late humeral head replacement (UCLA: 27.1 +/- 4.6 vs 22.5 +/- 5.6 P = 0.04; Constant-Murley: 65.6 +/- 18.5 vs 47.5 +/- 18.6, P = 0.02; HSS: 74.0 +/- 14.4 vs 63.5 +/- 17.6, P = 0.17). Self-assessment did not differ between these two groups. After early hemiarthroplasty, active forward flexion was significantly better. This study indicates that early humeral head replacement for three- and four-part proximal humerus fractures in elderly patients achieved better functional outcome than delayed humeral head replacement. The decision to perform prosthetic humeral head replacement in these cases should be made as early as possible after trauma.     

Veterinary ethics in the liberalized market: the Zambian environment

BACKGROUND: This study was performed to assess the functional capacity of the survivors of septal myectomy for the treatment of hypertrophic obstructive cardiomyopathy in long-term follow-up as assessed by dobutamine stress echocardiography. METHODS: Sixty-nine patients with hypertrophic obstructive cardiomyopathy underwent septal myectomy between 1975 and 1996. The mean age was 25.4 +/- 13.6 years (range, 6-58 years), and 10 of the patients were women. The early mortality was 4.3%. Hospital survivors (95.7%) were followed up for a mean of 43.8 +/- 28.7 months (range, 6-114 months). RESULTS: The postoperative mean functional capacity of the group was 1.47 +/- 0.56. No late deaths were reported. Forty-nine patients (74.2%) were evaluated with standard echocardiographic techniques, and 29 (43.9%) patients underwent dobutamine stress echocardiography. There was a significant decrease in the thickness of the interventricular septum after surgery. The mean preoperative and postoperative septal thickness was 1.99 +/- 0.59 cm (range, 1.3-3.8 cm) and 1.55 +/- 0.41 cm (range, 0.96-2.8 cm), respectively (p < 0.004). The mean posterior wall thickness was significantly less than the preoperative value (p = 0.008) and the left ventricular end-diastolic diameter was slightly greater in the postoperative measurements, but the difference was not significant (p = 0.162). Postoperative left ventricular outflow systolic gradients were reduced significantly when compared with preoperative values (preoperative mean, 78.4 +/- 33.6 mm Hg, range, 50-212 mm Hg versus postoperative mean, 17.9 +/- 15.9 mm Hg: range, 0-40 mm Hg; p < 0.0001). CONCLUSION: Septal myectomy for patients with hypertrophic obstructive cardiomyopathy is a safe procedure with excellent clinical and functional results in the long-term follow-up.     

Outcome of cardiac valve ring abscesses after medical treatment: attempt to identify criteria of favorable prognosis

OBJECTIVES: Identify factors predicting favorable outcome after medical management of valve ring abscesses in order to propose a surveillance schedule for conservative treatment. METHODS: A multicentric study conducted from July 1989 to February 1996 included 28 patients (mean age 64 +/- 16 years, range 26-83) hospitalized for active endocarditis and valve ring abscesses diagnosed at transthoracic or transesophageal echography. Conservative medical therapy was given because of a decision of the medico-surgical team (n = 9), high surgical risk (n = 12), or patient refusal of surgery (n = 7). Outcome was favourable in 18 patients (Group I) and unfavorable in 10 (Group II) due to death (n = 9) or subsequent surgery (n = 1). Univariate and multivariate analysis were used to determine differences between the groups in terms of clinical and laboratory data. RESULTS: Mean follow-up in Group I was 33 +/- 18 months and 15 +/- 10 months in Group II. Univariate analysis showed significant differences between Group I and II respectively for age (59 +/- 18 yr vs 72 +/- 10, p = 0.04), delay to apyrexia after antibiotics (4.3 +/- 2.8 vs 8.3 +/- 2.4 days, p < 0.0008), heart failure (5% vs 70%, p = 0.003), grade III or IV valvular regurgitation (5% vs 60%, p < 0.04), and mean surface area of the abscess (1.5 +/- 1.2 vs 5.4 +/- 6.4 cm2, p < 0.03). Independent factors at multivariate analysis were by decreasing order: lack of heart failure at admission, delay to apyrexia, abscess surface area, and age. Outcome was favorable (mean follow-up 33 +/- 10 months) in all patients with an abscess surface area < 1.5 cm2, no signs of heart failure, no grade III or IV valvular regurgitation, apyrexia after less than 8 days on antibiotics and no staphylococcus positive blood culture. CONCLUSION: Medical management of valve ring abscesses may be indicated in selected patients in care units with rigorous surveillance facilities. Further studies are needed to precisely identify surveillance and treatment criteria.     

Survival 15 to 20 years after coronary bypass surgery for angina

OBJECTIVES: The aim of this study was to determine the 15- to 20-year outcome of coronary bypass surgery in patients with angina. BACKGROUND: Coronary bypass surgery has been performed for > 20 years; we need to know the expected outcome of a very long-term follow-up. METHODS: Using actuarial techniques, we determined the outcome of coronary bypass surgery performed for chronic stable and unstable angina in 7,529 patients from 1969 to 1988. RESULTS: The 5-, 10-, 15- and 20-year survival rates (mean +/- SE) were 88 +/- 1, 73 +/- 1, 53 +/- 1 and 38 +/- 3%, respectively, for the whole group. Compared with patients operated on in 1974 to 1988 (n = 7,026), patients operated on in 1969 to 1973 (n = 503) were younger and had less coronary artery disease but had a higher operative mortality rate and a shorter long-term survival time; 15- and 20-year survival of the 1969 to 1973 cohort was 47 +/- 2% and 33 +/- 3%, respectively. The 1974 to 1988 cohort of patients had a 2.1% operative mortality rate and a 10- and 15-year survival probability of 74 +/- 1% and 55 +/- 2%, respectively. For 2,128 patients with "normal" left ventricular function, the 10- and 15-year survival probability was 82 +/- 1% and 64 +/- 3%, respectively, and for 2,413 patients with "abnormal" left ventricular function, it was 66 +/- 1% and 47 +/- 3%, respectively (p < 0.0001); for men it was 74 +/- 1% and 56 +/- 2%, respectively, and for women, 70 +/- 2% and 52 +/- 5%, respectively, p < 0.05. The actuarial percentages of reoperation and myocardial infarction at 15 years were 33 +/- 2% and 26 +/- 2%, respectively; these values did not differ significantly between men and women. There was a significant (p < 0.001) difference between men and women in angina status; 81% of the men versus 74% of the women had no angina or mild angina at the most recent follow-up study. CONCLUSIONS: Coronary bypass surgery is an effective form of therapy for angina (for 15 to 20 years) in both men and women.     

Carotid artery occlusion due to bacterial paranasal sinusitis

BACKGROUND: Many experts have suggested that blunt splenic trauma in patients older than 55 years should not be managed by observation because of supposed increased fragility of the spleen and decreased physiologic reserve in elderly patients. We sought to determine the outcome of nonoperative management of blunt splenic trauma in patients older than 55 years. METHODS: For the years 1994 through 1996, data for patients with splenic injury older than 55 years from seven trauma centers in a single state were reviewed. RESULTS: Blunt splenic trauma occurred in 41 patients older than 55 years. Eight patients were excluded from further analysis because of death from massive associated injuries within 24 hours of admission. The remaining 33 patients (mean age, 72+/-10 years) were divided into two groups: immediate exploration (10 patients) and observation (23 patients). Observation of blunt splenic injury failed in 4 of 23 patients (17%). No patient deaths were related to the method of management of the splenic injury. CONCLUSIONS: Observation of the elderly patient with blunt splenic trauma has an acceptable failure rate of 17%.     

Zinc dependent activation of cAMP-specific phosphodiesterase (PDE4A)

OBJECTIVES: This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system. BACKGROUND: Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome. METHODS: One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo Clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up. RESULTS: The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score < or = 8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 +/- 6% vs. 67 +/- 8%, p = 0.07) and free of all events combined (75 +/- 6% vs. 64 +/- 8%, p = 0.07) versus those patients with a score > 8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 +/- 4% vs. 40 +/- 4%) and free of all events combined (82 +/- 5% vs. 38 +/- 10%) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01). CONCLUSIONS: The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.     

Comparison of outcome of primary PTCA for acute myocardial infarction in patients younger and older than 70 years of age

BACKGROUND: The Primary Angioplasty in Myocardial infarction Study Group reported that the benefit of primary PTCA was observed mainly among patients who were classified as "not low risk" including those over age 70, with anterior infarction and heart rate > 100 bpm. The present study compares procedural success rate and in-hospital and one-month clinical outcome of primary PTCA in acute myocardial infarction patients < 70 and > or = 70 years of age. METHODS AND RESULTS: During 1995 121 patients with acute myocardial infarction underwent primary PTCA within 6 hours of symptoms onset or within 24 hours in case of evidence of ongoing ischemia. Eighty-two patients (Group I) were < 70 (mean age 56 +/- 9) and 39 patients (Group II) were > or = 70 (mean age 75 +/- 3). In group II there was a trend, although not significant, toward a higher prevalence of prior angina and infarction. Multivessel disease was more frequent in group II than in group I (69% vs 48%; p = 0.041). Ejection fraction was markedly depressed in both groups (38 +/- 10% in group I vs 34 +/- 11% in group II). Ejection fraction < or = 30% and shock on admission were more frequent in group II (39% vs 15% and 36% vs 21%, respectively). Optimal angiographic success (< or = 30% stenosis associated with TIMI grade 3 flow) was achieved in 77% of group II and in 98% of group I (p = 0.00059). The in-hospital mortality rate was 26% in group II and 1.2% in group I (p = 0.000042). Shock on admission and PTCA failure predicted high mortality rates. There was no difference between the two groups as regards to non-fatal reinfarction, recurrent ischemia, life-threatening arrhythmias, severe heart failure, revascularization procedures. There were no strokes. At one-month follow-up, recurrence of ischemia or positive response to stress test were more frequent in group II (24% vs 8%; p = 0.039). CONCLUSIONS: In patients with acute myocardial infarction < 70 years of age primary coronary angioplasty is associated with low rates of mortality and cardiac events. Mortality rate remains high in patients over age 70, especially when shock is present on admission or PTCA falls.     

Delta virus infection in cirrhotics in a north Indian hospital

Forty patients of HBV related cirrhosis of the liver were studied for the presence of delta infection and subsequently the clinical features, course and outcome of these delta infected cases was compared with those of delta uninfected cases. Out of 40 patients studied, only four patients (10%) were reactive for anti-delta antibodies. The incidence of delta infection was common in the younger age group (31.25 +/- 4.78 years) as compared to the older age group (48 +/- 7.25 years) at p < 0.001. Hepatic Encephalopathy was seen in only 13.88% of delta negative patients as compared to 75% of delta infected patients (p < 0.05). During follow up period of 1 year, 75% of patients died in the delta virus infected group as compared to 22.22% in the delta negative group. The mortality was significantly higher in Child's class C (P < 0.01). So delta virus infection is associated with a more severe course of illness and a poorer prognosis in HBV related cirrhotics.     

Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears

The functional outcome after surgery was determined in 21 patients an average of 29 months (range, 24-52 months) after surgery to evaluate the efficacy of arthroscopic repair of triangular fibrocartilage complex (TFCC) tears and ulnar shortening. All of the patients had reparable lesions of the TFCC treated after a delay of more than 6 months from the time of injury. The patients' average age was 32 years and all patients had wrist pain limiting them from work and/or sports prior to surgery. After surgery, there was a significant relief of pain (p < .01). Grip strength and range of motion averaged 83% +/- 18% and 81% +/- 16%, respectively, of that of the uninjured side. At follow-up evaluation, 14 patients with repairs underwent follow-up studies; the TFCC was noted to be intact in 12 patients.     

Intermediate-term outcome of cervical spinal cord-injured patients older than 50 years of age

STUDY DESIGN: This study retrospectively reviewed the intermediate-term clinical outcome of patients who were 50 years of age or older at the time they experienced their cervical spinal cord injury. OBJECTIVES: To establish reasonable expectations for the functional outcome in the older patient with cervical spinal cord injury. BACKGROUND DATA: The long-term morbidity and mortality of large groups of patients with spinal cord injury have been reported. The specific functional ability, disposition, morbidity, and mortality of this group of older patients injured after 50 years of age, however, have been less well defined. METHODS: Forty-one consecutive patients older than 50 years of age at the time of cervical cord injury were studied, and functional abilities, independence, need for assistance in activities of daily living, disposition, morbidity, and mortality were assessed. All patients had more than 2 years of follow-up examinations (mean, 5.5 years) by the same spine injury service. RESULTS: There were 13 complete and 28 incomplete cervical cord lesions. The mean age of the patients at follow-up examination was 67.5 years. The average follow-up period was 5.5 years after injury. None of the patients with complete cord injury improved, and all required extensive care. Twenty-one (80%) of 26 of the patients with incomplete cord injury were able to ambulate with some assistance. Nineteen of 26 patients had independent or near-independent abilities with activities of daily living. Twenty (77%) of 26 were able to return home. All patients with complete cord injury (13 of 13) had died by the time of the follow-up visit. Seventy-seven percent (10 of 13) of this patient group had died within the first year. Those surviving lived an average of 3.5 years after their injury. Fourteen of 28 patients with incomplete cord injury (50%) had died by the time of the follow-up visit. Six (43%) of the 14 deaths were attributed to complications of their spinal cord injury. CONCLUSION: The functional outcome of the person older than 50 years with a complete cervical cord injury is poor. Of the 14% who survived the first year, all required extensive attendant care, and no neurologic improvement was seen. The patient with an incomplete cord injury has an overall good outcome regarding ambulation and returning to home.