The authors disseminate their firsthand experiences from 100 clinical encounters in a geriatric hospital setting. By sharing these encounters, they aim to contribute to the collective knowledge base of healthcare professionals who work with elderly individuals. They offer practical insights, strategies, and lessons learned that can benefit other healthcare professionals and ultimately improve the quality of care for elderly individuals in similar clinical settings.

The admission electrocardiogram of an 88-year-old woman, showed sinus rhythm, biphasic P waves in leads II, III, with the terminal vector directed upward, P duration 130 msec, PR interval 200 msec, consistent with advanced inter-atrial block. Next, atrial bigeminy occurred originating in the left atrium and delaying the sinus P waves. With the ectopic P’ measuring 60 msec, the likely path of left atrial stimuli to delaying the sinus node was through Bachmann’s bundle, by retrograde conduction. This means that inter-atrial conduction via Bachmann bundle.

This case report presents the electrocardiogram findings of a patient in their 90s with end-stage dementia, pressure ulcers, extrapyramidal syndrome, paroxysmal atrial fibrillation, and hypothyroidism who experienced a massive aspiration of gastric content.

Vitamin K is essential for clotting factors II, VII, IX and X to be released in their active form. Under vitamin K deficiency a coagulopathy may develop that is marked by prolongation of the prothrombin time (PT). Patients receiving enteral feeding which does not cover the daily vitamin K requirements might be predisposed to develop a bleeding diathesis. Yet, current guidelines do not recommend monitoring the PT in patients receiving enteral feeding. In the present cross-sectional study, we assessed the prevalence of a prolonged PT in patients receiving long-term enteral feeding with one or a combination of the enteral formulas Osmolite®, Jevity®, Easymilk®. Sixty residents in long-term geriatric care received exclusively enteral feeding for a median 27 months (average 34.7, SD 29). The median daily vitamin K supplied by enteral feeding was 63.5 mcg (average 8.3, SD 17.2), i.e. less than the 150 mcg recommended by the Food and Drug Administration. In 57 patients the PT-INR was 0.9 - 1.2 (normal); the PT-INR was prolonged to 1.4 in 3 patients. There were 6 episodes of major bleeding and 4 episodes of minor bleeding during the study period, unrelated to prolonged PT and distributed at random along the time of enteral feeding. Accordingly, long-term vitamin K-deficient enteral nutrition did not affect vitamin K-dependent coagulation. This may argue against the need to regularly monitor the PT in patients receiving long-term enteral nutrition

Objective To compare 2 CoV-SARS-2 ('anti-s') antibody levels after vaccination between residents in long-term geriatric care (LTGC) and residents in assisted-living facilities who had received two doses of the BNT162b2 vaccine. SARS-CoV-2 serology was tested with Quant II IgG CoV-SARS-2. Blood samples were collected 3-4 months after administration of the second vaccine dose. Results Anti-s >= 50 AU/ml was found in 85.4% of 90 residents in LTGC (median 498 AU/ml) and 94.9% of 214 residents in assisted living (median 728 AU/ml). p = .006. Factors associated with anti-s < 300 AU/ml were multi-morbidity, diabetes mellitus and cancer.

Admitted to hospital with an ischemic stroke, a 63-year-old male was diagnosed with a left ventricular mural thrombus. Enoxaparin treatment was started. Over 6 weeks there were two episodes of major hemorrhage needing brief discontinuation of anticoagulation. A previously normal prothrombin time (PT) became prolonged upon which vitamin K deficiency was diagnosed. The deficiency was caused by enteral feeding using a formula which did not contain the required daily dose of vitamin K. A triple message emerges from this observation: theneed for monitoring the PT in patients receiving enteral feeding, more so in those receiving anticoagulant along with enteral feeding, and the appeal to fortify feeding formulas with vitamin K.

Panniculitis, when induced by physical trauma or by chemical agents at injection sites, presents as indurated subcutaneous nodules or plaques. The clinical picture may vary, but the context makes usually the diagnosis easy. Three case histories from our department illustrate the spectrum of traumatic panniculitis: subcutaneous nodules at injection sites, a large subcutaneous mass disproportionate to mild trauma, and, at the other end of the spectrum, severe adipose tissue necrosis with liquefied fat discharging through surface wounds. Traumatic panniculitis is self-limiting and only requires symptomatic treatment.

The association between venous thrombosis and malignancy, having typical features of a paraneoplastic syndrome, has been established for a century. Currently, it is recognized that arterial thromboembolism (ATE) may also behave as a paraneoplastic syndrome. Recent matched cohort studies, systematic reviews, and observational studies concur in showing an increased incidence of acute coronary events, ischemic stroke, accelerated peripheral arterial disease, and in-stent thrombosis during the 6-month period before cancer diagnosis, peaking for 30 days immediately before cancer diagnosis. Cancer patients with ATE are at higher risk of in-hospital and long-term mortality as compared with noncancer patients. In the present review, we focus on the epidemiology, clinical variants and presentation, morbidity, mortality, primary and secondary prevention, and treatment of cancer-associated ATE. The awareness that cancer can be a risk factor for ATE and that cancer therapy can initiate cardiovascular complications make it mandatory to identify high-risk patients, modify preexistent cardiovascular risk factors, and adopt effective antithrombotic prophylaxis. For ATE prophylaxis, modifiable patient-related risk factors and oncology treatment-related factors are levers for intervention. Statins and platelet antiaggregants have been studied, but their efficacy for prevention of cancer-associated ATE remains to be demonstrated. Results of revascularization procedures for cancer-associated ATE are worse than for ATE in noncancer patients. It is important that a multidisciplinary approach is adopted for making informed decisions, by involving the vascular surgeon, interventional radiologist, oncologist, and palliative medicine, as well as the patients and their family.

Unilateral calf pain and swelling are suggestive of deep vein thrombosis (DVT) but may also result from muscle or tendon tear, Baker's cyst, soft tissue infection, and inflammation.[1] [2] [3] To distinguish mimickers from DVT, the term pseudothrombophlebitis is used, meant to avoid potential harm from anticoagulant treatment, and foster disease-specific management. We describe pseudothrombophlebitis in the followings of iliac artery thrombosis, thromboendarterectomy, and rhabdomyolysis of calf muscles. Awareness to this rare occurrence is warranted.

Patients receiving enteral feeding may develop vitamin K deficiency if the nutrition formula does not meet their daily vitamin K requirement. Vitamin K is essential for clotting factors II, VII, IX and X to be released in their functional form. Under vitamin K deficiency a coagulopathy may develop which is marked by prolongation of the prothrombin time (PT). There might be a need, unrecognized to-day, for monitoring the PT in patients receiving enteral feeding to unmask a latent coagulopathy. We assessed the prevalence of a prolonged PT in patients receiving enteral feeding for 3 months of more with one or a combination of the enteral formulas Osmolite®, Jevity®, Easymilk®. Twenty-three residents in long-term hospital care received solely enteral feeding for an average of 37 months, SD 21 months. The median daily vitamin K supplied by enteral feeding was 96.8 mcg (average 103.3 mcg, SD 28.8); this does not satisfy the 150 mcg of vitamin K required by the Food and Drug Administration. In 21 patients the PT-INR was 1-1.2 (normal). The PT was prolonged in two patients. In one of the latter, prolongation of PT-INR was not confirmed two days later. In the second case, the patient having repeatedly a PT-INR 1.4 (and a normal APTT), administration of vitamin K did not correct the PT. In conclusion, long-term vitamin K-deficient nutrition did not affect the vitamin K-dependent coagulation. This data may argue against the supposed need to monitor the PT in patients receiving long-term enteral nutrition.

A 72-year-old man with basilar artery stroke was underwent successful angioplasty. Bilateral infarctions in the cerebellum, basal ganglia and capsula interna left the patient with central ataxia. His longstanding arterial hypertension (HT) had deteriorated. Orthostatic hypotension (OH) along with supine HT evolved, being indicators of efferent baroreflex failure. Managing the patient’s blood pressure (BP) became challenging, more so under repeated changes of the clinical scenario during a 6 weeks period. There was a reminder to the numerous faces of syndrome of supine HT associated with OH: 1. longstanding HT phenotype had acutely changed under a cerebrovascular involving the midbrain; 2. new-onset OH, supine HT and highly variable BP not influenced by mental challenge were consistent with efferent baroreflex failure; 3. BP management under efferent baroreflex failure was difficult and there was a need to compromise, giving priority for avoiding orthostatic symptoms; 4. intercurrent sepsis caused an persistent alteration of the patient’s BP status requiring discontinuation of antihypertensive medications.

The present paper explores the effects of the psychopharmacological agent fluoxetine on mnestic processes, using a model of passive avoidance on male Wistar rats with different nervous system phenotypes and different activity ratios of the monoaminergic systems of the brains. In the re-test session under administration of fluoxetine, the seizure-tolerant rats compared to the seizure-sensitive rats were characterized by a more pronounced fear response to the "unsafe" compartment and enhanced anxiety facilitating the retention of memory trace. The individual sensitivity of the animals to the action of fluoxetine and the direction of its effects on mnestic processes are supposed to be determined by different primary activity ratios of the monoaminergic systems of the brain.

Background: The red blood cell distribution width (RDW) is a simple measure of red blood cell size heterogeneity. A high degree of anisocytosis, expressed by RDW >15%, is observed in certain anemias, but also in other disorders, where RDW >15% is associated with worse prognosis. We questioned whether the RDW/hemoglobin ratio (RDW/Hb) might closer relate to disease severity than RDW. Design: Cross sectional study Patients: 76 residents of two Department of Comprehensive Nursing Care. Method: Physicians classified the patients according to their clinical status in three groups: "stable", “severe-unstable”, and "intermediate". An outside observer extracted from the patients' files the results of RDW (elevated if >15%), hemoglobin, iron, and transferrin. The RDW (%)/Hb (g/dL) ratio and tansferrin saturation (TSAT) were computed. The associations between RDW, RDW/Hb, TSAT, and the patients' clinical status were assessed. Results: In residents of Department A, RDW >15% was found in 33% of 19 stable patients, in 58% of 10 patients with intermediate severity, and in 81% of 10 patients classified severe-unstable. The RDW/Hb ratio >1.4 was found in 24% of stable patients, in 73% with intermediate severity, and in 93% of the severe-unstable patients. In Department B, 36 out of 38 patient's were classified stable: in 61.2 % the RDW was >15% and in 38% the RDW/Hb was >1.4. Conclusions: In a heterogenic population presenting multimorbidity, the RDW and to a higher degree the RDW/Hb (p <0.00001), correlated with the patients' disease severity.

During the course an outbreak of scabies in a nursing home, singular was the case of an elderly woman whose scabietic eruption was limited to her right hand and forearm.She had suffered a cerebral hemorrhage, was left aphasic with right hemiplegia.Her non-paralyzed left hand, restricted with a protective glove to prevent the patient drawing on the tracheostomy cannula, was not affected byeruption.This is what makes this case unusual and informative: while symptoms of scabies are mediated through inflammatory and allergylike reactions, the scabietic eruption may remain limited to the site of direct contact with the source, dissimilar to hypersensitivity reactions.Scabies is an infestation of the skin by the mite Sarcoptes scabiei resulting

A 48-year-old man suffered a cardiac event and was successfully resuscitated at home. He remained in vegetative state. During a lengthy hospital stay, he was weaned from mechanical ventilation and treated for urinary and pulmonary infections. On admission for aftercare, there were pressure ulcers in the presacral area and next to the scapula. A stage 3, right calf ulcer had a peripheral rim of new epithelium. A left …

To the Editors: Hyponatremia has been reported in 0.5% to 32% of patients treated with serotonin-reuptake inhibitors (SSRIs).1-3 According to common experience, SSRI-induced hyponatremia is not dose dependent; it develops within the first few weeks of SSRI treatment and subsides within 2 weeks after the SSRI is discontinued.1 There are a few reports of rechallenge with the same or another SSRI, in which, in some instances, hyponatremia recurred.4 Here we report the unusual occurrence of escitalopram dose-dependent hyponatremia. A 65-year-old woman diagnosed with anaplastic meningioma and neurocognitive decline was hospitalized in palliative hospice care. The patient's daily medication included alprazolam 0.5 mg, escitalopram 10 mg, zopiclone 7.5 mg, levetiracetam 1000 mg, omeprazole 20 mg, and prednisone 10 mg. The patient's blood pressure, pulse, and respiratory rate, the blood cell count, and her routine blood chemistry were within the normal range from January through June 2017. The serum sodium was 135-137 mEq/L. To cope with the patient's restlessness the dose of escitaloparam was increased in July to 20 mg/day. Other medications, the diet, and patient access to water were without change. Six days after the escitalopram dose was increased, blood tests revealed hyponatremia 124 mEq/L and hypoosmolality 263 mOsm/L. During hyponatremia we did not observe new neurologic signs or changes in the patient's symptoms of severe chronic disease. She appeared euvolemic. There were no signs of intercurrent illness responsible for acute hyponatremia. When other potential causes of euvolemic hypoosmolality, such as hypothyroidism, Addison disease, pituitary ACTH insufficiency, and diuretic use had been excluded, the likely diagnosis was inappropriate secretion of antidiuretic hormone. The apparent culprit was the 20-mg escitalopram dose. When escitalopram was discontinued, hyponatremia subsided. Yet, the patient's restlessness worsened and was not countered by doubling the alprazolam dose. An attempt was made to gradually reintroduce escitalopram therapy. On the previously tolerated 10 mg of escitalopram, the serum sodium had been maintained at acceptable levels (Table 1). Escitalopram dose-dependent hyponatremia was diagnosed based on the temporal relationship between escitalopram dose escalation and occurrence of hyponatremia, remission of hyponatremia soon after escitalopram discontinuation, exclusion of other causes of hyponatremia, analogy with mirtazapine dose-dependent hyponatremia,5 and the known pathophysiologic mechanism of SSRI-induced hyponatremia consistent with the findings in this patient.1, 6, 7 These data matched score 7 on the Naranjo causality scale, qualifying as probable escitalopram-induced dose-dependent hyponatremia.8 We could not find any report in the literature on escitalopram dose-dependent hyponatremia. SSRI-induced hyponatremia is thought not to be dose dependent1 but was dose dependent in this patient. Hyponatremia subsides when SSRI treatment is discontinued, which principle held true in the present case. Rechallenging with an SSRI is usually discouraged because hyponatremia may recur.9 In the present case hyponatremia did not recur when escitalopram was rechallenged to the previously tolerated lower dose. Pharmacovigilance to development of hyponatremia is recommended during escitalopram treatment initiation. The present observation suggests that vigilance might be warranted also when escitalopram dose is escalated on long-term treatment.

Guidelines of arterial hypertension treatment based on individualised expected outcomes are not available for frail older persons. In this paper, we review the evidence, concerning management of arterial blood pressure (BP) in frail older patients. We focused on the best affordable methods for BP measurement; the age-related optimum BP; specific BP goals in agreement with the patients’ general heath, frailty status, orthostatic and postprandial hypotension; balancing the benefits against risks of antihypertensive treatment. Lenient BP goals are generally recommended for older persons with moderate or severe frailty, multimorbidity and limited life expectancy. To this aim, there may be a need for deintensification of antihypertensive treatment.