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Abstract:Because of aging, multimorbidity and comobidities, the organ function reserve declines in elderly critically ill patients who are predisposed to infection, malnutrition, adverse drug reaction and organ injury. It results in very complex situation. Elderly critically ill patients suffer more complications, high incidence of multiple organ dysfunction syndrome, and increased mortality. Clinicians should attach importance to the disease complexity for elderly critically ill patients and take effective measures to improve their coutcome.

Abstract:Objective To investigate the clinical features and treatment efficiency of acute pancreatitis (AP) in the elderly. Methods The clinical data of 164 consecutive elderly patients (elderly group, aged over 60 years) with confirmed AP and 309 non-elderly AP patients (control group, younger than 60 years old) treated in our center in recent 3 years were collected and analyzed retrospectively. The clinical features and treatment efficiency were compared between the 2 groups. Results The most common etiology of AP in the elderly patients was biliary diseases, followed by hyperlipidemia. Compared to control group, the proportion of biliary AP was significantly higher (84.15% vs 59.55%, P＜0.001); meanwhile, the percentage of hyperlipidemic AP was obviously lower (9.14% vs 31.07%, P＜0.001). The main systemic complication was organ failure in both groups (20.12% vs 18.77%, P＞0.05), but the incidence of systemic infection and persistent systemic inflammatory response syndrome was significantly higher in the elderly group than in the control group (P＜0.05), and the incidence of local complications had no statistical difference between the 2 groups (P＞0.05). The incidence of severe AP was similar in the two groups (18.90% vs 18.77%), however, the elderly group had significantly higher mortality (7.93% vs 3.56%, P＜0.05). Conclusion The elderly patients with AP are prone to have systemic complications due to their comorbidities, and then the AP may deteriorate into severe AP with extremely high mortality. Early diagnosis and effective treatment could improve the prognosis of the elderly patients with AP.

Abstract:Objective To investigate the efficacy of vancomycin in the treatment of severe Gram-positive infections in very old patients and determine its effect on renal functions. Methods A total of 48 very old patients (age ≥80 years) with confirmed Gram-positive infection admitted in our geriatric unit from January 2007 to March 2014 were included in this study. They all received venous injection of vancomycin. Pathogen analysis was conducted for all the patients. Their signs and symptoms were observed before and after the treatment, as well as the clinical efficiency. And renal functions were evaluated dynamically during the treatment. Results The course of vancomycin treatment was averagely (18±9)d for the 48 patients, and the clinical efficiency was 72.92%. Among the 48 patients, 39 were infected by Gram-positive cocci in the bacterial culture or in smear test, and a total of 50 isolated strains were obtained. The bacterial clearance rate reached 82.25% after the vancomycin therapy. During the vancomycin treatment, 12 cases had renal toxicity, accounting for 25% of the total cases. Univariate logistic analysis showed that pre-treatment score of Acute Physiology And Chronic Health Evaluation (APACHE) Ⅱ (OR＝1.240, 95% CI: 1.061?1.449, P＝0.007）, mean trough concentration of vancomycin (OR＝1.268, 95% CI: 1.066?1.757, P＝0.014), the combined use of vasopressor agent (stratified into 3 groups, receiving no, small and large doses; OR＝4.33, 95% CI: 1.620?11.598, P＝0.0035), and the combined use of diuretics (stratified into 4 groups according to daily dose of furosemide, that is, ≤40, 41?80, 81?120 and ＞120mg/d; OR＝2.066, 95% CI: 1.189?3.589, P＝0.010) were risk factors for renal toxicity in the cohort during vancomycin treatment. Multivariate logistic regression analysis demonstrated that APACHE Ⅱ score ≥25 points, trough concentrations of vancomycin ≥18mg/L, and the combined use of diuretics (furosemide ≥40mg/d) would increase the risks of renal toxicity in the elderly patients. Conclusion Vancomycin is efficient in the treatment of severe Gram-positive infections in the elderly patients. But for them, the treatment leads to certain risk for renal toxicity, and the pre-treatment APACHE Ⅱ score ≥25 points, trough concentrations of vancomycin ≥18mg/L, and combined use of diuretics (furosemide ≥40mg/d) are independent risk factors for the toxicity.

Abstract:Objective To analyze the features of adverse drug reaction (ADR) in the elderly (＞65 years old) in order to improve its surveillance and coping strategies. Methods All ADR reports in the elderly patients from the First Affiliated Hospital, Nanjing Medical University during the years of 2012 to 2014 in the National Center for ADR Monitoring Database were collected and retrospectively analyzed. Results There were 212 ADR reports in the elderly patients (accounting for 21.3% of the total ADR reports). They were 91 males and 121 females, at an average age of (75.25±6.43)years. Ninety-one ADRs (42.9%) occurred in the outpatient or emergency department, and 114 reports occurred in the non-ICU inpatients. There were totally 98 drugs involved. The most ADRs were caused by anti-infective drugs (30.66%) and central nervous system drugs (26.42%). The common route of administration (86.32%) was venous injection. The system-organs involved by ADR in the cohort were mainly systematic damages (23.10%), and the damages in the skin and its appendages (19.49%). And the most common manifestations were hypersensitivity reactions and rash. Conclusion This study concludes the drugs and administration routes which are more likely to cause ADR and the main signs and symptoms of ADR in the elderly. We should focus on the patients receiving high-risk drugs administration and keep close monitoring during their whole course of medication. Attention should also be paid to the medication safety and the safety of oral drugs in the elderly in outpatient and emergency departments and in those outside a hospital. Due to the presence of uncounted ones, the rate in our report only partially reflects the incidence of ADR in the elderly. ADR surveillance and report for the elderly should be emphasized and strengthened.

Abstract:Objective To analyze the incidence and risk factors of delirium after cardiac surgery in the elderly patients during hospitalization in intensive care unit (ICU). Methods Retrospective study was performed in a total of 117 patients (over 60 years old) undergoing heart surgery in Nanjing Hospital from March to May 2014. The incidence of delirium was documented during hospitalization. Multivariate logistic regression analysis was used to evaluate the related factors. Results Postoperative delirium occurred in 27 out of the 117 patients, with an incidence of 23.08%. Univariate analysis showed that delirium was associated with left ventricular ejection fraction (LVEF), duration of mechanical ventilation, length of stay in ICU, blood transfusions, hyponatremia, hyperkalemia, and score of Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ) (P＜0.05). Based on multivariate logistic analysis, duration of mechanical ventilation (P＝0.022), low LVEF (P＝0.041) and length of stay in ICU (P＝0.031) were closely associated with postoperative delirium. Conclusion Low LVEF, long time of mechanical ventilation, and long stay in ICU are risk factors for delirium in the elderly after cardiac surgery.

Abstract:Objective To explore the risk factors for ventilator-associated pneumonia (VAP) in the patients over 70 years old after heart surgery and investigate the characteristics of the related etiology so as to guide clinical rational use of antimicrobial agents. Methods Clinical data of 33 elderly patients (over 70 years old) with the duration of mechanical ventilation more than 48h after cardiac surgery in our ICU from January 2013 to June 2014 were collected and retrospectively analyzed. The cohort was assigned into VAP and non-AVP groups, and their clinical data were compared and analyzed to screen the risk factors of postoperative VAP, pathogenic bacteria and their sensitive drugs. Results In the 33 patients, there were 16 patients having VAP. Univariate analysis showed that significant differences were seen in the scores of Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ), aorta blocking time, extracorporeal circulation time, mechanical ventilation time and length of ICU hospitalization between the VAP and non-VAP groups (P＜0.01). Multivariate analysis indicated that aorta blocking time and duration of mechanical ventilation were significantly associated with VAP. Among the 19 isolated strains of pathogenic bacteria, most of them were Gram-negative bacilli (84.2%). Klebsiella pneumoniae and Pseudomonas aeruginosa were the most common ones. The incidences of Gram-positive cocci and fungi were quite low. The antibacterial activity of vancomycin was 100% to Gram-positive cocci. Conclusion A variety of risk factors are related to postoperative VAP in the elderly patients after cardiac surgery. We clinicians should improve surgical skills to shorten the duration of mechanical ventilation and aortic cross-clamping time and use antimicrobial agents rationally so as to improve the prognosis of VAP in the elderly after cardiac surgery.

Abstract:Objective To compare the efficiency and complication incidence of the 2 routes of enteral nutrition(EN), through naso-jejunal tube and nasogastric tube, for critically ill elderly patients with swallowing dysfunction in order to explore more safe and effective way of EN. Methods A total of 53 critically ill elderly patients with swallowing dysfunction admitted in our hospital from January 2012 to November 2014 were recruited in this study. They were randomly divided into 2 groups according to different routes of EN, indwelling naso-jejunal tube (n＝31), and indwelling nasogastric tube (n＝22). In 2 weeks after EN, the nutrition indicators, incidences of complications and clinical outcomes were observed and compared between the 2 groups. Results Compared with the patients using nasogastric tube, those with naso-jejunal tube had more significantly elevated prealbumin, and obviously lower incidences of gastrointestinal complications and aspiration pneumonia (P＜0.05). However, no significant difference was seen in mechanical ventilation frequency and mortality between the 2 groups (P＞0.05). Conclusion Naso-jejunal tube for EN is more safe and effective for the critically ill elderly patients with swallowing dysfunction.

Abstract:Objective To investigate the clinical features of severe trauma in the elderly and analyze the risk factors for death. Methods Clinical data of 130 elderly traumatic patients and 120 young and middle-aged traumatic patients admitted in Intensive Care Unit (ICU) of our hospital from January 2010 to October 2014 were collected and retrospectively analyzed. The cause, traumatic condition, treatment and prognosis were analyzed and compared between the 2 groups. Results In the elderly trauma group, the scores of acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) was 19.71±12.48, 39.2% of them had comobidities, their mean length of ICU stay was (6.17±5.97)d, the rate of mechanical ventilation was 56.2%, the incidence of multiple organ dysfunction syndrome (MODS) and pneumonia were 36.9% and 22.3%, respectively, and the mortality was 34.6%. All these values were significantly higher than those in the young and middle-aged group (P＜0.05). Conclusion The mortality is higher in elderly than in young and middle-aged traumatic patients. The APACHE Ⅱ score, more comobidities and occurrence of MODS are the independent risk factors for death.

Abstract:Objective To determine the protective effect of bacterial lipoprotein (BLP) tolerance on myocardiocytes in aged mice, and compare its effect on cardiac function between aged and adult mice. Methods A total of 86 healthy male aged C57BL/6 mice (SPF grade, 24 months old) and another 55 healthy male adult C57BL/6 mice (SPF grade, 6 to 8 weeks old) were employed in this study. Low-dose BLP was used to pretreat the aged and adult mice to induce BLP tolerance. Then the mice were respectively divided into control, sham operation group (sham), sepsis group (CLP, inflicted by cecal ligation and puncture) and BLP tolerance＋CLP group. Echocardiography was carried out in adult mice in 0, 2, 6 and 12h after CLP to measure left ventricle shortening fraction (FS), ejection fraction (EF), left ventricular internal diameter at end-diastole (LVIDd) in adult mice, and in aged mice at time points of 0, 3, 6 and 12h for above-mentioned indices. Results The FS, EF and LVIDd showed a downward trend after operation in the sepsis group and BLP tolerance＋CLP group in aged mice, with the stronger decreases in the former than in the latter group. In the time from 0 to 6h, the BLP tolerance＋CLP group in adult mice had similar tendencies in the FS, EF and LVIDd with sepsis group, but lower than the later. Then the 3 indices were increased in the BLP tolerance＋CLP group in 6h after CLP, and became higher than those of sepsis group in 12h, with FS and EF having significant differences (P＜0.05). The FS in the BLP tolerance＋CLP aged mice presented a progressive decline tendency, but it was in a progressive increase trend after 6 h in adult mice, and was significantly higher than those of the sham and CLP groups at 12h (P＜0.05). The EF of CLP group in adult mice increased after operation, then decreased from 6h and became lower than the preoperative level at 12h. While the EF of CLP group in aged mice showed a progressive decline tendency after surgery. The EF of BLP tolerance＋CLP group in adult mice was in a progressive increase trend; on the contrary, the corresponding group in aged mice was tending downwards. The LVIDd of the BLP tolerance＋CLP group in aged mice was progressively reduced, while that of corresponding group in adult mice was below the preoperative level in 2h after operation (P＜0.05), then gradually recovered in 6h. Conclusion Sepsis has inhibitory effects on FS, EF and LVIDd, and the effects on cardiac systolic and diastolic functions are stronger in aged mice. BLP tolerance exerts protective effect on cardiac function. This protection is apparently effective in adult mice than in aged mice.

Abstract:Objective To investigate the clinical features of chronic lymphocytic leukemia (CLL) in the elderly. Methods A total of 12 elderly patients (over 60 years old) with CLL admitted in our hospital from June 1999 to June 2013 were enrolled in this study and retrospectively analyzed. Results The mean age was 75.5 years in the cohort. All patients had suffered from underlying diseases, and hypertension was the most common one. And some of them (3/12) even complicated with the secondary tumor. Nine cases received individualized treatments. The results showed that 5 patients suffered progressive disease (PD, Sample 1, 2, 3, 10 and 12 had the total survival time of 107, 64, 174, 69 and 4 months, respectively), 2 patients achieved complete remission (CR), 1 patient achieved partial remission (PR), and 1 patient reported stable disease (SD). Four patients died of progressive CLL, 1 of infection, and the other 3 of the secondary tumor. Conclusion Elderly CLL has atypical symptoms and many underlying diseases. Treatment should be individualized based on patient’s status.

Abstract:Objective To evaluate the clinical diagnostic and exclusive values of revised Geneva score and its combination with plasma level of D-dimer for suspected pulmonary embolism (PE) in the elderly patients. Methods A total of 276 patients with suspected PE due to chest pain and dyspnea admitted in our hospital from January 2009 to April 2014 were enrolled in this study. They were divided into 2 groups based on their age, that is, the aged group (≥60 years old) and the non-aged group (＜60 years old). Computed tomography pulmonary arteriography (CTPA) was considered as the gold standard for diagnosis. According to the revised Geneva score, the diagnosis of PE was categoried into different clinical probability, ie, low, medium and high probability, and their plasma level of D-dimer was also tested. Based on their clinical features, the diagnostic values of revised Geneva score, the exclusive values of plasma D-dimer, and that of combining revised Geneva score with D-dimer together were analyzed between the 2 groups. The receiver operating characteristics (ROC) curve was used to evaluate the overall accuracy of revised Geneva score in the diagnosis of PE. Results Among the cohort with suspected PE, 80 cases were definitely diagnosed as PE by CTPA (52 cases ≥60 years old, and 28 cases ＜60 years old). The area under the ROC curve (AUC) was 0.974 (95% CI: 0.940?0.992) for the aged group and 0.981 (95% CI: 0.924?0.998）for the non-aged one, with significant difference between them (P＜0.001). The negative predictive values of D-dimer, and the revised Geneva score combined with D-dimer were 93.8% and 100.0% respectively for the aged patients, and 88.9% and 100.0% for the non-aged patients. Conclusion The clinical features of PE are atypical in the elderly patients. The revised Geneva score has lower diagnostic value for the aged than the non-aged patients. Combination of revised Geneva score and plasma level of D-dimer is a safe strategy to rule out PE and is better than D-dimer alone for the aged and non-aged patients with suspected PE.

Abstract:Objective To investigate whether the intraoperative fluid therapy based on the parameters of arterial pressure wave analysis (FloTrac) could reduce the incidence of postoperative complications in the elderly patients after major surgery. Methods This was a prospective, open-labeled, randomized controlled trial. One hundred thirty-eight patients at an age of ≥65 years who were scheduled for major abdominal surgeries in our department from October 2013 to November 2014 were randomized into 2 groups. In the control group, routine monitoring was performed and intraoperative fluid therapy was administered according to conventional practice. In the goal-directed therapy (GDT) group, hemodynamic monitoring was performed using the FloTrac/Vigileo system, and the intraoperative goals were to maintain stroke volume variation (SVV)＜13%, cardiac index (CI) ≥2.5 L/(min·m2), and mean arterial pressure (MAP) ≥65mmHg. Results The incidence of postoperative cardiovascular complications was significantly lower in the GDT group than in the control group[2.9%(2/69) vs 11.6%(8/69), P＝0.049]. The incidence of postoperative infectious complications was slightly lower in the GDT group than in the control group, but the difference was not statistically significant [13.0%(9/69) vs 26.1%(18/69), P＝0.053]. There was no significant difference between the 2 groups with regard to the overall incidence of postoperative complications. Conclusion For the elderly patients undergoing major abdominal surgery, intraoperative GDT based on arterial pressure wave analysis decreases the incidence of postoperative cardiovascular complications, and also tends to decrease the incidence of postoperative infectious complications after surgery. However, its effects on the outcomes of the elderly need further study on larger samples.

Abstract:Objective To analyze the association of serum uric acid (SUA) with atrial fibrillation (AF) in the patients with chronic heart failure (CHF). Methods A total of 218 CHF patients admitted in our department from January 2010 to February 2014 were enrolled in this study. Their demographic data, medical history, blood biochemical parameters, ultrasonic echocardiogram and cervical vascular ultrasound results were collected and retrospectively analyzed. The patients were divided into 2 groups, that is, normal sinus rhythm group and AF group. Results Of 218 CHF patients, 49 patients (22.5%) had AF, and 169 patients were in normal sinus rhythm. SUA was significantly higher in the patients with AF than those with normal sinus rhythm (P＜0.05). AF patients were older than those with normal sinus rhythm [(64.32±9.87) vs (56.78±10.14) years, P＜0.05], had lower ejection fraction (EF, P＜0.05), higher values in echocardiographic parameters, such as left atrium diameter, left ventricular end-diastolic diameter, and left ventricular end systolic diameter, and obviously larger intimal medial thickness (P＜0.05). Multivariate logistic regression analysis showed that SUA was the independent risk factor for AF. Conclusion AF patients have significantly higher SUA levels, and poorer heart function.

Abstract:Objective To determine the effect of pioglitazone on visfantin-induced inflammatory injury in human vascular endothelial cells and investigate the underlying signal pathway of pioglitazone in improving endothelial functions. Methods Human umbilical vein endothelial cells (HUVECs) were treated by different concentrations of visfantin. Then Western blotting was used to detect the expression of Toll-like receptor4 (TLR4), intercellular cell adhesion molecule-1 (ICAM-1), nuclear factor-κB (NF-κB) and inhibitor of NK- κB-α (IκB-α). Their expression levels were measured again after the cells were respectively exposed to the agonist of peroxisome proliferator activated receptor gamma (PPARγ), pioglitazone. Results Compared with the control group, visfantin enhanced the expression of ICAM-1 in a dose-dependent manner, and also induced TLR4 up-regulation and IκB-α down-regulation (P＜0.05), with visfantin at dose of 1×10-5mol/L showing the strongest effect. However, pioglitazone inhibited the above effects of visfatin in a dose-dependent manner, with dose of 20 μmol/L having the maximal effect. Conclusion Pioglitazone exerts protective effect on visfantin-induced inflammatory injury in human vascular endothelial cells, which may be due to its blocking TLR4/NF-κB signal pathway.

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Abstract:The presence of an aberrant right subclavian artery (ARSA) arising from the proximal descending aorta is a relatively common anomaly of the aortic arch. These vessels may be involved in aortic dissections, either as the site of the primary intimal tear or as a dissected aortic branch, subject to flow limitation and future aneurysmal degeneration. We report a case involving a ruptured acute type A aortic dissection originating from ARSA. The coincidence of an ARSA with a complicated acute type A aortic dissection is extremely rare, as in the present case. This case was diagnosed preoperatively by computed tomography angiography (CTA), which is of great value for precise planning of surgical strategy in such cases. The aim of the case report is to make the clinicians aware of ARSA probably being accompanied with aortic dissection, so as to diagnose it and manage it rapidly and appropriately.

Abstract:With the speeding up of population aging, there are more and more elderly patients. Most of them suffer from various chronic diseases, so the demand for medical services is increasing. In the face of accelerated coming of aging society, we have to use the limited medical resources to provide efficient medical services for the elderly, which also becomes a serious challenge for our government and public health support system. It also needs medical workers to make great efforts and exploration. This paper introduced how Ledu Hospital to cope with the present situation of the aging in our district, such as promoting modern ideas on geriatrics and implementing rational use of medical resources in the area, and discussed the problems encountered and the solving measures.

Abstract:Gait is a complicated motor task controlled by different areas of the brain. Epidemiological studies show that gait is closely associated with cognitive function in the elderly. Older adults with gait impairment are of higher risk for developing cognitive impairments. Compared with normal healthy old people, those with cognitive impairment show more preference to have gait impairments, and are more prone to falling. Cognition and gait, which may have a mutual relationship, may occur in the same area of the brain. So, better overall gait is related to better overall cognitive function. In recent years, many abroad researches demonstrated that stride speed and stride-to-stride variability of stride time (STV) are predictors of cognitive impairment. However, there are few such researches in China. This article reviewed the new progress in the studies concerning walking speed and STV with cognitive impairment, and aimed at raising awareness of clinicians on this subject. We need to conduct neuropsychological tests based on the elderly gait in order to detect cognitive impairment as early as possible.