Rhabdomyolysis is a syndrome caused by injury to skeletal muscle. There is limited data of rhabdomyolysis in the elderly. The objective of this study is to investigate demographic data, etiologies, laboratory values, prognostic factors, and mortality of rhabdomyolysis in the geriatric population. A 4-years retrospective chart review study was conducted. Our inclusion criteria were age above 65 years and creatinine kinase level excess five times of normal upper limit. Among 167 patients, 47.3% were male. The median age at diagnosis was 80.11 (66-101) years. The duration of follow up in the study ranged from 0 to 48 months. Fall (with or without immobilization) was the most frequent cause of rhabdomyolysis in 56.9%. The mean baseline glomerular filtration rate (GFR), GFR at diagnosis, and peak decline in GFR was 76.94, 48.96, and 54.41 cc/min respectively. The mean CK at diagnosis and peak CK was 5097.22 and 6320.07. There were 45 deaths (21%) over the span of 4 years. Multivariate analysis demonstrated that number of medications pre-admission (Meds No.), peak decline in GFR, and acute kidney injury (AKI) are independent predictors for overall survival for rhabdomyolysis in the elderly. To our knowledge, this is the first epidemiological study of rhabdomyolysis in the elderly. Falls (with and without immobilization) were the most common etiology. Meds No. (>8), peak decline in GFR (<30 cc/min), and evidence of AKI are associated with shorter overall survival and can serve as potential independent prognostic markers for rhabdomyolysis in elderly patients.

NSAIDs, non-steroidal anti-inflammatory drugs, are one of the most commonly prescribed pain medications. It is a highly effective drug class for pain and inflammation; however, NSAIDs are known for multiple adverse effects, including gastrointestinal bleeding, cardiovascular side effects, and NSAID induced nephrotoxicity. As our society ages, it is crucial to have comprehensive knowledge of this class of medication in the elderly population. Therefore, we reviewed the pharmacodynamics and pharmacokinetics, current guidelines for NSAIDs use, adverse effect profile, and drug interaction of NSAIDs and commonly used medications in the elderly.

Falls are highly prevalent and lead to major health morbidity and mortality in older adults. We developed a "STOP-FALLING" checklist as a multifactorial intervention tool kit for a single long-term care facility. The objective of this study was to determine feasibility and adherence of the checklist, and to determine whether STOP-FALLING reduces total number of falls, frequent fallers, and fall-related injuries. This is a quality improvement demonstration project comparing the effect on falls 3 months before and 3 months after introducing a STOP-FALLING checklist. All older adult patients who lived in the long-term care unit of a single facility were included. PTs, geriatricians, and registered nurses participated in the STOP-FALLING initiative. Staff were surveyed on satisfaction by 8-item questionnaires, which were obtained 3 months after checklist implementation. Data on the rate of falls, the number of recurrent fallers, the number of minor injuries, and the number of major injuries 3 months prior and 3 months after the intervention were collected by facility fall log. A total of 32 patients were screened using the STOP-FALLING checklist. Staff survey revealed a high satisfaction rate with <= 15 minutes to complete the checklist. Data at 3 months after initiation of the checklist revealed a reduction in the fall rates (2.80-1.65 falls per person-year), number of frequent fallers (5.00-2.30/mo after), number of falls without injuries (3.00-1.67/mo), number of minor injuries (4.00-2.67/mo), and number of major injuries (0.33-0/ mo). We observed excellent staff satisfaction using the STOP-FALLING checklist. Our pilot project suggests that the intervention may decrease fall rates and other fall-related injuries. (C) 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

IN BRIEF Older adults with diabetes present unique challenges and require considerations that are not traditionally associated with diabetes management. In this review, we focus on issues that are unique to the older population and provide practical guidance for clincians who care for them.

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Background Acute coronary syndrome (ACS) can complicate acute ischemic stroke, causing significant morbidity and mortality. To date, literatures that describe poststroke acute coronary syndrome and its morbidity and mortality burden are lacking. Methods This is a single center, retrospective study where clinical characteristics, cardiac evaluation, and management of patients with suspected poststroke ACS were compared and analyzed for their association with inpatient mortality and 1-year all-cause mortality. Results Of the 82 patients, 32% had chest pain and 88% had ischemic ECG changes; mean peak troponin level was 18, and mean ejection fraction was 40%. The medical management group had older individuals (73 versus 67 years, p < 0.05), lower mean peak troponin levels (12 versus 49, p < 0.05), and lower mean length of stay (12 versus 25 days, p < 0.05) compared to those who underwent stent or CABG. Troponin levels were significantly associated with 1-year all-cause mortality. Conclusion Age and troponin level appear to play a role in the current clinical decision making for patient with suspected poststroke ACS. Troponin level appears to significantly correlate with 1-year all-cause mortality. In the management of poststroke acute coronary syndrome, optimal medical therapy had similar inpatient and all-cause mortality compared to PCI and/or CABG.

A 46-year-old female with hypertension, presented to the hospital with syncope. She was found to have unprovoked submassive bilateral pulmonary embolism. Serum troponin was 0.61. Echocardiography revealed right ventricular dilatation and positive for McConnell's sign. She received catheter-directed thrombolysis. On the third day of admission, her symptoms improved and she was transferred to medical floor. Heparin was transitioned to rivaroxaban. She reported new left-sided substernal chest pain. On physical examination, her vital signs were all normal, but there was a small hematoma on her right groin. EKG (Fig. 1) revealed ST elevation in aVL and V6, with reciprocal changes in lead II, III, aVF. What is the diagnosis? Due to positive R wave in V1, EKG leads position was checked. Every leads were attached to the patient at the right positions but lead V1 and LL were misconnected at the machine because the color looks similar. (Fig. 1) EKG with the corrected leads revealed T wave inversion in anterior leads. (Fig. 1) Patient was found to have demand ischemia secondary to blood loss from abdominal wall hematoma after procedure. She was transfused and her symptom improved. EKG lead misplacement occurs 0.4% and 4% in outpatient clinic and intensive care unit, respectively [[1]Rudiger A. Hellermann J.P. Mukherjee R. Follath F. Turina J. Electrocardiographic artifacts due to electrode misplacement and their frequency in different clinical settings.Am J Emerg Med. 2007; 25: 174-178Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar. It can lead to misdiagnosis and unnecessary treatment for the patient. When suspicious of electrode misplacement, verifying all lead connections and obtaining another EKG is recommended. The authors declare no competing financial interests.

pain, palpitations, dizziness and diarrhea, and severe ADR include congestive heart failure and myocardial infarction. The recommended dosing regimen for managing these ADR involves starting from 100mg/day and increasing the dose to 200mg/day on the fifth day. It has been reported that several patients could not continue treatment because of headache and tachycardia. There are no reports providing an accurate frequency of acute renal failure as an ADR to cilostazol. The present case provides a clinically valuable example showing that a serious sideeffect, such as iatrogenic acute renal failure, can occur from the use of cilostazol. Cilostazol is a useful drug for treating Alzheimer’s dementia, but blood tests must be appropriately and carefully carried out with sufficient understanding of the dose, method of administration and ADR.

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physician's awareness of NSM and its features to help tailor management according to the patient's clinical profile.

Background: Dialysis in older adults with chronic kidney disease (CKD) and comorbidities may not be associated with improved life expectancy compared to conservative management. To inform clinical practice, we performed a systematic review of all available studies examining this hypothesis. Methods: We performed a systematic review of retrospective and prospective cohort studies of older adults with stage-5 CKD who chose dialysis (hemodialysis or peritoneal dialysis) or opted for conservative management (including management of complications of CKD and palliative care). Outcomes of interest included hospitalizations and mortality. Results: Twelve cohort studies (11,515 patients) were identified with most of them focusing on older adults. Patients choosing dialysis were younger compared to those opting for conservative management and were less functionally impaired. Patients opting for conservative management received care in a multidisciplinary setting focusing on palliative care and management of complications of CKD. Patients choosing dialysis and conservative management had a median survival time of 8-67 and 6-30 months, respectively. In a subset of studies of patients 65 years and older with an estimated glomerular filtration rate <15 mL/min/1.73 m2, and where the multivariable analyses included age and comorbidities, by meta-analysis, patients choosing dialysis had a pooled adjusted hazard ratio for mortality of 0.53 (95% CI 0.30-0.91, p = 0.02) relative to those opting for conservative management; however, significant heterogeneity precluded definitive conclusions. Conclusions: When caring for older adults with advanced CKD who are contemplating dialysis therapy vs. conservative management, efforts must focus on promoting patient values and preferences, shared decision-making, and symptom burden alleviation.

Therapeutic plasma exchange has greatly increased the survival rate in thrombotic thrombocytopenic purpura.

e12069 Background: Estrogen receptor (ER) positivity in breast tumors has a beneficial prognostic profile. However, ER-positive and progesterone receptor (PR) negative tumors have a higher relative risk of mortality, as well as ER-negative/PR-positive and ER-negative/PR-negative tumors. HER 2/neu, when overexpressed, confers aggressive behavior to breast cancers. Ethnic differences between hormone receptor positivity in lobular breast carcinoma have not yet been fully described. Methods: We retrospectively ascertained patients at AEMC between 2003 and 2011 with lobular breast carcinoma by review of medical records. Age of diagnosis according with Her2, ER and PR positivity were evaluated with a student T-test, as well as according to race (African American vs. Non-Hispanic whites). We also assessed differences of hormone receptor positivity (ER/PR) and Her2/Neu between African Americans and Non-Hispanic whites with a Chi square test. Results: 143 cases were included. 84 patients were Non-Hispanic whites with lobular breast carcinoma, of which 4.76 % were Her2/neu-positive, 97.61 % were ER-positive, and 77.38% were PR-positive. From a total of 59 African Americans, 3.38% were Her2-positive, 98.30% ER-positive, and 74.57% PR-positive. No difference was found in the median age of diagnosis (67 years) among ethnic groups p=0.960 (p>0.05) or according to Her2/neu, ER or PR positivity (p=0.684, 0.5 and 0.23, respectively). ER positivity was more prevalent in Non-Hispanic Whites p=0.043 (p < 0.05). Her2/neu showed no difference in prevalence p=0.414. PR positivity was more frequent among the Non-Hispanic white population when compared with African Americans. Conclusions: In this study, lobular carcinoma showed higher prevalence of ER and PR positivity in Non-Hispanic whites. There was no statistical significance regarding Her2/neu positivity or median age of diagnosis between ethnic groups. These findings suggest that Non-Hispanic whites with lobular breast carcinoma have a more favorable hormone receptor profile. Race Number of ER+ tumors Number of HER2/neu+ tumors Number of PR+ tumors Black 58 2 44 White 82 4 65 Total general 140 6 109 p value 0.043 0.414 0.044

Vision, hearing, olfaction, and cognitive function are essential components of healthy and successful aging. Multiple studies demonstrate relationship between these conditions with cognitive function. The present article focuses on hearing loss, visual impairment, olfactory loss, and dual sensory impairments in relation to cognitive declination and neurodegenerative disorders. Sensorineural organ impairment is a predictive factor for mild cognitive impairment and neurodegenerative disorders in the elderly. We recommend early detection of sensorineural dysfunction by history, physical examination, and screening tests. Assisted device and early cognitive rehabilitation may be beneficial. Future research is warranted in order to explore advanced treatment options and method to slow progression for cognitive declination and sensorineural organ impairment.

Although the incidences of hiatal hernias increase with age, respiratory symptoms caused by hiatal hernias remain extremely uncommon. We report a case of an 88-year-old female who presented with 2-months of progressive shortness of breath. Upon arrival, the patient was found to be hypoxic with oxygen saturation 90% on room air. Physical examination also showed decreased breath sounds on left basal lungs and bilateral crackles at basal lungs. Plain radiograph demonstrated an increased opacity at the left lower lobe. Subsequent computerized tomography of the chest revealed a giant hiatal hernia, containing stomach, proximal duodenum, colon, and pancreas. This case highlights the giant hiatal hernia as an unusual cause of shortness of breath, especially in elderly patients.

Background: The public health burden of cancer and dementia in the geriatric population is well documented. There is limited data on how dementia predicts mortality among geriatric patients with solid tumors. The objective of this study is to determine the prognostic significance of dementia on survival in patients with solid tumors. Methods: We performed a 5-year retrospective study on elderly subjects aged ≥60 years with and without dementia that were diagnosed with solid tumors. Results: Among 3,460 patients with solid tumors, 132 (3.8%) patients were found to have dementia. The median age at diagnosis was 71 years. Kaplan-Meier curves demonstrated that patients with dementia had an inferior median survival compared to the nondemented group (30 vs. 56 months; log-rank p < 0.001). Cox proportional hazard regression modeling identified age >80 years, female gender, diabetes mellitus, congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, dementia, and radiation therapy as risk factors for decreased overall survival. Conclusions: We demonstrated that dementia is associated with shorter overall survival in elderly patients with solid tumors.