Israel Medical Association Journal

Background: Primary hyperparathyroidism in elderly patients is usually associated with additional co-morbidity that increases operative risk, and thus many geriatric patients are denied the benefit of surgery for a single parathyroid adenoma.

Objectives:  To evaluate the safety and efficacy of accurate single photon emission computed tomography sestamibi scintigraphy, enabling precise localization of a single adenoma, in the geriatric population

Methods: Twenty-two patients aged 70 years and over with biochemically proven PHPT[1] and with a single parathyroid adenoma identified by localization studies (sestamibi SPECT[2] scan and ultrasonography) underwent 23 operations over 29 months (out of a total of 140 patients operated upon during the same period). Immediate preoperative sestamibi scintigraphy and marking of focal adenoma uptake followed by intraoperative hand-held gamma probe were used for the removal of the parathyroid adenoma by unilateral minimal access surgery. Associated major co-morbid conditions and pre- and postoperative calcium, phosphorus and parathormone levels were recorded. Indications for surgery were listed and operative and postoperative complications were noted. The patients were followed for a mean period of 17.7 months using the same parameters.

Results: The 22 patients with PHPT had a mean age of 76.3 ± 5.9 years (range 70–88 years)  and a female to male ratio of 13:9. Associated co-morbidity included ischemic heart disease (n=15), hypertension (n=22), non-insulin-dependent diabetes mellitus (n=9), chronic obstructive pulmonary disease (n=3), and previous neck surgery (n=3). Mean preoperative serum calcium, phosphorous and PTH[3] were 11.7 ± 1.3 mg/dl, 2.5 ± 0.5 mg/dl and 160.9 ± 75.4 pg/ml respectively. In 20 of the 22 patients, surgery was successful in curing PHPT (91%). One patient had persistent hypercalcemia due to a missed adenoma, and repeat operation (by focused minimal access surgery) was successfully performed 2 weeks later. There were no complications and no morbidity postoperatively. Mean postoperative serum calcium, phosphorous and PTH were 9.6 ± 1.2 mg/dl, 3.0 ± 0.5 mg/dl and 35.2 ± 24 pg/ml respectively. In all patients, serum calcium levels remained normal (9.7 ± 1.3 mg/ml) after long-term follow-up (mean 17.7 ± 9.6 months).

Conclusions: Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is a safe and effective method to cure hyperparathyroidism in the elderly. Success of surgery is directly related to the surgeon's experience and to the precise localization marking provided by sestamibi scintigraphic SPECT localization and concurrent sonographic findings.

Objective: To reexamine the impact of prolonged nasogastric tube feeding on the oral microbiota and to explore the salivary flow and composition in elderly patients in long-term care.

Methods: We compared a group of elderly patients fed by nasogastric tube with a control group of elderly patients in long-term care who are fed orally. Bacteriologic studies were performed by culturing samples from the oropharynx. Saliva studies included quantitative and biochemical analysis of basal and stimulated salivary flow.

Results: Bacteriologic studies performed in 90 patients revealed a significantly higher prevalence of gram-negative bacteria in nasogastric tube-fed patients (73% vs. 13%, P < 0.001). It is emphasized that Pseudomonas aeruginosa and Klebsiella pneumoniae were commonly and exclusively isolated from the oral flora of the nasogastric tube-fed patients (P < 0.001, P < 0.05). In the saliva studies performed on 23 nasogastric tube-fed and 21 control patients, basal and stimulated salivary flow was not significantly different in the two groups, however the ratio of stimulated to basal flow was reduced in the nasogastric tube-fed group (P < 0.05). Significant differences were also found in the concentrations of sodium, amylase, phosphor and magnesium. Noteworthy was the concentration of uric acid, the main non-enzymatic antioxidant of saliva, which was significantly lower in nasogastric-tube fed patients (P < 0.002).

Conclusions: These findings suggest that prolonged nasogastric tube feeding is associated with pathologic colonization of the oropharynx and with alterations in the saliva that are related to the risk of aspiration pneumonia. Further research is called for, as well as a thorough revision of the existing oral cleansing procedures in these patients.

Background: Congestive heart failure is extremely common in octogenarians and is associated with severe fatigue, shortness of breath, recurrent hospitalizations, and death. These patients, many of whom are anemic, are often resistant to standard CHF[1] therapy including angiotensin-converting enzyme inhibitors, beta-blockers and diuretics.

Objectives: To examine whether correction of the anemia (hemoglobin <12 g/dl) in CHF patients lowers their resistance to therapy.

Methods: Forty octogenarians with anemia and severe resistant CHF were administered a combination of subcutaneous erythropoietin and intravenous iron sucrose.

Results: This combination therapy led to a marked improvement in cardiac function, shortness of breath and fatigue, a marked reduction in the rate of hospitalization and a stabilizing of renal function.

Conclusion: Anemia appears to be an important but ignored contributor to the progression of CHF, and its correction may improve cardiac and renal status as well as the quality of life in elderly patients.

Background: While age at death is on the rise, the number of postmortem examinations is declining and is disproportionately low among the elderly population. Research on the subject of gender-associated pathology in the elderly is also scarce.

Objective: To seek eventual gender-related differences in autopsies of elderly patients.

Methods: We analyzed the data extracted from a published report on 93 PMEs[1] performed at a geriatric hospital during the past 20 years.

Results: Ninety-three autopsies, representing 1.2% of the 8,101 deaths during these 20 years, were performed. Forty-five of the deceased were women and 48 were men. The incidence of pulmonary embolism was significantly higher in women (28%) than in men (10%) (P< 0.02). There was no significant difference in the gender distribution of the other diagnoses.

Conclusion: Gender distribution of PME-based causes of death in elderly patients revealed a significant rate of pulmonary embolism in women. A thorough search of the medical literature revealed two previous studies with similar findings. Further research will determine whether pulmonary embolism is more frequent or whether it has a worse prognosis in frail elderly women.

Matrix metalloproteinases are a family of enzymes that degrade different components of extracellular matrix. They play an important role in normal physiologic processes of maintaining tissue integrity and remodeling, as in wound healing, processes of development, and regeneration. However, excessive expression of MMP[1] has been observed in many disease states, including rheumatoid arthritis and osteoarthritis, vascular remodeling in atherosclerosis and aortic aneurysm formation, neoplastic processes, macular degeneration and many others.

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In 2001 the number of residents aged 65 and over in Israel was 639,000, or 10% of the population. The rate of increase of the elderly population is twice that of the general population, thus the predicted number of elderly for 2020 is around 1,025,000, representing a 60% increase. While this process is determined by a decline in both fertility and mortality, in Israel, immigration has also been a central factor in the process of aging. Life expectancy stands at 76.7 for men and 80.9 for women; at age 65 it is 16.4 years for men and 18.5 for women. The major factor influencing the increase in life expectancy during the past two decades has been the prevention of death among older people. Population aging, or “the demographic transition,” also represents an "epidemiological transition” – from high rates of infectious and communicable diseases, to high rates of chronic diseases among older people. During the past two decades, the number of disabled elderly has increased more than 2.5 times. In 2001, there were about 97,400 disabled elderly in Israel, constituting about 15% of all elderly. By the year 2010, the number of disabled elderly is expected to reach 120,100. The rate of increase of the disabled elderly population is almost double that of the total elderly population, due to changes in this population’s composition. However, recent research indicates that new cohorts of elderly are healthier than earlier cohorts but experience a decline in health at older ages. While advances in standard of living, medicine, and technology have made this possible, a greater allocation of resources is required to prevent disability and maintain the quality of life.

Background: Multifetal pregnancy reduction has been implemented for improving the outcome of multifetal pregnancies. Recent studies reported no difference in pregnancy outcome between reduced twins and non-reduced twins, but the neonatal course and subsequent outcome in reduced twin pregnancies were not well documented.

Objective: To compare the neonatal course and outcome, as well as the gestational and labor characteristics, in twins from reduced multifetal pregnancies and in non-reduced twins.

Methods: This is a retrospective case-control study of the neonatal course of twins from reduced multifetal pregnancies. We found 64 mothers with multifetal pregnancy reduction who delivered twins during 1989–1997; 64 gestational age-matched non-reduced twin pregnancies served as controls. The following neonatal variables were examined: major malformations; small birth weight for gestational age; and neonatal morbidities including respiratory distress syndrome, apnea, pneumothorax, bronchopulmonary dysplasia, hyperbilirubinemia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, seizures, intraventricular hemorrhage, periventricular leukomalacia, ventriculomegaly, and hydrocephalus. In addition, we evaluated several neonatal interventions (surfactant replacement, mechanical ventilation, phototherapy, total parenteral nutrition), and some laboratory abnormalities (thrombocytopenia, leukopenia, anemia, and hypoglycemia), duration of hospitalization, and neonatal mortality.

Results: Gestational and labor variables were not significantly different between multifetal pregnancies reduced to twins and non-reduced twin pregnancies. The neonatal morbidity and mortality were not significantly different between twin neonates from multifetal pregnancy reduction and non-reduced control twins.

Conclusions: Multifetal pregnancy reduction to twins appears to bear no adverse effect on the intrauterine course of the remaining fetuses or their neonatal course and outcome when born after 28 weeks of gestation.