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The cation distribution among the A, B, C, and D sites of 13 crystals of chevkinite-(Ce) by X-ray single-crystal diffraction and electron microprobe analyses is reported in this article. The general formula of chevkinite-(Ce) is A4BC2D2O8(Si2O7)2, where A = REE, Ca, Th, Sr; B = Fe, Mn, Mg; C = Fe, Ti, Nb, Zr, Mg, Al; and D = Ti. Ten crystals come from quartz-bearing syenite samples of Agua de Pau (Azores Islands), and three are euhedral chevkinite crystals of a quartz-bearing pegmatite from Tangir Valley, northwestern Pakistan. The real space group for these samples is P21/a, but the average structure in space group C2/mwas used for structural refinement and further interpretation. Cation distribution was determined by minimization of the function fΣNσ2$\begin{array}{} \displaystyle f_{\rm{\Sigma N_\sigma^2}} \end{array}$that represents the sum of the squared numbers of standard deviation by which each expected quantity differs from the calculated one. Both X-ray diffraction and electron microprobe data were considered in minimization. Our results show that the two non-equivalent A sites are occupied dominantly by REE and Ca, distributed mainly as a function of their ionic size. Lanthanum enters only the 10-coordinated A2 site, whereas heavier and smaller REE enter only the 8-coordinated A1. Furthermore, comparison between bond valence sum and formal charge revealed highly stretched bonds for the A1 polyhedron, suggesting that bond lengths are too long for HREE. These findings can help better characterize the well-known ability of chevkinite to fractionate LREE from HREE. The Azores chevkinite is particularly enriched in Nb relative to its host rock. Our results show that Ti occupancy in the D sites can be as low as ca. 50% due to the presence of significant amounts of Nb, besides Fe and Zr. For two Azores crystals showing patchy zoning, a complex history of late-stage crystallization is inferred, with multiple events of Ca and REE enrichments. One of these crystals showed the best structure refinement, implying that late-magmatic to deuteric alteration stages did not affect its crystallinity. The CaO content of Azores chevkinites practically spans the entire chevkinite field in the chevkinite/perrierite CaO vs. FeO discrimination diagram. In addition, we identified possible structural stability limits that can be linked to the occupancy of the B site at high CaO, and of the C sites at high-FeO contents. The Pakistan chevkinites were also analyzed by Mössbauer spectroscopy. Only one Fe3+component was identified, which occupies the C sites. Among the two ferrous doublets, the component with the highest isomeric shift value is Fe2+entering the most distorted crystallographic site B, while the other, representative of a less distorted octahedral site, corresponds to Fe2+entering the D sites.

•Cognitive frailty described coexisting physical frailty and cognitive impairment in nondemented older subjects.•Two subtypes have been proposed: “potentially reversible” cognitive frailty [physical frailty plus mild cognitive impairment (MCI)] and “reversible” cognitive frailty (physical frailty plus pre-MCI subjective cognitive decline).•The prevalence of potentially reversible cognitive frailty was 1 %, with all groups associated to increased incident rate ratios of dementia, disability, and mortality.•A significant difference in disability rates existed between the MCI and non-MCI groups in frail individuals with high inflammation.•With inflammation, a potentially reversible cognitive frailty model may have an additional predictive effect on the disability risk than frailty or MCI alone.

In the Cogne area (Aosta Valley, Western Italian Alps), magnetite mineralization occurs associated with different types of serpentinite (pseudomorphic, rodingitic and magnetite-rich serpentinites), which are also heterogeneous in terms of bulk chemical composition, mineral assemblage and mineral chemistry. The mineralization is hosted by a lizardite-, ±chrysotile-bearing serpentinite showing a pseudomorphic texture after oceanic peridotite. It contains fine-grained magnetite showing oscillatory zoning with Cr-poor cores (~ 0.4 wt.% Cr2O3), which are surrounded by Cr-rich inner euhedral rims (up to 17.0 wt.% Cr2O3), mantled in turn by partially resorbed Cr-bearing outer rims (~ 2.0 wt.% Cr2O3). This dramatic variation of Cr content in magnetite is described by the exchange vector Fe3+ Fe2+ Cr3+ -1 (Mn, Zn, Ni) 2+ -1. The absence of Cr-rich spinel cores suggests that the source of chromium was the Cr-Tschermak component of the orthopyroxene, made available during the serpentinization-related breakdown. In these rocks, lizardite, the primary serpentine phase, is partially overgrown by prograde antigorite, indicating that serpentinization occurred under relatively low-T conditions in a pre- orogenic (i.e., oceanic) setting, and was followed by an Alpine metamorphic re-equilibration. Rodingitic serpentinite and serpentinite rich in magnetite are composed of, in highly variable amounts, diopside (locally with inclusions of partially disordered graphite), calcite, magnetite, andradite/hydroandradite, prograde olivine, brucite and serpentine (mostly antigorite but also relict lizardite), with minor chlorite and accessory apatite. Magnetite content can be very high. In these rocks, magnetite is exceptionally Cr-poor (almost Cr-free). Such almost Cr-free magnetite is characterized by significant Fe2+ ? Mg substitution (2–15 mol.% MgFe2O4). Crystal-chemical investigations confirm that Mg, as in magnesioferrite, shows a strong preference for the octahedral site. Due to Fe2+ ? Mg substitution, the Fe2+ content available for Fe2+ – Fe3+ electron hopping in the octahedral site decreases leaving Fe3+ in excess and giving rise to a charge increase. Additionally, a small Fe3+ - Fe2+ disorder is present at the tetrahedral site (Fe2+T = 0.07 apfu). The bulk-rock compositions and the mineral associations of rodingitic serpentinite and serpentinite rich in magnetite point to a strong metasomatism and iron mobilization sustained by CO2-bearing fluids, developed at the expense of the host serpentinite. These processes likely occurred on the Tethyian seafloor, mediated by fluids sourcing from hydrothermal vents. Thermodynamic modelling suggests that mineral assemblages observed in the Cogne area are consistent with a process of serpentinization coupled with Ca (±Al) metasomatism at 300–360°C. This might have been driven by carbon-saturated C-O-H fluids characterized by CO2 contents comparable to present-day seawater, capable of fixing the redox potential of rocks close to the fayalite–magnetite–quartz buffer. Nevertheless, magnetite and associated Fe-Ni sulphides suggest slight variations in fO2 (and fS2) conditions recorded, ranging from relatively reducing (magnetite–heazlewoodite–pentlandite ± pyrrhotite) towards rather oxidizing (magnetite–millerite–pyrite) assemblages.

The crystal chemistry of the new mineral dissakisite-(La), the Mg-analogue of allanite-(La) with ideal formula CaLaAl2MgSi3O12(OH), was studied by single-crystal X-ray diffraction and Mössbauer spectroscopy. Diffraction data indicated that it has a partially metamict state with expanded cell parameters a = 8.959, b = 5.7226, and c = 10.232 Å, β = 115.19°, and V = 474.7 Å3. The crystal structure was refined to R(I/σ(I) > 4) of 3.45% and wR2 of 8.52% (S.G. P21/m). The displacement parameters are unusually large as consistent with positional disorder. Ca and REE are partitioned between the A1 and the A2 sites, Fe2+between the M3 and the A1 sites, and Fe3+between the M3 and the M2 sites. This confined to A1. The Mössbauer spectrum implies the presence of five different iron sites, three of which are attributed to Fe2+at the M3 site, one to Fe2+at the A1 site, and one to Fe3+at a rather distorted octahedral site.

Coronary disease is currently a major cause of disability and mortality in older populations. Due to several factors - including increased noncardiovascular mortality, atypical presentation of coronary events, selective survival, and, possibly, clustering of protective genetic traits - the relative risk associated with almost all risk factors decreases with advancing age. Nonetheless, all available evidences from both observational studies and randomized trials indicate that, due to the higher event rates, the absolute risk reduction yielded by preventive interventions is much greater in the older age segments of populations. Another implication of the complex relationships between risk factors and comorbid conditions in the pathogenesis of coronary-related events and mortality, typical of the elderly subjects, is represented by the multiple effects of treatment for single risk factors, such as the decrease in LDL-cholesterol levels and inflammation markers yielded by statins. Taken together, these factors account for the more favorable cost-effectiveness ratios of preventive interventions in the older, as compared with the middle-aged subjects. On the other hand, the high level of interaction between coexistent risk factors and comorbidity renders a global approach to the prevention of coronary events in older subjects mandatory for physicians, as well as for decision-makers. In fact, a multidimensional assessment - including the evaluation of cognitive, affective and social disturbances- driving a multidisciplinary treatment of risk factors -encompassing behavioral counseling and social support - is essential to improve patients compliance and to effectively reduce the burden of coronary-related morbidity and mortality in older populations.

Background and aims:Blood pressure is known to be influenced by the season, particularly in the elderly. The association between cold weather and unrecognized hypertension has not been previously studied. The present study aimed at assessing whether recognition of hypertension in the elderly follows a seasonal pattern. Methods:All patients over 64 with either first-listed or secondary diagnosis of hypertension at discharge (N=4487) out of 24585 consecutively admitted to 69 wards of Geriatrics or Internal Medicine during ten bi-monthly observation periods (May–June and September-October) were enrolled. The main outcome of the study was the prevalence of unrecognized hypertension, defined as no mention of hypertension and/or antihypertensive drugs in clinical histories collected on admission, and a first-listed or secondary discharge diagnosis of hypertension. Results:We found a total of 928 patients with unrecognized hypertension. Being admitted in the September–October period was independently associated with the outcome unrecognized hypertension (OR 1.25, 95% CI 1.08–1.46), as were smoking addiction (OR 1.57, 95% CI 1.23–2.0) and allocation to a medical ward (OR 1.21, 95% CI 1.04–1.41). Negative correlates of the outcome were multiple pathologies (OR 0.85, 95% CI 0.73–0.99), discharge diagnosis of coronary artery disease (OR 0.77, 95% CI 0.64–0.92) or diabetes mellitus (OR 0.81, 95% CI 0.67–0.97). Conclusions:Hypertension in the elderly may at least partly follow a seasonal pattern, and this finding may be relevant for screening and therapeutic decisions.

Three natural Mg(Al 2-yCr y)O 4spinels ( y ~0.07–0.16), highly ordered in terms of Mg–Al, and one Mg(Al 2-yFe 3+ y)O 4 spinel ( y~0.08), highly ordered also in terms of Fe 3+, were studied by means of X-ray single-crystal diffraction. All samples were heated in situ from 25 to 1000 °C in order to follow both thermal expansion and evolution of the structural state of spinel with temperature. Thermal expansion was monitored by means of the variation of cell edge a with temperature, and found to be well represented throughout the temperature range by a regression line a = a 0 (1+a? T), slightly different at lower and higher temperatures. Thermal expansion coefficient a 1, referring to the lower temperature range (i.e. during pure thermal expansion), was slightly lower than a 2, calculated only over the highest temperatures. The trend showed different slopes for individual crystals. Structural evolution with temperature was studied by means of the variation of oxygen positional parameter u, which is strongly influenced by intersite cation exchange and thus closely correlated with inversion parameter x. In particular, in the three Cr samples, in which Cr resides only in the octahedral site, u parameter variations and hence the order–disorder process, started at about 700 °C. Instead, in the Fe 3+ sample, this process was triggered at lower temperatures, starting at 550 °C with Fe 3+–Mg exchange followed at higher temperatures by that of Mg–Al. Cr contents in the Cr samples affected the occupancy of Al in the tetrahedral site at the highest temperatures. In both Mg–Al–Cr and Mg–Al–Fe 3+compositions, if Cr~Fe 3+, parameter u reached the same value only when the Mg–Al exchange was dominant, i.e. at the highest temperatures, but not before. Cation distribution at each temperature was obtained by the bond-length model, applying thermal expansion to pure bond lengths. This method is applied here to complex compositions for the first time.

Background and aims:The aim of this study was to analyze trends in the use of ACE-inhibitors in patients aged 65 and older with congestive heart failure (CHF) in the period from 1988 to 1998. Methods:We studied 2985 patients (mean age 79.7±7 years), hospitalized for CHF in 12 different bimonthly periods. Home therapy prior to hospitalization was assessed retrospectively, and data on in-hospital therapy and discharge prescriptions were collected prospectively. Results:Diuretics and digitalis were the most commonly used and prescribed drugs. The use of ACE-inhibitors between 1988 and 1998 increased from 13.4 to 46.7% prior to hospitalization, and from 25.8 to 59.2% as a discharge prescription. The most important factors associated with a prescription of ACE-inhibitors at discharge were previous use (OR 4.35, 95% CI=3.65–5.19), hypertension (OR 1.76, 95% CI=1.47–2.11), valvular heart diseases (OR 2.06, 95% CI=1.51–2.81) and diabetes (OR 1.58, 95% CI=1.29–1.93). Physical impairment was associated with a decreased use of ACE-inhibitors at discharge (OR 0.55, 95% CI=0.45–0.67). Conclusions:The use of ACE-inhibitors for the treatment of CHF progressively increased both at home and in hospital wards of general medicine and geriatrics in the 10-year period studied. Nevertheless, digitalis and diuretics continue to be the most commonly prescribed drugs. A widespread educational effort is needed to increase physicians’ awareness of the rationale for prescribing ACE-inhibitors for CHF patients.

Background and aims:Whether chronic obstructive pulmonary disease (COPD) carries a risk of cognitive dysfunction prior to the onset of arterial hypoxemia is not known. Our objective was to assess both the prevalence and main correlates of sub-clinical cognitive dysfunction in older patients with non-hypoxemic COPD. Methods:Home-dwelling non-demented subjects over 64 years of age consecutively attending 24 outpatient Departments of Respiratory Medicine or Geriatrics because of COPD (N=233), asthma (N=203), non-obstructive bronchitis (N=92) or chronic non-respiratory and non-dementing diseases (controls, N=1080) underwent a multidimensional assessment. Cognitive status was assessed by the Mini-Mental State Examination (MMSE). Independent correlates of MMSE<24 were identified by logistic regression analysis. In order to limit the confounding effect of collinearity between COPD group membership and the 6' walked distance, a properly designed multivariate analysis was performed. Results:Prevalence of MMSE<24 ranged from 16.7% (controls) to 21.9% (COPD). Education <9 years (Odds Ratio=1.56, Confidence Intervals=l.22-1.98), a score >6 on the 15-item Geriatric Depression Scale (OR=1.37, CI=1.16–1.62), a 6' walked distance <242 m (OR=1.22, CI=1.02–1.45), a Barthel Index greater than 80 (OR=1.48, CI=1.03–2.14) and a Forced Vital Capacity inferior to 80% of the predicted value (OR=1.17, CI=1.09–1.38) qualified as independent correlates of MMSE<24. The multivariate analysis confirmed that groups had comparable MMSE scores. Conclusions:Non-hypoxemic COPD did not increase the risk of subclinical cognitive dysfunction in an older population.

Abstract:  Two MgAl2O4 stoichiometric spinel crystals, one natural and one synthetic, were heated from 25 to 950 C and studied in situ by single-crystal X-ray diffraction. The natural crystal, quenched from 850 C, was further heated and cooled. Thermal expansion was characterized, and cation partitioning at the various temperatures was determined according to a model purposely constructed for high-temperature bond lengths. It was found that the structural evolution of the samples with temperature depended on order–disorder at room temperature. At the temperatures lower than the beginning of cation exchange, thermal expansion was completely reversible and the oxygen coordinate remained stable in spite of varying temperatures. At the temperature at which cation exchange starts, the disordered samples first tend to order and then to disorder at higher temperatures, at variance with the ordered sample, which tends to disorder steadily. In general, the evolution of the spinel structural state on cooling and heating over the same temperature range and the same time intervals does not follow the same path. In particular, in the 600–950 C range, only partially reversible order–disorder processes occurred in the time span used for the experiments.

Our study objective was to identify factors predicting length of hospital stay of older patients with exacerbated chronic obstructive pulmonary disease (COPD) through a multicenter, cross-sectional, retrospective study. We examined 3789 patients aged 74.3±11.1 years (mean±SD), 66.1% males, consecutively hospitalized in 32 wards of General Medicine and 31 of Geriatrics in acute care hospitals for exacerbated COPD in 10 bimonthly periods between 1988 and 1997. On admission, patients underwent a structured assessment of demographic data, nutritional status, cognitive and physical functions, comorbidity, and pharmacological therapy in the two weeks prior to admission. Patients were grouped according to whether their length of stay exceeded or not the 75th percentile of stay distribution in each bimonthly period. Variables univariately distinguishing groups were entered into a logistic regression analysis having long-stay as the dependent variable. Living alone (Odds Ratio 1.33, 95% Confidence Limits 1.03–1.70), use of more than 3 drugs prior to admission (OR 1.29, CL 1.09–1.51), use of drugs with respiratory depressant properties prior to admission (OR 1.24, CL 1.05–1.46), and the presence of more than 3 comorbid diseases (OR 1.88, CL 1.61–2.19) were independent correlates of long-stay. Age did not predict length of stay. In conclusion, selected health outcomes and indicators of disease severity, but not age, target COPD patients at risk of longstay. Research is needed to verify whether these data can help program interventions aimed at shortening length of stay and, thus, at reducing annual hospitalization costs of the elderly.

Cognitive dysfunction is a frequent finding among older patients with left ventricular systolic dysfunction; however, the clinical outcomes of such a finding are unknown. Also, disability is a common condition in heart failure, poorly responding to commonly used cardiovascular medications. The association between cognitive dysfunction and disability was assessed in 1583 patients with heart failure, but without cerebrovascular disease, previous stroke, or Alzheimer's disease, who were enrolled during 2 years of a multicentre pharmacoepidemiology survey. The association between groups of variables (demographics, comorbid conditions, medications, and objective tests, including the Hodkinson abbreviated mental test) and functional disability (as indicated by need for intensive assistance in at least one of Katz' activities of daily living) was first analysed using separate age and sex adjusted logistic regression models. Those variables, significant at a p&lt;0.1 level in these models, were simultaneously entered into an age and sex adjusted summary regression model. Among 1583 patients suitable for analysis, cognitive dysfunction (as detected by abbreviated mental test score &lt;7) was detected in 265/461 disabled patients, and in 150/1122 independent subjects (p&lt;0.0001). According to logistic regression analysis, cognitive dysfunction was associated with disability (OR=6.49; 95% CI=4.39-9.59) after adjusting for potential confounders.Thus, cognitive dysfunction in patients with heart failure is independently associated with disability, which currently represents an overwhelming medical and financial problem to patients, caregivers, and public health services. As early recognition and treatment of low cardiac output states might reverse cognitive dysfunction, cost effective treatment for heart failure should include systematic diagnostic and therapeutic approaches to cognitive dysfunction.

To assess the association between in‐hospital use of calcium antagonists and incident reduction in hemoglobin levels, as well as the impact of individual baseline risk for gastrointestinal bleeding on such an association. The association between calcium antagonists and hemoglobin decrease >1.2 g/dL was examined in 6721 patients enrolled in a collaborative pharmacoepidemiology study who did not take calcium antagonists before admission and with baseline hemoglobin ≥12 g/dL. Among these participants, 1076 patients started taking calcium antagonists during their hospital stays. Demographic variables, comorbid conditions, medications, and objective tests that were associated with incident hemoglobin loss in separate age‐ and sex‐adjusted logistic regression models were examined as potential confounders in a summary model. Higher risk for gastrointestinal bleeding was defined by diagnosis, treatment for peptic disease, or both. Hemoglobin decrease was detected in 24% of participants who started treatment with calcium antagonists and in 19% of other patients (P< .0001). In addition, use of calcium antagonists was independently associated with increased probability of hemoglobin loss (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.03 to 1.45; P= .018) after adjusting for potential confounders. Treatment with calcium antagonists was associated with hemoglobin loss in patients with higher baseline risk for gastrointestinal bleeding (OR, 1.67; 95% CI, 1.26 to 2.22; P< .0001) but not among other participants (OR, 1.02; 95% CI, 0.82 to 1.25). Starting treatment with calcium antagonists is associated with a reduction in hemoglobin levels during a hospital stay. However, the increased risk of hemoglobin loss seems to be limited to patients with diagnosis or symptoms of peptic disease. (Clin Pharmacol Ther 2000;67:314–22.) Clinical Pharmacology & Therapeutics(2000) 67, 314–322; doi: 10.1067/mcp.2000.104787

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The Italian Group of Pharmacoepidemiology in the Elderly (Gruppo Italiano di Farmacovigilanza nell'Anziano, GIFA) is a collaborative pharmacosurveillance study in hospitalized patients, sponsored by the Italian National Research Council (CNR) and the Italian Society of Gerontology and Geriatrics. It was founded in 1987 with the aim to constitute a multicentre research group to study quality of care and problems related to pharmacological therapy in the elderly. Until now the GIFA study has completed seven periodical surveys and enrolled a total of 28,411 hospitalized patients in 83 clinical centres. The database of the study contains approximately 174,000 in-hospital drug prescriptions, approximately 88,000 discharge diagnoses and a great deal of data on topical geriatric items such as cognitive performance, disability, comorbidity, adverse drug reactions and incontinence. This paper describes the general organization and the methods of the GIFA study and shows in detail the type of data collected.

We performed this case–control study to evaluate the risk of hypoglycemia associated with the use of antihypertensive drugs in older hospitalized diabetic patients treated with sulfonylureas and/or insulin. All diabetic patients admitted during 4 months in 1988, 1 month in 1991, 4 months in 1993 and 4 months in 1995 (n = 3477, mean age 71.4 ± 0.2 years, 1542 males and 1935 females) were enrolled in the study. During the four annual surveys 86 patients (mean age 71.1 ± 1.4 years, 33 males and 53 females) presented hypoglycemia during hospital stay. The patients who presented hypoglycemia were less frequently users of sulfonylureas and more frequently users of a combination of insulin and sulfonylureas. Use of antihypertensive drugs was similar in the two groups studied, and among potentially interacting drugs considered in the analysis, sulfonamides were more frequently used in patients who experienced hypoglycemia. Moreover, patients with hypoglycemia used a higher number of drugs, had a longer length of stay and had a greater prevalence of hypoglycemia as admission problem. Finally, although not significant, liver and renal diseases were more frequent among patients with hypoglycemia. In the multivariate analysis, contemporary use of insulin and sulfonylureas, liver disease and length of stay were significantly associated with hypoglycemia, while none of the antihypertensive drugs showed a significant association with the occurrence of hypoglycemia during hospital stay. Our results indicate that antihypertensive drugs do not increase the risk of hypoglycemia in elderly diabetic patients.

OBJECTIVES:To determine if body mass index (BMI = weight/height2), predictive of mortality in seriously ill hospitalized and institutionalized patients, is also predictive of mortality in a longitudinal epidemiologic study.

Abstract: A clinopyroxene suite from lherzolite inclusions associated with the Victorian (Australia) “Newer Volcanics” has been investigated with the aim of understanding the clinopyroxene crystal-chemical response to increasing temperature (e.g. a melting model and/or crystallization processes prevailing at high pressure). The M1 clinopyroxene polyhedron dominates the intracrystalline physical-chemical variations, essentially given by the triple substitution AlVIFe M12 Ti4+⇌Cr3+ Fe3+Mg M12+ corresponding to an increase in the volume of M1 with increasing Mg/Mg+Fe2+ (mg) for the clinopyroxene. A relative Ca2+ increase in M2 ensures the necessary charge balance. However, Na+ occupancy of M2 persists to the highest mg values, i.e. maximum thermal stability, where the volume of M2 is the largest due to Fe M22+ depletion. The variations of M1 and M2 volumes are greater than, and opposite to, the variations in the volume of T (tetrahedron) by factors of ca. 3 and 1.5, respectively. Inclusions with relatively low clinopyroxene content (Mt. Porndon specimens) show distinct intracrystalline variations, essentially reflecting lower AlVI, i.e. higher volume of M1, and implying a lower pressure regime compared to clinopyroxene-rich analogues (Mt. Leura specimens). The intracrystalline relationships of the Mt. Porndon clinopyroxene suggest that the host peridotite inclusions survived larger degree of mantle melting at shallower depths relative to the Leura analogues.

The effects of hospitalization on affective status were assessed by an original protocol in 214 consecutive elderly patients (mean age=78.3+/−5.0 years, range=70–92 years). Psychological decompensation was significantly related to length of stay (p&lt;0.01) and drug use (p&lt;0.05) and unaffected by sex, marital status, prior living place, diagnostic category. Affective status and functional status were directly correlated (p&lt;0.0001), although in 51% of medical patients the affective status worsened or remained unchanged despite improved physical function. Improvement in affective status occurred more frequently in surgical patients (p&lt;0.001) due to psychological improvement following surgery. Physicians providing medical and surgical care for geriatric patients must remain aware of the patients' emotional response to hospitalization and illness, given the accompanying risk for psychological decompensation.

The aim of this study was to assess whether assigning a geriatrician to provide daily medical care to geriatric patients in the orthopedic ward can improve the prognosis and reduce the length of stay. Time series analysis was performed in two parts: (1 prospective analysis of two years’ workload, and 2) retrospective analysis of data collected over the 4 years prior to the intervention. Intervention and control populations were pooled, and the effects of geriatric care and patient- related factors on outcome measures were assessed by logistic regression analysis. All subjects were patients aged ? 70 years who attended the orthopedic ward in a university hospital in years 1989–90 (studied group: 287 cases) and in years 1985–88 (control group: 474 cases). In the study period, mortality was 8.4% compared to 18% in 1985–86 (p<0.0006) and 14% in 1987–88 (p<0.01). The operation rate in the study period was 89.9% vs 83.8% in 1985–86 (p<0.02) and 81.8% in 1987–88 (p<0.005). Length of stay was 26.2± 14.4 days vs 32.9± 30.9 days in 1985–86 (p<0.05) and 26.9± 16.5 days in 1987± 88 (NS). Length of stay was more strikingly shortened in the subset of patients with femoral fracture undergoing surgical management (28.5± 12.7 vs 37.6± 32.6 days in 1985–86, p<0.003, and 30.8± 15 days in 1987–88, p<0.02). Given the positive relationship between geriatric care and operation rate (o.r.=1.5, CI=1.1–1.9), the protective effect of surgical treatment on mortality (o.r.=0.6, CI=0.4–0.8) to some extent may mask the collinear effect of geriatric care. We conclude that assigning a geriatrician to assist with the medical care of elderly orthopedic patients in orthopedic wards is associated with increased operation rate, decreased mortality and shortened length of stay. (Aging Clin. Exp. Res. 5: 207- 216, 1993)

Summary Three cases of surgically treated non-neoplastic diseases of the sella (two arachnoid cysts and one empty sella) are reported. All three patients had visual deficits but no gross endocrine disturbances. The study of these three clinical cases and an analysis of the relevant literature suggest a possible unitary hypothesis regarding the pathogenesis of sellar arachnoid cysts and empty sella.

OBJECTIVE:To determine whether older persons with hypertension who use specific calcium antagonists and ACE inhibitors have a different risk of mortality than those using β‐blockers.

Until recently, inotropic therapy has been regarded as the most direct remedy for the left ventricular systolic dysfunction that often underlies the development of heart failure. Nevertheless, all the agents with significant inotropic properties that have been evaluated to date (such as beta adrenergic stimulants, phosphodiesterase inhibitors, and high-dose vesnarinone) showed significant increases in mortality with long-term administration. However, it is noteworthy that the participants in trials to evaluate inotropic therapy were not representative of geriatric heart failure patients for age, gender, and comorbidity. Thus, results from these studies must be interpreted cautiously when treatment for chronic heart failure must be applied to elderly subjects. At present, digitalis is the only inotropic agent recommended for long-term treatment, because it improves symptoms and prevents disease progression through neurohormonal and baroreceptor mechanisms; nevertheless, its long-term safety is still undetermined. The role of low-dose vesnarinone, pimobendan and ibopamine, which share neurohormonal, rather than inotropic, mechanisms of action, is still under investigation. Pending the definition of these issues, ACE-inhibitors and diuretics remain the mainstay of therapy for chronic heart failure.

The objectives of this prospective observational study were to assess whether: 1) midarm circumference (MAC), previously shown to predict in-hospital mortality, maintains its prognostic implication after discharge; 2) in-hospital changes in aspecific indicators of the health status are predictors of long-term survival. The study population consisted of 249 patients from the general community [mean age 80±7 (70–99) years], consecutively discharged from geriatric and medical wards of an acute care hospital. Changes in health status during hospitalization were recorded (dynamic or δ variables) and health-related variables were collected at discharge (discharge variables). The relationship of both sets of variables to survival over a 3-year period was assessed by Cox’s proportional hazards regression analysis. The discriminatory efficacy of predictive models was estimated by the Hanley and McNeil method. Survival curves were drawn with the patients alternatively grouped according to the presence or absence of each of the predictive variables. Serum albumin<3.5 g/dL (hazard rate=0.57, 95% confidence limits=0.33–0.96) and dependency in at least one ADL (h.r.=0.87, c.l.=0.79–0.98) were found to be associated with increased mortality, and δMAC (h.r.=1.03, c.l.=1.01−1.05 ), i.e., there was a positive change or no change in MAC from admission to discharge, with increased survival. A slightly weaker predictive model was obtained using only discharge variables. However, Hanley and McNeil’s analysis showed that both models were far from achieving the optimal discrimination of high from low risk subjects. Effects on survival of individual variables varied in magnitude and dependency on time. We concluded that measuring inhospital changes in nutritional status might improve prediction of long-term survival. Attempts should be made to identify variables having the strongest prognostic implications, and to tailor dynamic assessment to the needs of selected categories of patients.

The aims of the present study were to define the respective roles of the cardiac and respiratory response to exercise as determinants of the age- related physiological decrease in exercise performance, and to assess the relationship between aging and interindividual variability in the response to effort. We studied 91 normal subjects recruited in three age- groups: Group A (42 children, aged 10± 2 years); Group B (29 young adults, aged 27± 5 years); Group C (20 elderly, aged 74± 9 years). All the subjects underwent an incremental cycle ergometer exercise test with a work load increase of 15 W every 2 minutes in groups A and C, and 25 W every 2 minutes in group B, until they achieved 80% of the predicted maximal heart rate. Ventilatory equivalent changes during exercise were significantly lower in group A than in the other two groups, and in group B compared to group C. Exercise- induced changes in oxygen pulse were significantly higher in group A, but no difference was found between groups B and C. Thus, gas- exchange function and overall exercise performance decrease with advancing age, whereas cardiovascular performance is well maintained in normal elderly subjects. Discriminant analysis showed that the exercise response conformed to the group- specific model in 74% and 79% of subjects in groups A and B, but only in 50% of the group C subjects; 5% and 45% of the elderly subjects were functionally classified in groups A and B, respectively. On the basis of these data, it may be concluded that aging accounts for a dramatic increase in interindividual variability in adaptation to physical effort, and that the inverse relationship between age and exercise performance is mainly related to the declining efficacy of the respiratory response to effort with age. (Aging Clin. Exp. Res. 6: 267–275, 1994)

Laxatives are frequently taken especially by older persons, who have multiple diseases and are disabled. Major differences exist among countries in the type of laxatives taken, and knowledge of the intake patterns is important because of the potential adverse effects associated with particular ingredients. Laxatives and factors related to their use are described in a sample of 3257 patients admitted to 58 hospitals of the Gruppo Italiano di Farmacovigilanza nell’Anziano (GIFA) in 1991. The mean age was 68.2 years, median 73 years, more than 30% were age ?80 years, and 48.7% were men. The overall prevalence rates of laxative use during hospital stay and prior to admission were 11.5% and 11.3%, respectively. Increasing age was independently associated with laxative use after adjusting for gender, activities of daily living, cognitive function, number of active medical problems, medications taken, Italian region and length of stay. After excluding the prescriptions for hyperammoniemia, lactulose was the most frequently taken laxative (prevalence: 6.7% during hospital stay and 4.3% prior to hospital admission), followed by anthranoid laxatives such as senna, cascara, rhein and aloe (1.9% in- hospital and 3.3% pre- hospital). Other less frequently taken laxatives were picosulfate, phenolphthalein, lactitol, glycerol, bisacodyl and docusate. These patterns differ substantially from those reported by surveys conducted in other countries. Further studies are needed to assess the risks and benefits related to the intake of specific laxative ingredients. (Aging Clin. Exp. Res. 7: 128–135, 1995)

The value and limits of ultrasonic cardiac imaging in elderly patients with congestive heart failure (CHF) are not yet fully known. We report the results of an echocardiographic survey on 154 consecutive elderly persons with chronic CHF. The aim of this study was to establish the feasibility and the diagnostic yield of echocardiography in this population, and the relationship, if any, between left ventricular systolic function and main clinical parameters. Satisfactory cardiac imaging was achieved in 118 patients (77%). All patients had abnormal echocardiograms, although no single abnormal finding was present in all the cases. Echocardiography (ECHO) confirmed 147 previously diagnosed CHFs, and further detected a silent coronary artery disease in 26 cases, a valvular disease in 22, and an atrial septal defect in one patient. The most frequent findings were left ventricular (LV) mass increase and dilation (70% and 68%, respectively), and mostly degenerative valvular disease (40%). The LV ejection fraction was within normal limits in 44% of the cases. Although a depressed LV systolic function was more common among patients in III or IV NYHA class, no clinical parameters could identify the 52 patients with normal ejection fraction. Thus, ECHO could play a key role in evaluating CHF in elderly patients. In these patients, due to misleading signs and symptoms, and to multiple CHF etiologies, basic structural and functional features are frequently missed by clinical investigation, chest x-ray and electrocardiography. (Aging 3: 257–262, 1991)

A retrospective study of the autopsy rate of the clinico-pathological correlations was made in a group of inpatients. The trend of autopsy rate was observed in all impatients died in a university hospital during a nine year period (from 1975 to 1983). The agreement between the clinical and pathological death diagnosis was retrospectively controlled in 294 consecutive patients died and submitted to autopsy in the same hospital during a 6 month period (from January to June 1983).

This study aimed to define the verbal memory profiles of very old normal subjects and subjects with Alzheimer's Disease, and to identify verbal memory indices having the highest discriminant power. Forty-three old normal subjects (mean age = 71 years, SD = 3, range = 65-75), 39 very old normal subjects (mean age = 81 years, SD = 4, range = 76-87), and 45 Alzheimer's patients (mean age = 70 years, SD = 5, range = 59-78) received the Rey test of verbal memory and the WAIS-R Digit Span forward and backward. All but one of the indices could distinguish very old from Alzheimer's subjects. A discriminant analysis disclosed a verbal memory profile of Alzheimer type in 15.4% of the very old group and of very old type in 16.2% of the Alzheimer's patients. Rate of forgetting, immediate and delayed Rey indices, and the true positive responses were, in decreasing order, the main determinants of the discriminant function. Thus, all of the components of verbal memory are differently affected by aging and Alzheimer's disease and contribute to define individual verbal memory profiles.

The case manager, like many “new professions” does not yet have a defined curriculum. We consider that the principal requisite for case managers is a proficient knowledge of assessment for the care of the elderly. Therefore, we focused a four-week teaching course for future case managers on the National Resident Assessment Instrument (RAI) of the United States and the Long-Term Care Program Application and Admission Form of British Columbia, Canada. We verified that this simple program provides students with adequate skills to become case managers.

Abstract: The crystallochemical variations of clinopyroxene in response to changes in fO2 and melt composition have been determined for a basalt-pantellerite suite (Boseti Complex, Main Ethiopian Rift) by crystal structure refinement and microprobe analysis. The pyroxene evolutionary trend has both a “Ca-minimum” and late iron enrichment. During crystallization from basalts to trachytes, clinopyroxene geometry depends mainly on the relationships between T and M2 sites; for example, high SiO2 activity in the magma causes high Si occupancy in T site, which in turn requires low Ca occupancy in M2 site in order to fulfill the local charge balance requirements. In contrast, clinopyroxene crystallized from acid melts is characterized by high Fe2+ (M1) content and therefore by a very large M1 site. Longer 〈M1-O1〉 and M1-O2 bond lengths require shorter T-O1 and T-O2 bond lengths and high Si occupancy in T site. It is concluded that the “Ca-minimum” in the clinopyroxene structure is regarded as the lowest value at which the charge balance requirements are satisfied in a C2/c clinopyroxene structure.

Identification of mechanisms accounting for verbal memory impairment in patients with severe COPD; assessing the relationship between verbal memory and the overall cognitive performance; verifying if verbal memory impairment affects medication adherence.

this study assessed neuropsychologic changes after internal carotid endarterectomy using a design that limited the confounding effects of surgical and anesthesiological stress. Twenty-eight patients (mean age = 65.9 years, SD = 8.4, range 45-79), underwent extensive neuropsychological assessment before and on the seventh day after carotid endarterectomy for symptomatic carotid stenosis greater than 75%. A similarly assessed control group of 30 patients underwent elective orthopaedic surgery. A third cognitive assessment was performed 4 months postoperatively on a subgroup of the study patients. No significant cognitive change occurred in the control group. The study patients showed significant improvement in verbal memory, constructive abilities, verbal attainment, and visual attention; a trend towards further improvement of verbal functions was evident at the late postoperative assessment. No side-specific cognitive change was observed. In conclusion, carotid endarterectomy performed for currently accepted indications significantly improves several cognitive functions.

The serum digoxin concentration (SDC) was measured in 100 consecutive patients with suspected digitalis—induced arrhythmias. In 24 (toxic group) of these subjects arrhythmias disappeared after glycoside withdrawal. The mean (± SD) SDC was 2.88 ± 1.89 ng/ml in the toxic group and 1.00 ± 0.61 in the nontoxic group (p< 0.0001). With respect to digitoxicity, the SDC showed a predictive accuracy rate of 88, a specificity rate of 89, and a sensitivity rate of 62. Since our results were obtained from symptomatic patients, we observed a better predictive accuracy rate than other authors, who studied symptomatic andasymptomatic subjects. The high percentage of false-negatives makes it impossible to consider the SDC by itself a diagnostic test for digitoxicity. However, the SDC is a useful test since all other parameters are less sensitive and/or less rapid indicators of probable digitalis intoxication.

To assess whether serum creatinine and age are associated with headache induced by nitrates, 2742 hospitalized patients taking nitrates were studied during their hospital stay. Those patients with admission serum creatinine levels from 97 to 133 μmol/L and >133 μmol/L were compared with patients with creatinine levels < 97 μmol/L. Gender, body mass index, comorbidity, cognitive status, new intake of nitrates, number of daily administrations, and daily dosage, as well as intake of angiotensin converting enzyme inhibitors, calcium antagonists, diuretics and nonsteroidal anti-inflammatory drugs were examined as possible confounders. Fifty-six patients had headaches that had a causal link with intake of nitrates. Compared with the lowest creatinine group, after adjustment for potential confounding variables, the odds ratios and 95% confidence interval (95% CI) for headache caused by nitrates associated with increasing serum creatinine levels were 0.6 (95% CI, 0.3 to 1.1) and 0.2 (95% CI, 0.0 to 1.2), respectively (p for trend = 0.013). Increasing age was inversely associated with headache (odds ratio for 10-year increase, 0.6 [95% CI, 0.5 to 0.7]). Serum creatinine and age were independently and inversely associated with headache caused by nitrates.

Summary In order to rule out age-related differences in the sinus node (SN) function, the effects of different substances were tested in SN isolated preparations from adult (4–5-month-old) and old (24–25-month-old) rats.

Summary The structural changes occurring in the clinopyroxenes with composition Di100, Di90En10 and Di80En20, due to the Ca-Mg substitution in the M2 site, have been studied. Evidence is given that with increasing Mg content a small percentage of the atoms converts from the M2 position to a new M2' position which is solely occupied by Mg. The maximum conversion of M2 to M2' found in this study is 7%. The closest parallel to the M2' geometry is found in the ZnSiO3 pyroxene (C2/c). The presence of this new site causes significant changes in the tetrahedral configuration, because the M2' atoms are not bonded to 03. The intermediate compositions, Di90En10 and Di80En20, may be thought of as the coexistence of two structural models: diopside and ZnSiO3 pyroxene (C2/c).

Summary The crystal structures of 20 natural diopsides have been refined. For some samples, microprobe analyses show a Si deficiency in the tetrahedron with no A1 present; this suggests that some Ti4+ may enter the tetrahedral site. Geometrical variations in these samples with respect to the others are discussed in the light of this Si ? Ti4+ substitution. The volumes of their M1 sites are larger because of the absence of R3+ cations, the octahedron being very regular; in the same way, the volumes of M2 sites of these samples are greater not because of different site occupancies but because of significant charge modifications around the O3 and O1 oxygens, caused by the tetrahedral site. The low distortion of M1 site and the lengthening of (M2-O1) and bond lengths are a clue to the presence of small amounts of Ti at the tetrahedral site.

Summary Microprobe analyses and X-ray crystal structure refinement data of Mg-Fe-Al-Cr spinels from different environments are compared. The investigated crystals represent both restitic and recrystallized spinels from an Alpine peridotitic massif, and restitic spinels from four suites of ultramafic xenoliths. Within each suite the crystals represent different steps of an increasing melting process, which causes a strong increase in Cr3+ and a moderate increase in Fe2+, with depletion of Al3+ and Mg2+. Within each suite, in spite of relevant bulk chemistry changes, the ratio of the octahedral to tetrahedral coordination distances, and consequently the oxygen positional parameterx, are kept constant. Conversely,x may differ in suites with similar bulk chemistry, mainly due to different Mg-Al ordering between octahedral and tetrahedral sites. This suggests that thex parameter is strongly affected by physical environment, and that consequently, within the range of the investigated compositions, it could be used as a marker.

In epidemiologic studies that collect comprehensive information on medication use, the complexity of dealing with a large number of trade and generic names may limit the utilization of these data bases. This paper shows the specific advantage of using two coding systems, one to maximize efficiency of data entry, and the other to facilitate analysis by organizing the drug ingredients into hierarchical categories. The approach used by two large surveys, one in the USA and one in Italy, is described: the Established Populations for Epidemiologic Studies of the Elderly (EPESE) and the ‘Gruppo Italiano di Farmacovigilanza nell' Anziano’ (GIFA). To enter the medications into a computerized database, codes matching the drug product names are needed. In the EPESE the prescription and over the counter drug products are coded with the Drug Products Information Coding System (DPICS) and the Iowa Nonprescription Drug Products Information Coding System (INDPICS), respectively. The GIFA study uses the coding system of the Italian Ministry of Health (MINSAN), with a unique numeric code for each drug product available in Italy. To simplify the analytical process the drug entry codes are converted into hierarchical coding systems with unique codes for specific drug ingredients, chemical and therapeutic categories. The EPESE and GIFA drug data are coded with the Iowa Drug Information System (IDIS) ingredient codes, and the Anatomical Therapeutic and chemical (ATC) codes, respectively. Examples are provided that show coding of diuretics in these two studies and demonstrate the analytic advantages of these systems.

Abstract: A two-stage model of oxidation was devised to explain the observed variations in crystallographic parameters in two artificially oxidized natural spinels. In the first stage, oxygen is added to the crystal boundary as cations are preserved, with Fe rising in total valence and vacant sites being formed. In the second stage, oxygen is preserved and α−Fe2O3 intergrowth occurs, at the expense of the oxygen of the parent spinel structure. On the basis of this model, crystallochemical formulae were calculated and cations partitioned in the various conditions. It was found that, both before and after oxidation, the spinel site population varies continuously in the direction of an increase in random charge distribution, depending on the increase of heat to the crystals. This trend was found to be reversible. Cation vacancies produced during oxidation are distributed between tetrahedral site T and octahedral site M.