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Biomedical subjects

D D Tresch

Publications and source records attributed to D D Tresch.

At least 37 records · Page 2Linked to original sources
PubMed1991

CPR in the elderly: when should it be performed?

Data comparing the success of CPR in elderly hospitalized persons, those living in the community, and those in long-term care facilities show varying results. In general, elderly patients who receive CPR following arrest do not fare as well as younger patients, but there appears to be a subgroup of elderly in whom the success rate is relatively high. Specifically, patients who demonstrate ventricular fibrillation or ventricular tachycardia are more likely to survive than are those demonstrating asystole or electromechanical dissociation. Most studies have not shown a difference in mental or functional impairment between older and younger survivors of cardiac arrest.

Activities of Daily Living↗
PubMed1991

Clinical characteristics of patients in the persistent vegetative state.

Little is known concerning the specific clinical characteristics of patients in persistent vegetative states (PVS). Fifty-one patients from four nursing homes, approximately 3% of the total patients, were identified as being in a PVS. The mean age of the patients was 64.8 +/- 3.2 years (range, 19 to 96 years) and the mean duration of the PVS was 3.3 +/- 5.0 years (range, 1 to 16.8 years), with 13 patients' PVS being longer than 5 years. Cerebrovascular accidents and dementia were the most common causes of the PVS, accounting for 32 of the cases (63%). In the younger patients cerebral trauma secondary to motor vehicle accidents was the most common cause. All 51 patients were fed via tube feeding and 35 patients had urinary catheters (75%). All patients were receiving daily medications, with greater than 50% taking daily vitamins. Over 30% were taking digitalis and/or diuretics and over 32% were taking H2 blockers. Transfer of patients to an acute care hospital was not uncommon, with 31 patients (61%) requiring 63 acute care hospitalizations during their stay in the nursing home. As expected, infections were the most common reason for acute care hospitalization, although 15 of the patients were hospitalized for surgical procedures. Another common problem encountered by the patients was pressure sores, with 78% of patients requiring specific therapy for at least one pressure sore. Surprisingly, only 27 (53%) of 51 patients had a specific resuscitation status designation in the medical chart, and neither presence of a chart designation nor specific resuscitation order was related to the patient's age or the cause or duration of PVS. From these data it would appear that clinical characteristics of patients in PVS are variable. Some patients are young, others are old. The cause varies from cerebrovascular accidents to cerebral trauma. Survival may be prolonged; complications are not uncommon, with some patients requiring acute care hospitalization.

Adult↗
PubMed1991

Comparison of efficacy of automatic implantable cardioverter defibrillator in patients older and younger than 65 years of age.

PURPOSE: The efficacy of the automatic implantable cardioverter defibrillator (AICD) was compared in elderly patients and younger patients with life-threatening ventricular tachyarrhythmias. Clinical characteristics, surgical complications, and long-term survival rates were compared between the two age groups. PATIENTS AND METHODS: A retrospective study was conducted of 54 elderly patients (greater than 65 years) and 79 younger patients (less than 65 years) who had had AICDs implanted for recurrent symptomatic ventricular tachycardia and/or ventricular fibrillation. RESULTS: In 85% of elderly patients and 78% of younger patients, coronary artery disease was the underlying disease (NS). The mean left ventricular ejection fraction was 31.4 +/- 14.3% in the elderly patients and 35.7 +/- 17.6% in the younger patients (NS). Concomitant myocardial revascularization was performed in 37% of elderly patients and 29% of younger patients (NS); however, only 4% of elderly patients had concomitant left ventricular resection or cryoablation, compared with 15% of younger patients (p less than 0.001). Two patients in each age group died perioperatively (4% versus 3%, NS), and no significant difference in surgical morbidity or length of hospital stay following AICD implantation was noted between the age groups. In conjunction with AICD, elderly patients more commonly received antiarrhythmic drugs, with 54% of elderly patients taking amiodarone at the time of hospital discharge compared with 29% of the younger patients (p less than 0.008). In contrast, beta-blockers were more commonly used in younger patients (16% versus 2%, p less than 0.03). At a mean follow-up of 25 months, 11 (20%) elderly patients and 16 (20%) younger patients had died. Six deaths in elderly patients and five deaths in younger patients were classified as arrhythmic deaths (NS); however, only one younger patient and three elderly patients died suddenly (NS). Calculated survival curves demonstrated similar survival rates in the two age groups with approximately 90%, 87%, and 80% of the patients alive at 1, 2, and 3 years, respectively. Theoretic survival curves calculated from appropriate AICD shocks demonstrated significantly lower survival compared with actual survival. CONCLUSION: It is concluded that AICD is a very effective treatment for life-threatening ventricular tachyarrhythmias, and this benefit applies to elderly patients as well as younger patients.

Adolescent↗
PubMed1990

Comparison of outcome of paramedic-witnessed cardiac arrest in patients younger and older than 70 years.

To obtain further information concerning differences in the mechanism of out-of-hospital cardiac arrest between elderly and younger patients, 381 consecutive patients who experienced out-of-hospital cardiac arrest, and whose arrest was witnessed by paramedics, were studied. In 91% of cases the arrest occurred at the time the patient's cardiac rhythm was monitored. Patients were divided into 2 age groups: elderly patients were greater than 70 years (187) and younger patients were less than 70 years (194). Elderly patients more commonly had a past history of heart failure (25 vs 10%, p less than 0.003) and were more commonly taking digoxin (40 vs 20%, p less than 0.005) and diuretics (35 vs 25%, p less than 0.004). Before the cardiac arrest, elderly patients were more likely to be complaining of dyspnea (53 vs 40%, p less than 0.009), whereas younger patients were more likely to complain of chest pain (27 vs 13%, p less than 0.001). Forty-two percent of younger patients demonstrated ventricular fibrillation as the initial out-of-hospital rhythm associated with the arrest, compared to only 22% of elderly patients (p less than 0.001). Besides patient age, initial cardiac rhythm varied according to the patient's complaint preceding the arrest. Sixty-eight percent of patients with chest pain demonstrated ventricular fibrillation, whereas only 21% of patients with dyspnea demonstrated ventricular fibrillation. Elderly patients could be as successfully resuscitated as younger patients; however, 24% of younger patients survived, compared to only 10% of elderly patients (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1989

Should the elderly be resuscitated following out-of-hospital cardiac arrest?

PURPOSE: Elderly and younger patients who were successfully resuscitated and hospitalized following out-of-hospital cardiac arrest were studied to determine if there was a significant difference in hospital course and long-term survival between the two groups. PATIENTS AND METHODS: The study consisted of 214 consecutive patients, divided into two age groups: elderly (more than 70 years, n = 112) and younger (less than 70 years, n = 102). Hospital charts and paramedic run data were retrospectively reviewed for each patient and findings were compared between the two age groups. RESULTS: Prior to cardiac arrest, 47 of 112 (42 percent) elderly patients had a history of heart failure, compared with 19 of 102 (18 percent) younger patients, and were more commonly taking digitalis (51 percent versus 29 percent) and diuretics (47 percent versus 26 percent). Younger patients, however, more often had an acute myocardial infarction at the time of the cardiac arrest (33 percent versus 16 percent). At the time of cardiac arrest, 83 percent of younger patients demonstrated ventricular fibrillation, compared with 71 percent of the elderly. In contrast, electromechanical dissociation was five times more common in the elderly patients. Although hospital deaths were more common in the elderly (71 percent versus 53 percent), the length of hospitalization and stay in intensive care units were not significantly different between the age groups. The number of neurologic deaths was similar in both age groups, as were residual neurologic impairments. Only five elderly patients and six younger patients required placement in extended-care facilities. Calculated long-term survival curves demonstrated similar survival in both age groups, with approximately 65 percent of hospital survivors alive at 24 months after hospital discharge. CONCLUSION: Resuscitation of elderly patients in whom out-of-hospital cardiac arrest occurs is reasonable and appropriate, according to the findings of this study. Even though elderly patients are more likely than younger patients to die during hospitalization, the hospital stay of the elderly is not longer, the elderly do not have more residual neurologic impairments, and survival after hospital discharge is similar to that in younger patients.

Adult↗
PubMed1989

Interventions in the therapy of electromechanical dissociation.

Electromechanical dissociation (EMD) is a major arrest rhythm for which there is often inadequate treatment. The purpose of this study was to evaluate the different pharmacological and non-pharmacological interventions considered in the treatment of EMD. During the 6-year period, January 1st, 1980 to December 31st, 1985, 503 evaluable adult patients presented in a non-traumatic, non-poisoning cardiopulmonary arrest with the initial rhythm of EMD. One hundred nineteen patients obtained a pulse during resuscitation efforts following drug administration. The average time to obtaining pulses after the last drug administration was 1.97 +/- 2.21 min. The following drugs were last administered prior to transient pulses: bicarbonate, 31/119 (26%); epinephrine, 26/119 (22%); atropine, 26/119 (22%); dopamine, 13/119 (11%); calcium, 11/119 (9%); isoproterenol, 7/119 (6%); other drugs, 5/119 (4%). Ninety-five percent of the successful resuscitations received eight or less drug interventions and all saves received three or less drug interventions. Two hundred twenty-four patients (44.5%) had 288 non-pharmacological interventions. Twenty-three patients developed a pulse after intervention in the following distribution: MAST suit (N = 9), pericardiocentesis (N = 6), fluid challenge (N = 5), needle thoracostomy (N = 1), and intervention combinations (N = 2). The time interval between intervention and the onset of pulse was as follows: MAST suit, 4 +/- 2.8 min; pericardiocentesis, 3.7 +/- 3.6 min; fluid challenge, 4.8 +/- 4.1 min; needle thoracostomy, 6 min. The overall save rate for intervention patients was 0.9% whereas for those not having intervention it was 7.2% (P less than or equal to 0.0003).(ABSTRACT TRUNCATED AT 250 WORDS)

Atropine↗
PubMed1989

Coping with DRGs--a nursing home's experience.

The introduction of prospective payment system (PPS) based on diagnostic related groups (DRGs) has had a significant impact on hospitals. To determine the impact of PPS on nursing homes, the authors studied the activity of a Veterans Administration teaching nursing home (admissions, acute hospital transfers, and discharges) during 1 year preceding implementation of DRGs and for 3 consecutive years following implementation of DRGs. In 1983, pre-DRGs, a total of 36 patients, were admitted to the nursing home. Following implementation of DRGs, a sevenfold increase was noted in the number of patients admitted when comparing 1983 and 1986, with the monthly average of patients admitted increasing from 3 in 1983 to 9.7, 22, and 23.8 in 1984, 1985, and 1986, respectively. Associated with the increase in patients admitted following DRGs was an increase in patients requiring transfer to the acute hospital, within 30 days of admission to the nursing home. In 1986, approximately 27% of patients admitted to the nursing home required transfer to the acute hospital within 30 days of their admission. The number of patients discharged from the nursing home also increased following DRGs. None of the patients admitted to the nursing home in 1983 were discharged within 30 days of admission. Subsequent to introduction of DRGs, an average of two patients per month were discharged within 30 days of nursing home admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1988

Coping with diagnosis related groups. The changing role of the nursing home.

In an attempt to document the changing role of a specific nursing home in the delivery of medical care since the initiation of diagnosis related groups (DRGs), we studied 100 consecutive patients initially admitted to the Veterans Administration Medical Center-Milwaukee Nursing Home Care Unit (NHCU) during the first 23 weeks of 1986 (post-DRGs). Patient characteristics, reason for NHCU admission, and patients' final disposition were determined and compared with those of consecutive patients admitted to the same facility during an identical time period in 1983 (pre-DRGs). More than seven times as many patients were admitted in 1986, and prior to NHCU admission the acute care hospital stay was significantly shorter in 1986 (22 vs 60 days). Whereas in 1983, most patients (94%) were admitted to the NHCU for long-term care placement, in 1986, the majority of patients (64%) were admitted for continuation of therapy started in the acute care hospital. In 1983 only two patients (9%) required hospital readmission within ten days of NHCU admission, compared with 22 (22%) of the patients in 1986. At the termination of the study period, none of the 31 patients admitted to the NHCU in 1983 had been discharged; in comparison, 33% of the patients in 1986 were discharged home. We conclude that in 1986 certain nursing homes drastically changed their role in the delivery of medical care, and are now functioning as extensions of acute care hospitals. Such a role is advantageous in allowing patients to be quickly discharged from the acute care hospital; however, the changing role presents new problems and challenges.

Aged↗
PubMed1987

Refractory symptomatic ventricular tachycardia and ventricular fibrillation in elderly patients.

The problem of refractory life-threatening ventricular tachyarrhythmias in elderly patients has not been previously studied. To determine if clinical, anatomic, or electrophysiologic variables and prognosis are significantly different in elderly subjects, 49 elderly (68 to 84 years) and 44 younger (44 to 53 years) survivors of refractory symptomatic ventricular tachycardia and/or ventricular fibrillation secondary to coronary artery disease were studied. Elderly patients displayed more extensive anatomic coronary artery disease, with 80 percent having three-vessel disease in comparison with 30 percent of the younger patients (p less than 0.001). Prior myocardial infarction, heart failure, and cardiomegaly were more common in the elderly group (p less than 0.01, p less than 0.001, and p less than 0.034, respectively), whereas angina was more common in the younger group (p less than 0.001). In 55 percent of the elderly patients and 58 percent of the younger patients, electrophysiologic testing demonstrated inducible sustained ventricular tachycardia that required treatment with an investigative antiarrhythmic drug and/or cardiac surgery, including implantation of an automatic defibrillator. Elderly patients tolerated aggressive evaluation as well as did younger patients, and despite the difference in clinical and anatomic findings, long-term survival curves were similar, although the probability of survival at 20 months was 62 percent in the elderly and 80 percent in the younger patients. This difference in early survival is explained by eight surgical deaths in the elderly group, compared with two in the younger group.

Age Factors↗
PubMed1987

Atypical presentations of cardiovascular disorders in the elderly.

Despite the high prevalence of cardiac disease in the elderly, specific cardiac disorders are often missed or misdiagnosed in this age group. Not uncommonly, the clinical manifestations are significantly different from those in the younger patient with the same disorder. The classical findings of aortic valve stenosis may not be present and the disorder is frequently misdiagnosed as mitral valvular incompetence. Mitral valve prolapse, usually considered a benign disorder in the young and middle-aged, may present with heart failure in the elderly, and mitral valve surgery may be necessary. Instead of angina pectoris, dyspnea may be the first manifestation of coronary artery disease in the elderly. Acute myocardial infarction may be silent or present in an atypical manner with abdominal distress, acute signs of cerebral insufficiency, or dyspnea.

Aged↗
PubMed1986

Unexplained sinus bradycardia: clinical significance and long-term prognosis in apparently healthy persons older than 40 years.

The significance of sinus bradycardia (SB) in clinically healthy, non-endurance-trained, middle-aged and older persons is unknown. From 1,172 normal volunteers, aged 40 to 96 years, enrolled in the Baltimore Longitudinal Study of Aging, 47 subjects, aged 58 +/- 13 years, with SB (less than 50 beats/min) were identified by rest electrocardiography and were compared with a group of control subjects matched for age and sex. The prevalence of unexplained SB was approximately 4% and was nearly identical in men and women. At the latest follow-up examination, after a mean follow-up of 5.4 years, the SB group had a higher prevalence of associated conduction abnormalities (first-degree atrioventricular [AV] block, left-axis deviation, and complete or incomplete right bundle branch block) than the control group (43% vs 19%, p less than 0.05). On maximal treadmill exercise testing, performed in 44 patients within 1 visit of their most recent examination showing SB, maximal heart rate (157 +/- 18 beats/min) did not differ significantly from that of control subjects (163 +/- 19 beats/min); exercise duration, however, was greater in the former group, 11.0 +/- 2.8 vs 9.7 +/- 3.1 minutes (p less than 0.05). No patients with SB had syncope, high-degree AV block or other manifestation of sick sinus syndrome during follow-up. Angina pectoris, myocardial infarction, congestive heart failure or cardiac death occurred in 8% of patients with SB and 11% of control subjects over the observation period (difference not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1985

Long-term follow-up of survivors of prehospital sudden cardiac death treated with coronary bypass surgery.

Although coronary artery bypass surgery is beneficial to patients with severe coronary artery disease, its role in preventing the recurrence of prehospital cardiac arrest in patients is not clear. In this article, we report on the long-term follow-up of 49 survivors of prehospital coronary arrest who had coronary artery bypass surgery. Prior to their prehospital cardiac arrest, 14% of the patients had a history of unstable angina. Coronary angiograms obtained after prehospital cardiac arrest showed that 71% of the patients had three-vessel coronary artery disease and 6% had single-vessel disease. The mean left ventricular ejection fraction was 45%. There were four postoperative deaths; three were caused by pump failure, and one was caused by refractory ventricular arrhythmias. After a maximum follow-up period of 102 months (mean of 55.4 months), there were seven cardiac deaths; five of the patients died of recurrent ventricular fibrillation, and two patients' deaths were related to refractory heart failure. Actuarial analyses of the 49 patients showed that the probability of survival at 6 months, 1 year, 2 years, 3 years, and 5 years was 92%, 92%, 89%, 82%, and 72%, respectively. After surgery, 35 of the 45 patients who were discharged from the hospital were asymptomatic, and 23 of the 32 patients who were employed when their prehospital cardiac arrest occurred returned to their employment. We concluded that coronary artery bypass surgery is beneficial to certain survivors of prehospital sudden death. After surgery, most patients are asymptomatic and capable of returning to their employment and the recurrence of prehospital sudden death is low.

Aged↗
PubMed1985

Mitral valve prolapse requiring surgery. Clinical and pathologic study.

The clinical, hemodynamic, surgical, and pathologic findings in 30 patients who required mitral valvular surgery and who had a preoperative diagnosis of mitral valve prolapse were reviewed. The mean age of the patients was 59.5 years; 28 patients were over 45 years of age and 10 were over 60 years. Surprisingly, 20 were males. A long history of systolic murmur was common, whereas symptoms of heart failure were of abrupt onset. At the time of surgery, a local holosystolic murmur typical of mitral regurgitation was present, although a mid- to late systolic click was not heard in any of the patients. Electrocardiographic abnormalities were present in all patients, with 13 patients demonstrating atrial fibrillation. Only four patients had a normal heart size radiographically. Echocardiography confirmed the radiographic findings, in that 27 patients demonstrated left atrial and ventricular enlargement. All 29 patients undergoing cardiac catheterization and angiography demonstrated a prolapsing mitral valve with severe regurgitation. Surgical and pathologic examination revealed findings characteristic of a myxomatous valve in all patients, with 19 also demonstrating ruptured chordae tendineae. This study demonstrates that heart failure requiring valvular surgery occurs in a subset of patients with mitral valve prolapse. In this subset, males predominate and most are over 50 years of age. These patients may be asymptomatic for many years, demonstrating mild to moderate mitral valvular regurgitation, before heart failure develops.

Adult↗
PubMed1985

Prevalence and significance of cardiovascular disease and hypertension in elderly patients with dementia and depression.

The prevalence and significance of clinical heart disease and hypertension were compared in three groups of elderly patients. One group was diagnosed as dementia of an Alzheimer's type (AD), another as multiinfarct dementia (MID), and the third as major depression. Clinical heart disease and hypertension were uncommon in the AD group with the prevalence being lower than that reported in most epidemiologic studies. Four percent of the AD patients had a history of myocardial infarction, 5% angina, 1% arrhythmias, and 3% heart failure. Electrocardiographic changes of an old myocardial infarction were present in 9%, atrial fibrillation in 1%, and left ventricular hypertrophy in 3%. A history of hypertension was present in 24% of the AD patients. In comparison, a history of myocardial infarction, angina, and heart failure was five times greater, and electrocardiographic abnormalities were twice as prevalent in the MID group. A history of hypertension was three times more common and actual blood pressure readings were higher. In the depression group heart disease was not uncommon and the prevalence, in general, was comparable with the MID group. However, a history of increased blood pressure and actual increased blood pressure readings were statistically less than in the MID group.

Aged↗