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Background Age-related alterations in the clinical characteristics and performance of severity scoring systems for community-acquired pneumonia (CAP) are unknown. Methods Consecutive patients with CAP presenting to the emergency department were prospectively studied. Patients were classified as younger adults (age 18–64 years), elderly (age 65–84 years) and very old subjects (age ≥85 years). Clinical characteristics, complications, outcomes and validity of the pneumonia severity index (PSI) and CURB-65 categories were compared across these three age categories. Results Analysis involved 348 (35.3%) younger adult patients, 438 (44.3%) elderly patients and 201 (20.0%) very old patients. Compared with younger adults, elderly and very old patients had a higher burden of comorbidities and a higher incidence of CAP-related complications. The 30-day mortality rate was 5.2% in younger adults, 7.1% in elderly patients and 9.5% in very old patients. The area under the ROC curve (AUCs) for PSI were 0.87 (95% CI 0.77 to 0.97), 0.85 (95% CI 0.803 to 0.897) and 0.69 (95% CI 0.597 to 0.787) and the AUCs for CURB-65 were 0.80 (95% CI 0.67 to 0.93), 0.73 (95% CI 0.65 to 0.82) and 0.60 (95% CI 0.47 to 0.73) in the younger adult, elderly and very old patients, respectively. A modified PSI or CURB-65 excluding the age variable increased the AUC in most age categories. There was no significant effect of age on 30-day mortality after adjusting for other PSI or CURB-65 variables. Conclusion Elderly patients with CAP have more atypical clinical manifestations and worse outcomes. The underperformance of the PSI in elderly patients may be due to the inappropriate weight given to the age variable. A modification of the cut-off point for PSI or CURB-65 to define severe pneumonia may improve the score performance in elderly patients.

We sought to determine the diagnostic value of a D-dimer test for myocardial infarction (MI). The pro- spective cohort study was carried in the ED of a university hospital. All included patients were tested for D-dimer and cardiac troponin I (cTnI) on ED admission and additional cTnI 6 h later. AMI was retrospectively confirmed by employing the ESC-ACC-AHA-WHF 2007 universal definition. The discriminative value of D-dimer test was assessed by ROC curve analysis. Multivariate analysis was used to identify independent risk factors associated with D-dimer elevation other than MI. A total of 178 patients were included in this study. Median D-dimer levels were significantly higher in MI patients. A D-dimer value greater than 200 ng/ml was significantly associated with MI. When used alone, the test has a high sensitivity of 91.8% but a low specificity of 23.9%. Combined use of cTnI and D-dimer tests raised the sensitivity to 98.4% and helped early triage a subgroup of low risk patients. However, the test had the downside of 58% false positives. High false positives could be partly explained by the high prevalence of underlying hypercoagulable comorbidities. Diabetes mellitus with chronic renal insufficiency was identified as the strongest risk factor associated with D-dimer elevation in patients without MI. D-dimer test alone has a low diagnostic value for MI. Co-existing hypercoagulable conditions may confound the results. Combining cTnI and D-dimer tests enables early identification a low risk group of patients for MI at the cost of high false positives.

Difference of the clinical characteristics and outcome of acute appendicitis (AA) between young old (age 60 to 79 years) and octogenarian patients (age 80) is unknown. We hypothesized that octogenarian patients would have more atypical presentation and worse outcomes.Our study was a 10-year retrospective analysis of a hospital based database. All patients with histopathologically confirmed AA from 1995 to 2005 registered in this database were selected for study. Demographic data, preexisting conditions, clinical manifestations, Alvarado score, delay in surgery, complications, and mortality were compared between the octogenarians and young old. Independent effect of age on outcomes was examined by logistic regression model controlling for sex, comorbidities, and time delayed for surgery.Octogenarian patients constituted 93 (14.8%) of 628 geriatric patients with AA. On clinical manifestations, migrating pain and localized iliac fossa tenderness were less common in the octogenarians. Low sensitivity of Alvarado score in diagnosing AA was noted in both young old (50.7%) and octogenarian (44.1%) patients. Compared with young old patients, octogenarians had a longer delay in surgery and worse outcomes. Octogenarians had a significantly higher perforation rate (65.6% vs 49.5%, P0.001), postoperative morbidity rate (18.3% vs 10.1%, P0.001), and mortality rate (6.5 % vs 1.5 %, P0.001). Octogenarian age was independently associated with appendiceal perforation (OR, 95% CI; 1.94, 1.23 approximately 3.08), postoperative morbidity (2.0, 1.10 approximately 3.62), and mortality (4.5, 1.54 approximately 13.41).The clinical presentation of AA in octogenarian patients is atypical and the outcomes are worse than young old patients.

Abnormally elevated alanine aminotransferase (ALT) of nonspecific causes is a common outpatient problem. Without considering ethnicity, several studies had suggested that it was associated with insulin resistance (IR).To investigate whether nonspecific elevated ALT in Taiwanese population could reflect a likely underlying IR and was associated with impaired fasting glucose or type 2 diabetes mellitus (IFG/T2DM).The health examination profiles of 1313 Taiwanese were investigated cross-sectionally. The prevalence and odds ratios (ORs) for IFG/T2DM and metabolic abnormalities in relation to elevated ALT were analyzed.Subjects with metabolic syndrome (MS) all had IFG/T2DM. The elevated ALT significantly correlated with MS and IFG/T2DM (i.e., 19.9-29.2% vs. 7.8% for MS, and 27.0-31.5% vs. 16.1% for IFG/T2DM). However, after excluding MS and adjustment for age and sex, the elevated ALT alone was not consistently associated with IFG/T2DM (36ALT ≤ 80 IU/L with OR 0.97, 95% CI 0.58-1.61; 80ALT ≤ 120 IU/L with OR 0.55, 95% CI 0.13-2.37; none with ALT120 had IFG).In a cross-sectional analysis of Taiwanese industrial employees, elevated ALT associated with MS, but in subjects who did not meet MS criteria, elevated ALT by itself did not associate with IFG/T2DM.