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PYLORIC STENOSIS (GASTRIC OUTLET OBSTRUCTION)

Pyloric stenosis is rarely due to stenosis at the pylorus. More commonly, the obstruction is on one side of the pylorus, either in the first part of the duodenum due to chronic scarring from a duodenal ulcer or in the antrum due to a carcinoma. True pyloric stenosis can arise from a pyloric channel ulcer or very rarely from a congenital web or adult hypertrophic pyloric stenosis. Some instances of gastric stenosis are caused by inflammatory oedema surrounding an active ulcer and these often resolve with conservative treatment. The common causes of gastric outlet obstruction are:

•         chronic duodenal ulceration/fibrosis;

•         antral gastric carcinoma;

•         carcinoma of the head of the pancreas.

Barium meal showing gastric outlet obstruction caused by fibrosis following healing of chronic duodenal ulcer.

Barium meal showing hour-glass deformity caused by a lesser curve ulcer in the middle third of the stomach. The deformity resolved with medical treatment. However, some of these deformities are fibrotic in nature (contractures) when obstructive symptoms persist depite ulcer healing. These require dilatation or surgical treatment.

Rare causes include a variety of benign tumours, lymphomas, Crohn's disease, duodenal haematoma, adult pyloric hypertrophy, annular pancreas and mucosal diaphragm. Benign pyloric stenosis usually occurs in a patient with long-standing symptoms of ulceration. Vomiting and anorexia supervene. The typical vomiting of pyloric stenosis is projectile and the vomitus is characterized by an absence of bile and the presence of partially digested food eaten hours or even days previously. With repeated vomiting and failure to eat, the patient often becomes constipated, although in some cases diarrhoea may develop. Examination usually shows an underweight patient, dehydration and often a degree of iron-deficiency anaemia. A succussion splash may be present and visible contractions passing across the upper abdomen from left to right may be observed on inspection. Prolonged vomiting of gastric contents results in characteristic electrolyte disturbances. Initially, the major loss is fluid rich in hydrogen and chloride ions so that dehydration is accompanied by hypochloraemic alkalosis. At this stage the serum sodium is usually normal and hypokalaemia may not be obvious. More marked metabolic changes supervene as a result of continued losses and secondary changes in renal function. Initially, the urine is characterized by a low chloride content and is appropriately alkaline because of enhancedbicarbonate excretion compensating for the metabolic alkalosis but at the expense of sodium. If gastric losses continue, the patient becomes progressively hypovolaemic and hyponatraemic. In an attempt to conserve circulating volume, sodium is retained by the kidneys and exchanged for hydrogen ions and potassium. At this late stage, the patient has a metabolic alkalosis and, paradoxically, an acid urine. As a secondary effect of the alkalosis, the concentration of plasma ionized calcium may fall so that disturbances of consciousness and tetany may be apparent. The priority in management of the advanced case of pyloric stenosis is correction of the fluid and electrolyte

CT showing pyloric obstruction by an antral carcinoma.

disturbances. Rehydration is achieved by saline infusions with potassium supplements as indicated by electrolyte determinations. Gastric lavage is performed with a widebore tube using isotonic saline daily until the returning

fluid becomes clear. The surgical treatment of pyloric stenosis caused by duodenal ulceration/fibrosis is truncal vagotomy and posterior gastroenterostomy. In western countries the majority of cases of gastric outlet obstruction are caused by distal gastric cancer.

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PEPTIC ULCER DISEASE

Worldwide, duodenal ulcers are more common than gastric ulcers and there is a significantly higher incidence of duodenal ulceration in males of all age groups. Dietary factors, drug ingestion (NSAIDs) and smoking are important in the aetiology. The most common causes are environmental ulcerogens (chemical or infective) acting in consort with factors that impair gastric mucosal resistance to injury and healing of mucosal lesions thereby leading to chronicity. The most important infective agent responsible for peptic ulceration (duodenal and gastric) is H. pylori. Not all patients who are infected with this organism develop ulcers. The risk of peptic ulceration is determined by the severity of the H. pylori-associated gastritis. The organism impairs the mucus-bicarbonate protective layer and is responsible for the chronicity and the tendency to relapse, as evidenced by the permanent healing when infection is eradicated by appropriate antibiotic therapy. Strains of H. pylori with vacA signal-sequence type S1A are associated with severe gastritis and duodenal ulcers, whereas vacA S2 strains cause mild gastric mucosal inflammation without ulceration. The most important group of chemical ulcerogens is constituted by aspirin and other NSAIDs. These are the most common cause of peptic ulceration in H. pylorinegative individuals. However, these drugs are not specific gastroduodenal ulcerogens as they also induce damage and ulceration of the small and large intestine. There are a number of differences between ulcers caused by H. pylori and those caused by NSAIDs.

•      NSAID-associated ulcers are more likely to cause gastrointestinal haemorrhage. Thus, overall 75% of patients with upper gastrointestinal bleeding from peptic ulcers are on NSAID medication.

•      Gastric ulcers caused by H. pylori are rarely encountered on the greater curve (5%), being most commonly situated on the lesser curve (85%). In contrast, NSAIDassociated ulcers (in the absence of H. pylori infection) occur along the lesser and greater curvatures in 35 and 45% respectively.

Infection with H. pylori and use of NSAIDs is encountered in 20% of patients. Eradication of the infection does not influence the healing and recurrence of gastric and duodenal ulcers associated with chronic NSAID medication.

Although some 30-40% of duodenal ulcer patients exhibit acid hypersecretion, the overlap between the acid secretory status of these patients and controls is considerable. Gastric acid is an important factor in the chronicity of the disease and suppression of acid secretion by medical or surgical treatment undoubtedly permits healing in the majority of patients. The secretory characteristics of the usual duodenal ulcer patient include increased acid secretory capacity, increased gastrin response to food and insulin, increased sensitivity to gastrin and defective inhibition of acid secretion. There is an increased concentration of pepsins in the gastric juice of patients with duodenal ulceration, especially pepsin I (the most mucolytic). The disruption of the mucus-bicarbonate layer by pepsin I exposes the underlying mucosa to injury by ulcerogens and impairs healing by removal of the protective mucus cap (blister effect). Stress induces gastric hypersecretion and can lead to acute (stress) ulceration in seriously ill patients.

Upper gastrointestinal endoscopy showing duodenal ulcer.

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UPPER GASTROINTESTINAL BLEEDING

Bleeding from the gastrointestinal tract may be caused by lesions located in the foregut (oesophagus, stomach and duodenum), midgut (small bowel up to mid transverse colon) and hindgut (distal colon and rectum). The bleeding  may be acute when the patient presents with hypovolaemia, or chronic when the clinical picture is that of symptomatic anaemia. The common causes of acute upper gastrointestinal haemorrhage are:

• •         chronic peptic ulceration;
• •         NSAID-induced bleeding;
• •         oesophagogastric varices.

Irrespective of the cause, the vomited blood (haematemesis) may be fresh (in severe active bleeding as from ruptured oesophageal varices) or chemically altered (because acid digestion simulates 'coffee grounds'). Extensive gastrointestinal bleeding also gives rise to the passage of black  foul-smelling liquid faeces known as melaena. Patients taking NSAIDs have a threefold risk of gastrointestinal haemorrhage, surgery and death compared with non-users. The risk from bleeding is greatest in:

• •         first few months of treatment;
• •         the elderly (> 65 years);
• •         patients with concomitant steroid use;
• •         patients with a previous history of gastrointestinal events.

Of all the NSAIDs known to cause bleeding or perforation, aspirin produces the most damage. There is some evidence that the newer NSAIDs (e.g. nabumetone) that selectively inhibit cyclooxygenase-2 are less damaging to the gastroduodenal mucosa and hence significantly less ulcerogenic but they appear to be less effective clinically in relieving pain. The other problem with NSAIDs is the development of non-specific ulceration of the upper small intestinal mucosa, which can bleed and perforate. Gastrointestinal haemorrhage may be caused by both benign and malignant tumours. However, acute haemorrhage is more commonly associated with benign  lesions such as neurofibromatosis and mesenchymal (smooth muscle) tumours. Malignant tumours (carcinoma and lymphomas) more usually cause chronic blood loss with the development of iron-deficiency anaemia, although massive bleeding may be precipitated by combination chemotherapy (see later). Life-threatening bleeding or perforation from necrosis of the tumour may complicate chemotherapy for gastrointestinal tumours,  especially lymphomas. Stress ulceration is usually encountered in critically ill patients nursed in the intensive care unit, although its incidence has declined.

Other causes of acute upper gastrointestinal bleeding include Dieulafoy's lesion, portal hypertensive gastropathy and watermelon stomach.

•         Dieulafoy's lesion (exulceration simplex) consists of a nodule containing a visible vessel covered with normal mucosa. Treatment is by endoscopic electrocoagulation or sclerotherapy.

•         Portal hypertensive gastropathy develops in some patients with cirrhosis and portal hypertension with progressive liver damage and affects predominantly the fundus but may be generalized.

•         Diffuse vascular ectasia (watermelon stomach) consists of ectatic mucosal sacculated vessels in the lamina propria traversing the antrum and sometimes the duodenum. The endoscopic appearance bears some resemblance to the stripes of a watermelon. The bleeding is often recurrent requiring multiple transfusions. Portal hypertensive gastropathy and diffuse gastric vascular ectasia are probably related.

The treatment of acute upper gastrointestinal haemorrhage is based on the following principles.

•         Resuscitation: volume replacement with crystalloids, colloids and blood.

•         Early endoscopy: for diagnosis and endoscopic control of bleeding.

•         Combined management by gastroenterologists and surgeons with early recourse to surgery if bleeding continues or recurs.

Sometimes there is clear evidence of upper gastrointestinal bleeding without apparent cause. In these patients, mesenteric angiography and small-bowel enteroscopy often locate the source of the bleeding.

Chronic gastrointestinal bleeding is unnoticed by the patient and for this reason is referred to as occult. The constant drain results in depletion of iron stores and thus the development of iron-deficiency (hypochromic microcytic) anaemia. When discovered this must always be investigated as follows:

•         faecal occult blood;

•         upper gastrointestinal endoscopy;

flexible sigmoidoscopy and barium enema or colonoscopyif upper gastrointestinal endoscopy is negative. Carcinoma of the caecum and ascending colon most commonly presents as iron-deficiency anaemia as does carcinoma of the stomach.

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DYSPEPSIA

Gastroduodenal disease produces varied symptoms described by the term 'dyspepsia'. Dyspeptic symptoms are extremely common in the general population. An agreed international definition is 'episodic or persistent abdominal symptoms, often related to the intake of food, which patients or physicians believe to be due to disorders of the proximal portion of the digestive tract'. The symptoms included in this generic definition of dyspepsia are:

•         pain or discomfort in the upper abdomen;

•         nausea and vomiting;

•         early satiety;

•         epigastric fullness and regurgitation.

There are two categories of dyspepsia: organic and nonorganic (no demonstrable focal lesion). The prevalence of organic dyspepsia increases above the age of 40-45 years. There are four subgroups of dyspeptic patients based on the predominant symptoms:

•          ulcer-like;
•          reflux-like;
•          dysmotility-like;
•          non-specific.

Symptoms alone do not differentiate between organic and non-organic disease. Hence history does not always predict the underlying cause of dyspepsia and for this reason investigation by endoscopy is necessary for certain

groups:

•          patients who are H. pylori positive;
•          patients with a history of using non-steroidal anti-inflammatory drugs (NSAIDs);
•          patients with alarm/sinister symptoms (loss of appetite, weight loss, bleeding).

Alarm symptoms

Loss of appetite, weight loss, recent-onset dyspepsia, constant upper abdominal pain and evidence of bleeding are regarded as alarm or sinister symptoms and thus require urgent endoscopy, particularly if the patient is over 40 years of age. Weight loss and loss of appetite associated with early satiety/abdominal discomfort are suspicious of a gastric neoplasm.

Investigations

Endoscopy and radiology

Upper gastrointestinal endoscopy is necessary for the following

groups of patients.

•         Individuals > 45 years old testing positive for H. pylori, with persistent symptoms despite eradication treatment.

•         Individuals > 45 years old, never investigated, H. pylori-negative and no intake of NSAIDs, with persistent symptoms despite acid-lowering treatment.

•         Individuals > 45 years old with a previous history of gastric ulcer, no H. pylori testing or H. pylori test negative, with persistent symptoms despite acid-lowering drugs.

•         Gastrointestinal bleeding: acute and chronic. Contrast swallow and meal examination is seldom used in the investigation of patients with dyspepsia because endoscopy has a higher diagnostic yield and permits biopsy with histological diagnosis. However, contrast radiology is needed in:

•         patients with gastric cancer undergoing surgery (precise location of lesion);

•         patients with hiatus hernia undergoing surgery (type and size of hernia);

•         suspected perforation/anastomotic leak (water-soluble contrast must be used). Barium studies are unreliable in the assessment of a patient with acute upper gastrointestinal bleeding. Endoscopy is the preferred investigation in this situation.

Tests for H. pylori infection

The most commonly performed are the rapid ureasetests, which are carried out on endoscopic biopsies. These tests use kits such as the Campylobacter-like organism (CLO), Hpfast and Pyloritec and provide a result within 3 h of endoscopy. Other tests include culture in a microaerobic environment, polymerase chain reaction, histology of the antrum and corpus (Giemsa or Warthin-Starry silver stain), 13C urea breath test, and serology for detection of H. pylori-specific antibodies.

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WEIGHT LOSS IN GERIATRIC

Weight loss improves many of the adverse health outcomes associated with obesity, including preventing or delaying the onset of diabetes, improving blood sugar control in those with diabetes, reducing low-density lipoprotein (bad cholesterol), raising high-density lipoprotein (good cholesterol), improving hypertension, improving symptoms of osteoarthritis, and providing an improved sense of well-being. Individuals must only lose a small percentage of their weight (B5–10%) to begin seeing these improved health outcomes. As many people know from their personal experiences, weight loss is difficult and lost weight is often regained for a variety of reasons. Returning to the original concept of energy balance, the formula for weight loss is predictable. To lose weight, energy expenditure must be greater than energy consumption.

The first recommendation therefore is lifestyle modification with a combination of increased exercise and decreased intake (diet modification). The amount of exercise needed to lose weight is variable. Current recommendations from the US Surgeon General is for adults to engage in an activity of moderate intensity (such as brisk walking) for 30 min daily or more strenuous activities (such as jogging) for 15–20 min daily. Additional exercise will increase energy expenditure and may result in further favorable health outcomes. Caloric restriction through dieting is also essential for losing weight. The ideal diet has not yet been established, but the principle of reducing caloric intake along with ease of long-term compliance remains the cornerstone of any diet. The American Dietetic Association currently changes their recommendation periodically in an effort to determine the most helpful, practical diet, based on current data. The problem with short-term dieting is that weight loss can rarely be maintained once the diet has ended. Exercise may help maintain some of the weight loss.

Some medications exist for weight loss. These medications are moderately effective, although they often have side effects that limit their widespread use. The history of diet medications has been plagued with adverse health outcomes, including valvular heart disease and heart arrhythmias. Many of these medications have focused on increasing the metabolic rate or suppressing appetite. One such medication that has been approved for use in the United States for weight loss is orlistat. This medication uses a novel mechanism to prevent the body from digesting a portion of the fat that has been ingested, thereby lowering the number of 280 Obesity calories absorbed. The undigested fat is excreted out of the body via bowel movements. This medication has minimal systemic side effects since there is little absorption; however, it results in uncomfortable changes in bowel movements such as oily discharge and increased frequency of bowel movements. Another medication available for weight reduction is sibutramine. The mechanism of action is inhibition of norepinephrine, dopamine, and serotonin reuptake, resulting in weight loss from appetite suppression, possibly combined with an increase in thermogenesis from stimulation of adipose tissue. Use of this medication combined with diet and exercise results in modest reduction (B7%) in weight at 1 year, although sustained weight loss at 2 years is less robust. Because of the high failure rates of lifestyle modification and medical therapies, surgical approaches for weight loss are becoming widely available. The most successful of these surgeries is the gastric bypass. It works by decreasing the size of the stomach, to achieve satiety earlier, as well as by bypassing part of the small intestine, which results in fewer calories being absorbed. This surgery is very effective in achieving weight loss and improving many of the obesity-related diseases. Complications include nutritional deficiencies, postoperative wound infections, leaks at the surgical sites, and postoperative mortality (B1.5%). Due to these risks, this therapy should be reserved for patients who are morbidly obese (BMI 440 or BMI 435), who have obesityrelated diseases, and who have failed behavioral modification therapies.

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THE IMMUNE MECHANISM

The actual body's defence mechanism is a remarkable safeguard procedure. That creates quick, particular, and also safety responses from the range likely pathogenic microbes in which inhabit the entire world by which we reside. The tragic examples of acquired immunodeficiency syndrome (AIDS) and the inherited severe combined immunodeficiencies (SCID) graphically show the outcomes of a nonfunctional adaptive body's defence mechanism. HELPS individuals and also young children using SCID frequently tumble unwilling recipient to be able to attacks which might be of minimal end result to be able to individuals with normally functioning immune system techniques. The actual body's defence mechanism even offers a role in the rejection of growths and also, when dysregulated, may well promote a few autoimmune illnesses, which include insulin-dependent diabetes mellitus, several sclerosis, rheumatism, systemic lupus erythematosus, and also inflammatory intestinal illnesses, and the like.

Fundamental Immunology offers since its goal this authoritative presentation with the simple portions of this body's defence mechanism, with the implies through which this mechanisms of protection take action throughout many clinical problems, which include healing coming from infectious illnesses, rejection of growths, transplantation of structure and also internal organs, autoimmunity as well as other immunopathologic problems, and also allergy, and also how the mechanisms of protection may be marshaled by means of vaccination to offer security versus microbial pathogens.

The objective of this kind of beginning page is always to produce audience having a basic launch to the existing perception of this body's defence mechanism. It should be of unique relevance for anyone having a constrained backdrop throughout immunology, offering all of them using the preparing meant for succeeding chapters with the book. Instead of offering comprehensive sources on this page, each one of the theme headings will certainly reveal this chapters in which cope in more detail using the theme under conversation. People chapters is not going to provide an prolonged treatment with the theme, nevertheless will even provide this readers having a extensive research listing.

Major Guidelines of Immunity

The actual key rules with the immune system reaction are generally:

•           Elimination of the many microbial agencies throughout the nonspecific safety mechanisms with the inborn body's defence mechanism.

•           Cues on the inborn body's defence mechanism advise this tissues with the adaptive body's defence mechanism regarding unique appropriate to manufacture a reaction and also the type of respond to produce.

•           Cells with the adaptive body's defence mechanism show exquisitely particular recognition of unusual antigens and also mobilize effective mechanisms pertaining to removal of microorganisms displaying such antigens.

•           The body's defence mechanism displays memory space of its past responses.

•           Tolerance of self-antigens.

The others on this starting page will certainly illustrate temporarily this molecular and also cellular time frame with the program and also how most of these key traits with the immune system reaction may be discussed.

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CLASIFICATION ACUTE CORONARY SYNDROME: UNSTABLE ANGINA AND NON-ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Acute coronary symptoms (ACS) details your procession of myocardial ischemia of which runs coming from unpredictable angina on just one end with the range in order to non–ST segment height myocardial infarction (MI) in the other end. Unsound angina is actually known coming from stable angina ( Section 70 ) by the new beginning or maybe difficult of signs or symptoms in the previous sixty nights or maybe by the growth of post-MI angina a day and up following your beginning of MI. If the clinical photo of unpredictable angina is actually coupled with increased guns of myocardial personal injury, for instance troponins or maybe heart failure isoenzymes, non–ST segment height MI is actually determined. The variation in between non–ST segment height MI in addition to MI along with SAINT segment height ( Section 72 ) is actually medically crucial since serious recanalization remedy is very important regarding enhancing the actual end result with SAINT height MI yet is actually less critical with non–ST segment height MI.

CLASIFICATION

Unique major coming from supplementary unpredictable angina is actually of clinical value. Extreme difficult of any coronary stenosis will cause major unpredictable angina through restricting coronary blood flow. Extra unpredictable angina arises because of improved myocardial o2 require superimposed in serious underlying heart problems. The disorders with the probable in order to induce supplementary unpredictable angina contain tachyarrhythmia, fever, hypoxia, anemia, hypertensive problems, in addition to thyrotoxicosis. Extra unpredictable angina ought to take care of along with productive cure with the precipitating ailment. Affected individuals along with non–ST segment height ACS needs to be categorized according to the level of short-term possibility since patients on better possibility make use of earlier, a lot more aggressive cure, in contrast to low-risk patients do not.

Numerous types are actually proposed regarding major unpredictable angina on the basis of showing signs or symptoms. The most frequent tactic  contains several amounts of severeness in addition to several clinical instances, in order to provide 9 classes in most. This particular distinction can be used generally in order to categorize patients regarding study uses, yet no technique can be used extensively with clinical practice.

CLASS OF UNSTABLE ANGINA

Type I 

New-onset, serious or maybe quicker angina (angina <2 a few months with length of time, serious or maybe happening >3 times/day, or maybe angina that is certainly noticeably a lot more regular in addition to precipitated through noticeably less exercise; no relax soreness inside of 2 months)

Type II

Angina on relax, subacute (angina on relax in the before calendar month however, not in the before forty eight hours)

Type III

Angina on relax, serious (angina on relax in the before forty eight hours)

CLINICAL CONDITIONS

Type A

Secondary unpredictable angina (a clearly identified ailment extrinsic on the coronary vascular sleep which includes become more intense myocardial ischemia, at the. gary., anemia, hypotension, tachyarrhythmia)

Type B           

Primary unpredictable angina

Type C           

Post-infarction stable angina (within a couple weeks of any written about myocardial infarction)

DEPTH OF THERAPY

1. Lack of cure or maybe small cure

2. Normal remedy regarding chronic stable angina (conventional dosages of common β-blockers, nitrates, in addition to calcium-channel blockers)

3. Optimum remedy (maximally tolerated dosages of several kinds of common remedy in addition to 4 nitroglycerin)

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CORONARY HEART FAILURE

Cardiovascular failure is often a heterogeneous symptoms by which abnormalities associated with cardiac functionality have the effect of the inability of the heart in order to water pump blood vessels in a production sufficient to satisfy the needs associated with metabolizing tissue as well as a chance to accomplish that only in abnormally raised diastolic challenges as well as quantities. One's heart failure symptoms will be seen as a signs associated with intravascular along with interstitial amount clog (shortness associated with breath of air, rales, raised jugular venous strain, along with edema) and/or manifestations associated with inferior tissue perfusion (impaired exercising patience, tiredness, indications associated with hypoperfusion, renal dysfunction). Cardiovascular failure might happen caused by  bothered myocardial contractility (systolic dysfunction, commonly indicated because lowered eventually left ventricular [LV] ejection small percentage [EF]) enhanced ventricular tightness as well as bothered myocardial peace (diastolic dysfunction, which can be commonly of a fairly standard LVEF) various some other cardiac abnormalities, including obstructive as well as regurgitant valvular sickness, intracardiac shunting, as well as disorders associated with heart rate as well as tempo; as well as claims where the heart is unable to cover with regard to enhanced peripheral circulation as well as metabolic needs. Inside grown ups, LV effort is sort of always found even though this manifestations tend to be mostly individuals associated with suitable ventricular (RV) dysfunction (fluid retention without dyspnea as well as rales). Cardiovascular failure might derive from a intense slander in order to cardiac functionality, such as a huge myocardial infarction (MI), as well as, more commonly, at a serious practice. This focus on this chapter will be within the symptoms associated with serious heart failure, including their business presentation in the acutely decompensated condition. The most common causes of de novo intense heart failure, including MI ( Section seventy two ), valvular sickness ( Section seventy-five ), myocarditis ( Section fifty nine ), along with cardiogenic shock ( Section 108 ), tend to be reviewed anywhere else.

Cure associated with hypertension, which has a focus on this systolic strain, reduces this incidence associated with heart failure by means of 50%. This input is still useful also with affected individuals over the age of seventy-five years old ( Section 66 ). Virtually any input which reduces the chance of any primary as well as repeated MI (e. h., remedy associated with hypertension as well as dyslipidemia, antiplatelet treatment with high-risk individuals, along with aggressive supervision associated with diabetes) will even reduce the incidence associated with heart failure Inside post-MI affected individuals ( Section seventy two ), these kinds of methods in addition β-blockers along with angiotensin-converting enzyme (ACE) inhibitors, using coronary revascularization with selected individuals, can certainly nonetheless prevent the progress associated with heart failure. Inside affected individuals using lowered LVEF, STAR inhibitors along with β-blockers keep as well as wait modern LV dysfunction along with dilation and also the attack as well as deteriorating associated with heart failure. Well-timed input with regard to modern valvular sickness affords a different possiblity to keep inevitable heart failure.

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GERIATRI PARADIGM

Geriatrics is the practice of care for frail older people. The epitome of geriatrics is treating multiple interactive problems that cross domains. In essence, geriatrics represents the intersection of chronic disease care and gerontology. Clinicians caring for older persons need to understand that diseases present differently in older persons, and their management is complicated by the presence of other factors. Older people take more medications, and hence are at greater risk of drug interactions. Older people may face problems in other sectors of their lives, such as their social roles, their economic status, their cognition, and their affect, which complicates treatment for specific health problems.

May be as hard to detect as a new peak among the Alps. The second relevant concept is based on the changes associated with aging. In general, age-related physiological changes are most evident in dynamic measures. Older people do not react to stress as well as their younger counterparts. Most of the manifestations of disease, what we call signs and symptoms, are usually not the effects of the disease per se, but the body’s reaction to the stress produced  by the disease. Little wonder, then, that older people would not show the classic symptoms of a disease, but instead some muted or general response. Whereas a younger person having a heart attack might complain about chest pain, an older person might present with confusion. This same symptom could be caused by pneumonia or a drug reaction. Thus, diagnosing disease in older people is often a much more difficult feat than with younger patients.

Diagnosis is hindered still further by communication problems created by problems with vision, hearing, or dementia. On top of these communication problems, older people often suffer from multiple diseases, making it harder to distinguish the onset or change of a given symptom. The basic technology of geriatrics is the comprehensive geriatric assessment (CGA). Experience has taught that exposing frail older persons to such an evaluation and then returning them to the same care environment did not sustain the effects. Gradually the concept of geriatric evaluation and management (GEM) evolved, which involved treating the patient for as long as needed to implement and sustain the necessary changes in the regimen. Few other approaches to care have been studied as thoroughly as CGA and GEM. Unfortunately, the results have provided a confusing and often contradictory story. Although meta-analyses imply that CGA is effective, the pattern is not consistent. Table 3 summarizes the results of several inpatient CGA/GEM randomized trials. Table 4 offers a comparable summary of outpatient studies. One of the largest and most recent studies was a multisite trial that involved both types of care. Although it was carefully targeted to patients who were deemed likely to benefit, it found scant effects. By contrast, a study that involved a simple home visit by a nurse practitioner to unselected older persons living at home yielded potent benefits, as did a preventive assessment by occupational therapists.

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HEALTH AND CARE SERVICES

Health care for older people involves managing chronic illness. In essence, geriatrics represents the intersection of chronic disease care and gerontology. Diseases present differently in older persons, and their treatment is complicated by the presence of impairments in other domains, such as affect, cognition, and economics. In the United States, older persons are the only group covered by a universal health care insurance system. Nonetheless, there remains substantial geographic variation in access to care. In general, older people still suffer from ageism; decisions about what care they should receive is influenced by beliefs about what is age appropriate.  The story of health care for older persons is inexorably linked to chronic disease. Indeed, chronic disease is the dominant factor in health care for all ages, but its predominance is especially high for older persons.If for no other reason than because such conditions accumulate with time, older people are disproportionately heavy users of health care, largely because they have a heavier illness burden. Figure 1 shows the distribution of chronic illness among elderly persons. In the United States, elderly persons are the only demographic group that has virtually universal health coverage, under Medicare. Addressing chronic care effectively implies drastically changing the current health system, which was developed to address primarily acute problems. The implied reformation addresses a wide range of aspects of care, including the definitions of concepts such as prevention, the role of patients, and even time. Prevention is best thought of in terms of avoiding major catastrophes. In effect, good chronic disease care will handle problems proactively to prevent emergency room visits and hospitalizations

 It is unrealistic to think about managing chronic disease without actively involving patients in their own care. They are the ones who must deal with the disease every day. The challenge lies in determining how to create a productive partnership between patients and their clinicians. Programs designed to give patients a greater sense of empowerment have been promising. Another approach encourages patients to record systematic observations on defined parameters that reflect the clinical course of their diseases and to notify their clinicians when the observed course deviates from what had been expected. Time too takes on a new meaning, beyond that implied by the term ‘chronic.’ In effect, chronic care means thinking in terms of investments. One provides active primary care with the expectation of recouping that effort in terms of subsequent care avoided. Focusing attention on high-risk periods, such as immediately after a hospital discharge, can pay dividends. Nurses working with patients in these situations can improve compliance with postdischarge regimens and prevent subsequent readmissions. Scheduling encounters need to be overhauled. Instead of seeing patients on a fixed time schedule based on a loose expectation of when another assessment is needed, visits should be triggered by patients’ actual courses. They need to be seen when their condition deviates from the predicted path; then they need to be seen quickly to treat the problem before it becomes serious.

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CANCER AND AGE

Cancer is the second leading cause of mortality after heart disease and the leading cause of death among women ages 40 to 79 and men ages 60 to 79. Within the 65þ age group, the population 85 years and older is projected to double from 4.3 million in 2005 million by 2030.

Life expectancy has increased. More people are treated successfully after a cancer diagnosis, resulting in a greater prevalence of the elderly living with or developing cancer. It is important for all professionals dealing with the elderly to understand what the disease is and how to deal with it. In the past, the elderly were denied treatment because they were considered ‘too old.’ We now know that in many instances the elderly do as well or better with cancer treatments than the young. This article reviews the causes and biology of cancer, possible ways of preventing it, clinical descriptions of some of the common cancers, how to screen for cancer, and new targeted treatment options. Cancer may be defined by the four characteristics that describe how cancer cells behave differently from normal cells:

1. Cancer usually begins from a single cell that proliferates to form a clone of malignant cells.

2. Cancer cells grow autonomously, are not regulated by the normal controls, and do not die appropriately via programmed cell death (apoptosis).

3. Cancer cells do not differentiate in a normal coordinated manner and do not look the same as the normal cells surrounding them.

4. Cancer cells develop the capacity for discontinuous growth and spread to other parts of the body (metastasis).

Cancer is also called malignant neoplasm. This implies that the growth is a new growth (neoplasm) that if unchecked will kill the host (malignant). Normal cells can express some of the preceding properties at certain appropriate times, such as in wound healing, embryogenesis, organ repair and regeneration, and revascularization, but the proliferation is coordinated, orderly, and self-limited. In cancer, however, these characteristics are excessive, disordered, and not self-limited, resulting in an inappropriate proliferation (tumor burden) and spread that is inappropriate to the host and that has morbid implications if not successfully treated.

Cancer traditionally was classified as being either a carcinoma or a sarcoma named for the presumed cell of origin: epithelial (carcinoma) or mesenchymal (sarcoma). Recent evidence has demonstrated that most if not all neoplasms arise from immature stem cells that then differentiate along normal cell lines, but mutate and acquire the properties of autonomous growth as described previously. We now realize that carcinomas of the lung, breast, and stomach do not arise from well-differentiated ‘normal’ cells in these organs but from stem cells that begin to differentiate in the direction of these tissues but then become autonomous and have impaired apoptosis. These cells lose their normal self-limiting capacity and acquire properties that allow them to enter the circulation and spread to other organs. These cancer cells are the ‘seed,’ and if other organ’s ‘soil’ supports their growth, metastases grow distant to the primary site.

So the golden age to growth the cancer is in geriatric or in old age so care your health today and keep healthy every day.

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TREATMENT OF HYPERTENSION

The ability to find vulnerable plaques will make it possible to test the hypothesis that vulnerable patients require lower blood pressure, e.g., 120/70 mm Hg. As noted earlier, ACE inhibitors not only reduce blood pressure, stroke risk, and mortality in congestive heart failure, but also reduce the risk of reinfarction and of progressive atherosclerosis. Several mechanisms may contribute, including the anti-inflammatory action of ACE inhibitors. Related and equally promising drugs are the angiotensin receptor blockers, which have the putative benefits of blocking angiotensin-II formed by the action of tissue chymases and of increasing the stimulation of the type 2 receptor of angiotensin-II.207,208 However, limited clinical information, to date, suggests that the benefits are similar to those of ACE inhibitors, albeit with a lower incidence of angioneurotic edema and cough.209 β-adrenergic blockade reduces blood pressure, cardiac contractility, increases diastolic filling time, and decreases vulnerability to arrhythmias. It also reduces the risks of reinfarction and of mortality in congestive heart failure. The mechanism(s) by which beta-blockers reduce the risk of infarction are not clear, but may simply relate to the reduced number of heart beats and the reduced rate of pressure rise in the coronary arteries. The recently released Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) suggested that the benefits of diuretics are essentially equal to that of ACE inhibitors and beta-blockers, but the caveat is that most ALLHAT patients did not have coronary atherosclerosis.

Thus, the multiple demonstrated benefits of ACE inhibitors and beta-blockers in patients with known coronary disease should not be ignored. Inhibition of Neovascularization Inhibition of neovascularization is another potential method for stabilizing plaques and reducing plaque growth. Folkman’s lab 212 used recombinant murine angiogenesis inhibitors (endostatin and TNP-470) in apolipoprotein E–deficient (apoE−/−) mice and showed that these drugs significantly reduce plaque progression (by 85% and 70%, respectively) without affecting cholesterol levels.

Local and Regional Therapies Stenting, clopidogrel, and GPIIb/IIIa inhibitors reduce the incidence of acute complications with angioplasty. New drug-eluting stents, in particular, have been shown to markedly reduce restenosis rates. Together with the recent recognition that percutaneous coronary intervention (PCI) serves mainly to reduce angina and increase walking distance some 20% to 30%, whereas most MIs and coronary deaths are precipitated by thrombosis of a plaque less than 50% diameter stenosis (DS), and that most patients with MI have a second or even a third vulnerable lesion, interventional cardiologists are now planning trials of stenting for hot plaques. Despite their cost, drug-eluting stents are particularly attractive for treatment of vulnerable plaques because macrophage content has repeatedly been shown to predispose to restenosis.214 Moreover, Stefanadis . 100 found that warmer lesions post–percutaneous transluminal coronary angioplasty (PTCA) had a higher rate of subsequent events. Interventionalists have also noted that plaque vulnerability could help decide whether to intervene on a 50% to 70% DS lesion, or influence stent selection. For example, if a 20% stenosis that is 10 mm downstream of the ischemia-causing culprit is hot or otherwise vulnerable, the interventionalist may select a stent that is long enough to treat both lesions.

Balloon Angioplasty with Drug-Eluting Stents Balloon angioplasty has been used in humans since 1977, and the advent of coronary stenting in 1986 led to a marked reduction in the postangioplasty restenosis rate. Further improvement has been achieved with stents coated with antiproliferative drugs (such as sirolimus and paclitaxel), which can potentially abolish in-stent restenosis. The concept of local drug delivery via coated stents offers both the biologic and the mechanical means of preventing such restenosis. Several drugs are being used for this purpose. Paclitaxel- and sirolimus-eluting stents have been studied extensively with major success in minimizing the risk of in-stent restenosis.

Newer stent designs and new molecatheroscl erotic vulner abl e plaque s 633 ular and cellular stents including those covered with stem cells are under development and may confer major improvements in the field. The potential benefit of stenting hemodynamically nonsignificant but vulnerable (e.g., hot, remodeled) plaques remains to be investigated in randomized clinical trials. Several drugs with different mechanisms of action (antiproliferative, anticoagulant, antiinflammatory, gene transferring, etc.) are being investigated for use in these stents. Better characterization and classification of each lesion with new detection techniques will help investigators decide which coated stent is best suited for treating a specific lesion. Use of antiproliferative drugs in oral form after stent implantation is another promising therapy for preventing restenosis. Farb and ,coworkers223 used oral everolimus (amacrolide of the same family as sirolimus) to inhibit in-stent neointimal growth in the iliac arteries of rabbits. This drug reduced in-stent neointimal growth significantly (42% to 46%). The safety and efficacy of such treatment in humans.

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HYPERTENSION

Casual Office Blood Pressure Blood pressure is normally distributed within the population, with no natural cutoff point allowing discrimination between normotensive and hypertensive individuals. Moreover, the tendency for blood pressure to rise with age makes it difficult to apply uniformly any criteria of normal blood pressure. In women the blood pressure rise is steeper after menopause.The definition of hypertension is in some way arbitrary. By choosing specific blood pressure levels as upper limits of normal it is meant that the cardiovascular risk becomes high enough to warrant an intervention. Most socalled hypertensive individuals have only slightly elevated blood pressures. Even small blood pressure reductions in these hypertensives are associated, in terms of public health, with a substantial reduction in cardiovascular morbidity and mortality. The proposed definitions of normo- and hypertension proposed by major guidelines are very similar.192–196Table 86.8 gives as an example the definitions proposed by the Joint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure in the U.S.A. (JNC 7 Report).The key point is that a blood pressure 140 mm Hg for systolic and/or ≥90 mm Hg for diastolic has to be considered as abnormally elevated. Isolated systolic hypertension is defined as a systolic blood pressure ≥140 mm Hg together with a diastolic blood pressure <90 mm Hg. Individuals with blood pressures at the upper range of normalcy should be followed regularly and be advised to initiate lifestyle modifications. The definitive diagnosis of hypertension should be based on repeated blood pressure measurements on different occasions. The goal of treatmentis to bring blood pressure below 140/90 mm Hg using lifestyle measures together with pharmacologic treatment when needed. Strict blood pressure control (<130/80 mm Hg) is required in patients with diabetes or chronic renal disease. Lower targets are even desirable if proteinuria is >1 g/day.

 Noninvasive Ambulatory Blood Pressure in hypertension

Monitoring Blood pressures recorded during everyday activities away from the medical setting are usually lower than casual office blood pressures.198 Target-organ damage is more closely associated with ambulatory blood pressures than conventional casual blood pressures, as a consequence mainly of the large number of blood pressure readings made available by ambulatory recordings.226 Nighttime blood pressure is normally lower than daytime blood pressure. The lack of a normal nocturnal decline in blood pressure may be seen in patients with essential hypertension, but is observed particularly in patients with secondary forms of hypertension, in preeclampsic women, in patients with sleep apnea syndrome, and in diabetics with peripheral neuropathy. A blunted day–night fall in blood pressure seems to be harmful. An extreme nocturnal dipping, however, may represent an increased risk of stroke. Table 86.9 shows the normal ranges that are currently proposed. There is still no firm consensus on the use of noninvasive blood pressure monitoring. This technique allows the detection of patients with white-coat hypertension, that is, patients whose blood pressures are high only in a medical setting.227 White-coat hypertension is encountered commonly, in approximately 20% of mild hyper tensives. In general, target-organ damage in white-coat hypertension is less prevalent than that in sustained hypertension. Patients with white-coat hypertension, however, seem to have a higher cardiovascular risk than do normotensives. They should be advised to initiate lifestyle changes and followed regularly as they are prone to develop sustained hypertension.The main indications for ambulatory blood pressure monitoring are considerable variability of office blood pressure, high office blood pressure in patients with low global cardiovascular risk, treatment-resistant hypertension, and the presence of symptoms possibly attributable to hypo- or hypertension.

Self-Measurement of Blood Pressure in hypertension

Self-monitoring of blood pressure by patients at home has become increasingly popular in recent years, in parallel with the exploding availability of electronic, easy to use, and affordable blood pressure measuring devices.228 Home blood pressures are usually lower than office blood pressures and have a better prognostic significance than blood pressure obtained in a clinical setting. The value of 135/85 mm Hg may be considered as the upper limit of normality. Training of patients is essential to obtain reliable blood pressure readings. Patients should measure their blood pressure at home twice in the morning and twice in the evening for at 3 working days if a therapeutic decision has to be taken. Self–blood pressure monitoring is particularly helpful to detect white-coat hypertension, to guide antihypertensive therapy, and to improve the patient’s compliance with antihypertensive therapy.

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PREVENTION ABOUT CARDIOVASCULAR DISEASES

For many years, organizations have sought to prevent the development of coronary heart disease in the many countries of the world. The World Health Organization (WHO) in its constitution states that health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. In the declaration of Alma Ata in 1978, it is further stated that the existing gross inequality in the health status of the people, particularly between developed and developing countries, is politically, socially, and economically unacceptable, and it is therefore of common concern to all countries. Others have spoken of the moral principles underlying the care of others.26–28 However, it is only recently that this problem has been approached more directly. The Framework Convention on Tobacco Control adopted at the 56th World Health Assembly in 2003 has had considerable impact around the world, not only in encouraging countries to introduce legislation, but also in changing the mood and minds of the public to regard smoking as the loathsome habit it is. Equally, the Global Strategy on Diet, Physical Activity, and Health, which was adopted at the 57 World Health Assembly in 2004, may have the same consequence. Informing the public and politicians of the size and nature of the problem may have greater consequences overall than many other approaches. Those responsible for intervening are many, but too often groups of experts claim this problem to be their own. The greatest need is for more cooperation among experts. Epidemiologists, health economists, the media, and politicians need to demonstrate a more active role. Nurses, health workers, and primary physicians can influence the public and patients and their families. Hospital physicians, cardiologists, and university scholars must emphasize the importance of the prevention of disease rather than the cure of the acutely ill. There is a role for medically qualified persons, but a greater role in prevention for those who work in professions closely allied to medicine. Perhaps the greatest responsibility resides with political leaders who need to consider the implications for coronary heart disease when making political decisions on socioeconomic factors in a country and on fiscal matters. Reducing multiple risk factors will not bring about total equity around the world in terms of healthy life expectancy, but it will reduce substantially the current differences in equality. The reduction in the costs of drugs as they come off patent will make them more available to the global population. International collective action,30 engagement of developed countries,31 action by civil society,32 and above all, involvement of the public and patients are essential for a successful program of prevention. 

The preventive approach to heart disease is undervalued and underused around the world. This is partly because of a lack of knowledge and partly because of the desire of physicians to treat the acutely sick. Gains from prevention are not immediately evident so that the elation associated with bringing about an immediate impact on a patient’s condition is absent. Some commercial interests may obstruct policy.

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FACT, ARTHEROSCLEROSIS IN CARDIOVASCULAR DISEASES

Consequences of atherosclerosis are grouped under the broad phrase “cardiovascular diseases,” which is made up of coronary heart disease, cerebrovascular disease, and other circulatory disorders. These afflictions include the many manifestations of coronary heart disease, such as myocardial infarction, acute coronary syndromes, and heart failure, and the consequences of peripheral disease, such as stroke, peripheral vascular disease, aortic disease, and renal failure. Myocardial infarction and stroke have become the major global causes of death and disability around the world. Much is now known about the natural history and pathophysiology of atherosclerosis. The disorder begins in childhood and the lesions in the arterial vasculature develop over many decades. The clinical sequelae appear in middle age or later life. Cardiovascular disorders are becoming more common and dominate patterns of disease in most countries primarily because of the epidemiologic transition from communicable (infectious disease) to noncommunicable disease (chronic diseases) as the major cause of death and disability around the world.7,8 With the decline of infectious diseases, particularly in the young, life expectancy, the global population, and the proportion of elderly persons in most countries has increased. In 1950, the global population was 2.5 billion. In 2000, it was 6.0 billion, and it is estimated to reach 9.0 billion by 2050. These demographic changes are the second major cause of the increase in the impact of cardiovascular disease.

The size of the problem around the world is difficult to estimate. Whereas reliable figures may be available in developed countries, in many parts of the world, there is not sufficient organizational capacity to obtain accurate figures. The diagnosis may be used to explain deaths to the satisfaction of grieving relatives with little attention to accuracy. In many countries, coronary artery disease is a socially acceptable cause of death. Without postmortem evidence, the diagnosis may be in error. Equally, it may be overlooked particularly in patients dying suddenly where often the diagnosis is in fact acute myocardial ischemia. A further difficulty can arise in some countries because health authorities have no interest in coronary artery disease, regarding it as a disease of the elderly, a pleasant way to die, a personal responsibility, a disease of affluence, and a problem limited to the male gender. All five of these beliefs and attitudes are serious misconceptions and untrue. The consequences of atherosclerosis in causing cardiovascular deaths have been estimated by the World HealthOrganization (WHO)

Changing Pattern of Disease Around

the World

The 20th century saw a most remarkable increase in public health. Life expectancy measured in years accrued is possibly the crudest but simplest measure of public health. Over the last century, life expectancy in what are now developed countries increased from about 40 years to almost 80 years. In general, women have a life expectancy 1 or 2 years greater than men, and that greater longevity has been maintained as life expectancy has increased. The large increase in life expectancy has been brought about partly as a result of

medical treatments, but also as a consequence of social and hygienic change reducing the impact of infectious diseases. One consequence is that the proportion of elderly persons in populations is changing rapidly and will do so for the next several decades. Such an alteration in the demography

of society has major implications for economic and social change in many countries. A second consequence is that in developed countries there has been a major switch in the causes of death. The pattern of disease whereby infections were the dominant causes of death has been replaced by chronic diseases, and notably atherosclerosis, as the primary cause. That epidemiologic transition in health is common around the world. However, in poorer countries noncommunicable diseases continue to be the dominant cause of death

. Those countries can be expected to change their pattern of disease as public health improves.

It is a common belief that poverty and economic prosperity are closely linked to health, but it is not so. Among countries with a high life expectancy, there is considerable variation in income per capita. Among countries with a low income per capita, there is a large difference in life expectancy. The precise reasons are many and complex.

Risk Factors cardiovascular diseases

The so-called risk factors for coronary heart disease are well known. These risk factors appear to be similar across all countries regardless of gender, geography or ethnicity.  Variation in the prevalence of heart disease among countries can be largely explained on the basis of the degree to which any particular risk is present. One study19 claims that nine risk factors can account for 90% of cardiovascular events. Furthermore, these risk factors are the same risk factors that are related to cancer, diabetes, and respiratory diseases. The consequence for public health policy is that the modification of risk factors may bring greater benefit to a country than the treatment of specific diseases.

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