Clinical Backgrounds and Outcomes of Elderly Japanese Patients with Gastrointestinal Bleeding

Onychomycosis in older adults: The age and associated factors affecting the complete cure rate

BACKGROUND

Limited studies exist on the factors associated with a complete cure of onychomycosis in older adults.

OBJECTIVES

To determine the age and factors associated with a complete cure among older adults diagnosed with toenail onychomycosis.

METHODS

A retrospective cohort study was conducted of 95 older adult patients (aged ≥ 60 years) diagnosed with toenail onychomycosis between January 2016 and December 2017. Demographic data, mycological findings, treatments and durations to a complete cure were reviewed.

RESULTS

The complete cure rates of the patients aged < 70 years and ≥70 years were 67.4% and 44.9%, respectively (P = 0.027). Patients aged ≥ 70 years were significantly higher in male gender, had higher history of smoking, peripheral arterial disease, impaired renal function, antihypertensive drug and amorolfine nail lacquer usage, and polypharmacy. A multivariate analysis revealed that being aged ≥70 years and having a nail thickness >2 mm were associated with failure to achieve a complete cure. The median times to a complete cure for older adults aged <70 years and ≥70 years were 20 months and 47 months, respectively (P = 0.007).

CONCLUSIONS

An age ≥ 70 years was related to a lower cure rate and delays in achieving a complete cure. A nail thickness > 2 mm was a poor prognostic factor for a complete cure. Moreover, very old adults were more likely to suffer side effects arising from the use of systemic antifungal medications.

Risk factors of poor prognosis and impairment of activities of daily living in patients with hemorrhagic gastroduodenal ulcers

Background

Impairment of activities of daily living (ADL) due to hemorrhagic gastroduodenal ulcers (HGU) has rarely been evaluated. We analyzed the risk factors of poor prognosis, including mortality and impairment of ADL, in patients with HGU.

Methods

In total, 582 patients diagnosed with HGU were retrospectively analyzed. Admission to a care facility or the need for home adaptations during hospitalization were defined as ADL decline. The clinical factors were evaluated: endoscopic features, need for interventional endoscopic procedures, comorbidities, symptoms, and medications. The risk factors of outcomes were examined with multivariate analysis.

Results

Advanced age (> 75 years) was a significant predictor of poor prognosis, including impairment of ADL. Additional significant risk factors were renal disease (odds ratio [OR] 3.43; 95% confidence interval [CI] 1.44–8.14) for overall mortality, proton pump inhibitor (PPIs) usage prior to hemorrhage (OR 5.80; 95% CI 2.08–16.2), and heart disease (OR 3.05; 95% CI 1.11–8.43) for the impairment of ADL. Analysis of elderly (> 75 years) subjects alone also revealed that use of PPIs prior to hemorrhage was a significant predictor for the impairment of ADL (OR 8.24; 95% CI 2.36–28.7).

Conclusion

In addition to advanced age, the presence of comorbidities was a risk of poor outcomes in patients with HGU. PPI use prior to hemorrhage was a significant risk factor for the impairment of ADL, both in overall HGU patients and in elderly patients alone. These findings suggest that the current strategy for PPI use needs reconsideration.

Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review

BACKGROUND

Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed.

METHODS

Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients.

RESULTS

Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary.

CONCLUSION

Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.

Outcomes of Patients Undergoing Endoscopic Hemostasis for the Upper Gastrointestinal Bleeding Were Not Influenced by the Timing of Hospital Emergency Visits: A Situation Prevailing in Japan

BACKGROUND

The aim of the present study was to determine differences in the prognosis of patients in Japan who underwent emergency endoscopic hemostasis (i) during regular hours versus off hours and (ii) as outpatients versus hospitalized patients.

METHODS

The present retrospective study included 443 patients who underwent emergency endoscopic hemostasis for non-variceal upper gastrointestinal bleeding from January 2008 to December 2014. These patients were classified into 2 groups: hospitalized patients and outpatients. The outpatients were further subclassified into those who visited the hospital during regular hours and those who visited during off hours.

RESULTS

The outcomes of outpatients who underwent emergency hemostasis during off hours did not differ from patients treated during regular hours. Multivariate analysis revealed that outcomes of hospitalized patients, including mortality, need for blood transfusion and length of hospitalization, were worse than those of outpatients; it also revealed that patient age, malnutrition rate and prevalence of diabetes and neoplasms were higher among hospitalized patients than those in outpatients.

CONCLUSIONS

The clinical outcomes of patients who underwent emergency endoscopic hemostasis for upper gastrointestinal bleeding during off hours did not differ from those of patients treated during regular hours. Outcomes were worse among hospitalized patients, mainly because of their bad general condition.

High Cost of Hospitalization for Colonic Diverticular Bleeding Depended on Repeated Bleeding and Blood Transfusion: Analysis with Diagnosis Procedure Combination Data in Japan

BACKGROUND

Bleeding from a colonic diverticulum is serious in aged patients. The aim of this study was to determine the risk factors for high-cost hospitalization of colonic diverticular bleeding using the diagnosis procedure combination (DPC) data.

METHODS

From January 2009 to December 2015, 78 patients with colonic diverticular bleeding were identified by DPC data in Saga Medical School Hospital. All patients underwent colonic endoscopy within 3 days. The patients were divided into 2 groups: the low-cost group (DPC cost of <500,000 yen) and the high-cost group (DPC cost of >500,000 yen).

RESULTS

Univariate analysis revealed that aging, hypertension, rebleeding, a low hemoglobin concentration at admission, and blood transfusion were risk factors for high hospitalization cost. Multivariate analysis revealed that rebleeding (OR 5.3; 95% CI 1.3-21.3; p = 0.017) and blood transfusion (OR 3.8; 95% CI 1.01-14.2; p = 0.048) were definite risk factors for high hospitalization cost.

CONCLUSION

Rebleeding and blood transfusion were related to high hospitalization cost for colonic diverticular bleeding.

Deep vein thrombosis of the lower extremities after laparoscopic surgery for gastrointestinal cancer: Incidence and risk factors

AIM

To compare the incidence of deep venous thrombosis (DVT) of the lower extremities after laparoscopic and open surgery for gastrointestinal malignancies.

METHODS

A total of 158 patients who underwent radical resection for rectal or gastric cancer at our hospital from December 2015 to December 2017 were selected and randomly divided into either an observation group (79 patients) or a control group (79 patients). The observation group underwent laparoscopic surgery, and the control group underwent traditional laparotomy. Operative time, intraoperative blood loss, postoperative exhaust, hospital stay, complications, and preoperative and postoperative thromboplastin time (TT), D-dimer (DD), activated partial thromboplastin time (APTT), prothrombin time (PT), and thromboelastography (TEG) were compared between the two groups.

RESULTS

Operative time was significantly longer and the number of DVT cases was significantly more in the observation group than in the control group (209.47 min ± 30.17 min vs 174.33 min ± 30.29 min, 26 vs 15, P < 0.05). Postoperative blood loss and postoperative complications were significantly lower in the observation group than in the control group (300.18 mL ± 50.29 mL vs 379.45 mL ± 50.49 mL, 6 vs 16, P < 0.05). At 1 d after surgery, PT was prolonged and APTT was shortened in the observation group compared with preoperative value and that of the control group (PT: 12.94 s ± 0.88 s vs 11.19 s ± 0.86 s, 11.75 s ± 0.90 s, P < 0.05; APTT: 26.28 s ± 2.54 s vs 30.23 s ± 2.68 s, 30.99 s ± 2.51 s, P < 0.05). The DD contents at 1, 3, and 5 d after operation (1.77 s ± 0.23 s, 2.30 s ± 0.45 s, and 2.28 s ± 0.46 s, respectively) were significantly higher in the observation group compared with preoperative value (1.29 s ± 0.25 s) and those of the control group (1.49 s ± 0.26 s, 1.68 s ± 0.42 s, and 1.70 s ± 0.41 s, respectively) (P < 0.05). The MA values at 1, 3, and 5 d after surgery in the observation group were higher than those of the control group (69.68 mm ± 6.48 mm vs 65.97 mm ± 6.15 mm, 70.51 mm ± 6.41 mm vs 67.02 mm ± 6.31 mm, 72.03 mm ± 6.89 mm vs 69.60 mm ± 6.47 mm). The α values at 1, 3, and 5 d in the observation group (70.02 ± 4.33, 70.71 ± 4.47, and 73.08 ± 4.25, respectively) were significantly higher than preoperative value (60.20 ± 4.29) and those of the control group (65.69 ± 4.22, 67.48 ± 4.36, and 68.98 ± 4.51, respectively) (P < 0.05). There was a significant difference in age, smoking status, ASA classification, tumor stage, and hypertension between DVT and non-DVT patients (P < 0.05).

CONCLUSION

The incidence of DVT after laparoscopic surgery for gastrointestinal cancer surgery is higher than that after traditional laparotomy.

Gastrointestinal bleeding after emergency coronary intervention in elderly patients: Influencing factors and preventive measures

AIM

To analyze the factors influencing gastrointestinal hemorrhage (GIB) after percutaneous coronary intervention (PCI) in elderly patients and explore possible preventive measures.

METHODS

Fifty-six elderly patients who underwent emergency PCI at our hospital between July 2016 and May 2017 were included. Based on the occurrence of GIB or not, the patients were divided into an observation group and a control group. The patients in the observation group developed GIB in 6 months after PCI, and the control group did not. Univariate and multivariate analyses were performed to identify factors influencing GIB after emergency PCI.

RESULTS

Univariate analysis demonstrated that coronary artery triple vessel disease, right coronary artery disease, operative time, intraoperative use of heparin, ACEI/ARB drugs, and preventative proton pump inhibitors were significantly associated with GIB after emergency PCI (χ² = 7.286, 10.196, 3.420, 4.578, 6.475, 4.968, P < 0.05). Operative time, use of ACEI/ARB drugs, diuretics, and prophylactic proton pump inhibitors, coronary artery triple vessel disease, and intraoperative heparin were identified to be independent risk factors for GIB after emergency PCI (P < 0.05)

CONCLUSION

Operative time, use of ACEI/ARB drugs, diuretics, and prophylactic proton pump inhibitors, coronary artery triple vessel disease, and intraoperative heparin are independent risk factors for GIB after emergency PCI in elderly patients.