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(AN-85: dp. 775 (f.),1. 168'6", b. 33'10"; dr. 10'9"; s. 12 k.; cpL 46; a. 1 3"; cl. Cohoee)
Oneota (AN-85), originally designated YM-110, was laid down 9 February 1944 by the Marine Iron and Shipbuilding Co., Duluth, Minn.; named Oneota, 26 February 1944 launched 27 May 1944- sponsored by Mrs. Peter S. Rudie and commissioned 12 March 1945, Lt. Robert W. Morgan in command.
On 10 April 1945 Oneota steamed out into Lake Superior enroute to the St. Lawrenee and the Atlantic. Arriving Boston early in May, she remained in southern New England waters for a month, then headed for the Pacific. Between 25 July 1945 and 21 January 1946 she operated along the west coast from the Naval Net Depot, Tiburon, Calif., and on 29 January she arrived at Pearl Harbor for a 2 month stay
Assigned to JTU 1.2.7 the salvage group for operation "Crossroads" in March, see steamed for Bikini on the 22nd. There on 2 April she johled others of her task group in preparing nearby waters for atomic tests Able and Baker. Until July she planted moorings and assisted in the arrangement of target vessels. Following the tests of 1 and 25 July, she participated in salvage operations and, on 26 August, departed for Kwajalein and Guam. Between 13 September and 15 October she plied between Guam and Rota, then steamed east for the United States. After stays at Pearl Harbor and San Francisco, she arrived at San Diego, 26 January 1947, for inactivation. Decommissioned 6 February, she remained at San Diego as a unit of the Pacific Reserve Fleet until transferred to the Maritime Administration's National Defense Reserve Fleet and laid up at Suisun Bay 7 November 1962 where she remains into 1970.
The Selectric Typewriter
The IBM ® Selectric typewriter was a radical innovation that completely disrupted the business typewriter market. It transformed the speed, accuracy and flexibility with which people could generate the written word, and helped pave the way for the use of typewriter keyboards as the primary method for humans to interact with computers.
The selectric typewriter
The Selectric typewriter, launched in 1961, was an overnight hit. “Sales of [the Selectric] in the first 30 days exceeded the forecast for six months. We figured in our branch office that we’d sell 50 or 60 and sold 500 to 600,” IBM salesman John Vinlove told USA Today in 1986 for a story about the typewriter’s 25th anniversary. The manufacturing facility expected to make 20,000 Selectric typewriters in its first year. By the end of 1961, they had orders for 80,000. And by 1986, more than 13 million Selectric typewriters had been sold. For more than 25 years, the Selectric was the typewriter found on most office desks.
With 2800 parts, many designed from scratch, the Selectric was a radical departure even for IBM, which had been in the typewriter business since the 1930s and was already a market leader. It took seven years to work out the manufacturing and design challenges before the first Selectric was ready for sale.
At the physical heart of the Selectric typewriter’s innovation was a golf-ball-shaped type head that replaced the conventional typewriter’s basket of type bars. The design eliminated the bane of rapid typing: jammed type bars. And with no bars to jam, typists’ speed and productivity soared.
The golf ball typing element was designed by an engineering team led by Horace “Bud” Beattie. The team members, according to a 1961 advertisement for the Selectric, “began their search by forgetting the past fifty years of typewriter design.” The first type head design had been shaped more like a mushroom, but under Beattie’s direction, IBM engineer John Hickerson revised the type head toward its ultimate spherical configuration.
One other innovation in the design—a changeable typeface—was borrowed from a turn-of-the-century model, the Blickensderfer typewriter. Although it is not documented, it is believed that the Selectric name was inspired by adding this changeable typeface selection to an electric typewriter. By making the golf ball interchangeable, the Selectric enabled different fonts, including italics, scientific notation and other languages, to be swapped in. With the addition in 1964 of a magnetic tape system for storing characters, the Magnetic Tape Selectric Typewriter (MT/ST) model became the first, albeit analog, word-processor device.
The aesthetic design of the Selectric was the responsibility of Eliot Noyes, an architect and industrial designer who served as consulting design director to IBM for 21 years. The elegant, curvaceous form he created followed the Selectric typewriter’s distinctive function: the golf ball, which moved across the page, eliminated the traditional carriage return. That enabled the Selectric to operate in a smaller footprint and opened up possibilities for a new profile. For the Selectric, Noyes drew on some of the sculptural qualities of Olivetti typewriters in Italy. The result was a patented, timeless shape, and a high-water mark for IBM’s industrial design and product innovation. “A writer’s machine if ever there was one,” noted Jane Smiley in Writers on Writing, Vol. II.
Less well-known is the Selectric typewriter’s role as one of the first computer terminals. While personal computers, notebook computers and word processing software may have relegated the paper-based typewriter to twentieth-century artifact, the Selectric was the basis for the keyboard input on the revolutionary IBM System/360. A modified version of the Selectric, dubbed the IBM 2741 Terminal, was adapted to plug into the System/360, and enabled a wider range of engineers and researchers to begin talking to and interacting with their computers.
Yet to IBM computer scientist Bob Bemer, the Selectric represented “one of the biggest professional failures of my life.” Bemer had pioneered the creation of the American Standard Code for Information Interchange, or ASCII, which still defines the alphabet for computers. When prototypes of the Selectric were already being manufactured at IBM’s typewriter plant in Lexington, Kentucky, Bemer reviewed the Selectric typewriter’s specifications. To him, the Selectric would make a natural computer keyboard. He argued that the type ball should be designed to carry 64 characters required for ASCII, rather than the typewriter standard 44. That would make it relatively easy to convert the Selectric for computer input. The response, as Bemer remembers it, was dismissive. As a result, the Selectric never spoke ASCII, instead employing a unique code based on the tilt and rotate commands to the golf ball. While Bemer viewed this as his failure, engineers continued to rig Selectric typewriters to function as the first generation of computer keyboards and input devices.
In 1971, the Selectric II was released, with sharper corners and squarer lines, as well as new features such as the ability to change “pitch” from 10 to 12 characters per inch and, starting in 1973, a ribbon to correct mistakes. The final model, the Selectric III, was sold in the 1980s with more advanced word processing capabilities and a 96-character printing element. But as personal computers and daisy-wheel printers began to dominate, the Selectric brand was retired in 1986.
Patrick Troiano, MoMM2c – WWII-era Crew Member
Patrick Troiano, originally from Carey, Ohio, enlisted in the Navy in August 1942. He attended boot camp near Great Lakes Naval Base, Illinois, and reporting for duty aboard the Calvert on October 1st, 1942. He was aboard for the Calvert’s commissioning, making him a plank owner. During his time aboard he served as a Fireman (F) and Motor Machinist (MOMM). According to John Regan, a fellow shipmate, Patrick served in the A division and had the nickname “Gizmo.” Patrick departed the Calvert in early 1946 and joined the USS Oneota (AN-85) in San Diego.
As part of the Navy Reserve Pacific Fleet in San Diego he continued to serve aboard the USS Oneota (AN-85) and was honorably discharged in July 1948.
After the war Patrick returned to Galion, OH where he began building his own house, and maintained a farm. He married Margaret Martin, his high school sweetheart, and they had two children, Michael and John. He farmed, golfed, rode motorcycles, fished, and traveled.
According to his family he didn’t speak much about his time served during the war, only to say that he wasn’t going to waste his life away knowing that others died and he didn’t. He said that if he had died in action, he would want those who survived to live life to the fullest.
Sadly, Patrick passed away in 2010. His obituary is available here: http://www.masfh.com/obituary/Patrick-J-Troiano/Galion-OH/804586
Patrick’s granddaughter, Natalie, provided the above information above as well as all of the photographs below.
Although it is uncertain if any of the pictures below were taken aboard the Calvert, they are posted here in the spirit of his service aboard the Calvert and his service to our country when we needed him the most.
According to the Navy History Department these are two of very few known pictures of the USS Oneota (AN-85). These are from Patrick’s personal photograph collection, taken while he served aboard her after the war.
Here are pictures of Patrick, his shipmates and his friends from his time in the Navy. Although it is uncertain if any of these were taken during Patrick’s time aboard the Calvert, please let me know if you recognize any of the other men in these photographs.
USS Calvert LCVPs illustration, D-Day, 1944
In memory of those who participated, and those who died, D-Day, June 6th, 1944.
Squadron/Signal Publications’ WWII Landing Craft in Action book is a good source of information on WWII-era landing craft and landing ships. Two of the Calvert’s landing craft appear on the cover of this book, which depicts landings in Normandy on June 6th. In reality the Calvert was in the Pacific on June 6th, 1944. In any case, it is great to see the Calvert’s boats on the cover of a book.
LST 325, also pictured on the cover, did participate in the landings at Normandy. The caption accompanying the front page states: “An M4 Sherman tank moves out of the Landing Ship, Tank (LST)-325 on the beach in Normandy, France on 6 June 1944. Two Landing Craft, Vehicle Personnel (LCVPs) (PA32-25 and PA32-21) are beached to port of the LST. Both LCVPs were assigned to the attack transport USS CALVERT (APA-32). An ambulance delivered by one of the LCVPs is driving onto he beach. These landing craft were joined by hundreds of vessels in Operation OVERLORD, the Allied invasion of Northern France.
Although this book is no longer actively in print, used copies are available on Amazon and Half.com. More details on this book are available here.
The Seven Stages Of Dementia
One of the most difficult things to hear about dementia is that, in most cases, dementia is irreversible and incurable. However, with an early diagnosis and proper care, the progression of some forms of dementia can be managed and slowed down. The cognitive decline that accompanies dementia conditions does not happen all at once - the progression of dementia can be divided into seven distinct, identifiable stages.
Learning about the stages of dementia can help with identifying signs and symptoms early on, as well as assisting sufferers and caretakers in knowing what to expect in further stages. The earlier dementia is diagnosed, the sooner treatment can start.
Stage 1: No Cognitive Decline
Stage 1 of dementia can also be classified as the normal functioning stage. At this stage of dementia development, a patient generally does not exhibit any significant problems with memory, or any cognitive impairment. Stages 1-3 of dementia progression are generally known as "pre-dementia" stages.
Stage 2: Age Associated Memory Impairment
This stage features occasional lapses of memory most frequently seen in:
- Forgetting where one has placed an object
- Forgetting names that were once very familiar
Oftentimes, this mild decline in memory is merely normal age-related cognitive decline, but it can also be one of the earliest signs of degenerative dementia. At this stage, signs are still virtually undetectable through clinical testing. Concern for early onset of dementia should arise with respect to other symptoms.
Stage 3: Mild Cognitive Impairment
Clear cognitive problems begin to manifest in stage 3. A few signs of stage 3 dementia include:
- Getting lost easily
- Noticeably poor performance at work
- Forgetting the names of family members and close friends
- Difficulty retaining information read in a book or passage
- Losing or misplacing important objects
- Difficulty concentrating
Patients often start to experience mild to moderate anxiety as these symptoms increasingly interfere with day to day life. Patients who may be in this stage of dementia are encouraged to have a clinical interview with a clinician for proper diagnosis.
Stage 4: Mild Dementia
At this stage, individuals may start to become socially withdrawn and show changes in personality and mood. Denial of symptoms as a defense mechanism is commonly seen in stage 4. Behaviors to look for include:
- Decreased knowledge of current and/or recent events
- Difficulty remembering things about one's personal history
- Decreased ability to handle finances, arrange travel plans, etc.
- Difficulty recognizing faces and people
In stage 4 dementia, individuals have no trouble recognizing familiar faces or traveling to familiar locations. However, patients in this stage will often avoid challenging situations in order to hide symptoms or prevent stress or anxiety.
Stage 5: Moderate Dementia
Patients in stage 5 need some assistance in order to carry out their daily lives. The main sign for stage 5 dementia is the inability to remember major details such as the name of a close family member or a home address. Patients may become disoriented about the time and place, have trouble making decisions, and forget basic information about themselves, such as a telephone number or address.
While moderate dementia can interfere with basic functioning, patients at this stage do not need assistance with basic functions such as using the bathroom or eating. Patients also still have the ability to remember their own names and generally the names of spouses and children.
Stage 6: Moderately Severe Dementia
When the patient begins to forget the names of their children, spouse, or primary caregivers, they are most likely entering stage 6 of dementia and will need full time care. In the sixth stage, patients are generally unaware of their surroundings, cannot recall recent events, and have skewed memories of their personal past. Caregivers and loved ones should watch for:
- Delusional behavior
- Obsessive behavior and symptoms
- Anxiety, aggression, and agitation
- Loss of willpower
Patients may begin to wander, have difficulty sleeping, and in some cases will experience hallucinations.
Stage 7: Severe Dementia
Along with the loss of motor skills, patients will progressively lose the ability to speak during the course of stage 7 dementia. In the final stage, the brain seems to lose its connection with the body. Severe dementia frequently entails the loss of all verbal and speech abilities. Loved ones and caregivers will need to help the individual with walking, eating, and using the bathroom.
By identifying the earliest stages of dementia as they occur, you may be able to seek medical treatment quickly and delay the onset of later stages. Though most cases of dementia are progressive, some may be reversible, and sometimes dementia-like conditions may be caused by treatable underlying deficiencies or illnesses. The more aware you are of these stages, the quicker you will be able to react and seek help, either for yourself or for a loved one.
Source: Global Deterioration Scale for Assessment of Primary Degenerative Dementia
Oneota is a designation archaeologists use to refer to a cultural complex that existed in the eastern plains and Great Lakes area of what is now the United States from around AD 900 to around 1650 or 1700. The culture is believed to have transitioned into various Macro-Siouan cultures of the protohistoric and historic times such as Ioway. A long-accepted ancestry to the Ho-chunk has yet to be conclusively demonstrated.
Oneota is considered a major component of Upper Mississippian culture. It is characterized by globular, shell-tempered pottery that is often coarse in fibre. It often had a spherical body, short necks and/or a flat lip. Sometimes the vessels had strap handles. Decoration includes wavy and zigzag lines, often in parallel. Most decoration was done on the top half of the vessel. [ 1 ] Analytically, the culture has been broken down into various stages or horizons. Generally accepted are the following: the Emergent Horizon (ca. AD 900-1000), the Developmental Horizon (ca. AD 1000-1300), the Classic Horizon (ca. AD 1300-1650) (previously called the Oneota Aspect), and the Historic Horizon (post-contact, generally after 1650). In addition, the Oneota culture has been divided geographically based on stylistic and socio-economic differences. Some of these traditions are Orr, Langford, and Fisher-Huber.
The Oneota diet included corn, beans, and squash, wild rice, nuts, fish, deer, and bison, varying according to the region and locale. [ 2 ]
Relationships with Middle Mississippian were present but are not yet clearly understood. Whether Oneota developed in situ out of Late Woodland cultures, was invasive, was the result of influence from (proto-)Middle Mississippian peoples, or was some mix of these, is not clear.
The Value of Children’s Literature
Giving children access to all varieties of literature is extremely important for their success. Educators, parents, and community members should help students develop a love and passion for reading. Not only is reading literature important in developing cognitive skills to be able to succeed in a school or work setting, but it is valuable for other reasons as well. Although there are countless values in exposing children to literature, Donna Norton (2010) identifies the value of literature for young people in her book Through the Eyes of a Child. Children’s literature is important because it provides students with opportunities to respond to literature it gives students appreciation about their own cultural heritage as well as those of others it helps students develop emotional intelligence and creativity it nurtures growth and development of the student’s personality and social skills and it transmits important literature and themes from one generation to the next.
The first value to note is that children’s literature provides students with the opportunity to respond to literature and develop their own opinions about the topic. This strengthens the cognitive developmental domain as it encourages deeper thought about literature. Quality literature does not tell the reader everything he/she needs to know it allows for some difference in opinion. One reader may take something completely different away from the piece of literature than the next reader, based on the two personal viewpoints and experiences. Students can learn to evaluate and analyze literature, as well as summarize and hypothesize about the topic. Norton says that for children, “wordless picture books are excellent stimuli for oral and written language” (2010, p. 9). Students reading wordless books like A Ball for Daisy (Raschka, 2011), The Yellow Umbrella (Liu, 1987), or The Red Book (Lehmann, 2004) will be able to analyze the illustrations and develop their own dialogue for the story. This strengthens students’ cognitive functions in being able to form opinions on their own and to express themselves through language in summarizing the plot of a wordless book.
Second, children’s literature provides an avenue for students to learn about their own cultural heritage and the cultures of other people. It is crucial for children to learn these values because, “developing positive attitudes toward our own culture and the cultures of others is necessary for both social and personal development” (Norton, 2010, p. 3). In saying this, however, when teaching students about the cultural heritage of others, one should be very careful in selecting which books to recommend to young readers. There are many stories, some folktales, which contain blatant stereotypes and inaccuracies about certain cultural groups. This includes books such as Brother Eagle, Sister Sky (Jeffers, 1991), or The Rough-Face Girl (Martin, 1992). Both of these stories depict Native Americans in a misguided way and contain misinterpretations of what actually occurred in history. For example, the Iroquois tribe in The Rough-Face Girl (Martin, 1992) historically lived in longhouses, but the illustrator depicts these Native Americans as living in teepees. This is a clichéd view, and it can be very damaging in perpetuating stereotypes if we as adults are not cautious in the books we have in our classroom and home libraries. However, there are some children’s books that are more accurate in teaching the cultural differences of others. A story called “Eric” from Tales from Outer Suburbia (Tan, 2009) is a touching story about a family who takes in a foreign exchange student and must learn about their guest and accept the differences between their cultures. It has a positive message about encouraging acceptance of the cultural differences between people, which is something that we want to help nurture in our students. Another book that helps discuss culture is Going Home (Bunting, 1996), which is the story of a Mexican immigrant family with the children who were born in the U.S. There is a difference in what “home” is for the parents and the children, and when they take a trip to Mexico, the children realize how important their parent’s culture and homeland is for them. Many books are available that depict culture as an important piece of society that is to be treasured and valued, and those books can have great value for students.
Third, children’s literature helps students develop emotional intelligence. Stories have the power to promote emotional and moral development. Children’s literature “contains numerous moments of crisis, when characters make moral decisions and contemplate the reasons for their decisions,” an important skill for children to see modeled (Norton, 2010, p. 34). Guji Guji (Chen, 2004), for example, is a story about a crocodile who is adopted into a family of ducks. Ultimately he must choose between betraying his adopted family and going back to his own “species,” and he decides to remain true to his beliefs and not betray his family. The Scar (Moundlic, 2007) is an effective book to read with students in order to teach them about responding to grief, as it is about a boy whose mother dies. This requires a complex level of emotional intelligence, as many young children do not understand death. The topic of death would be more appropriate for an older grade level, but it is an important topic to discuss with students. Another book that encourages emotional intelligence is Selma (Bauer, 2002), which discusses what it takes for a young sheep to be happy. It is a philosophical story within a picture book, and challenges students to think about what happiness really is. The Big Box (Morrison, 1999) is a story about children who have their freedom taken away by being put into a box and the deeper problems that exist with not being given one’s freedom. Children’s literature encourages students to think deeper about their own feelings.
Children’s literature also encourages creativity. Norton stresses “the role that literature plays in nurturing and expanding the imagination” (2010, p. 4). The House in the Night (Swanson, 2008) depicts the creativity that a young girl has in her dreams at night, as she flies about the dark neighborhood on the wings of a bird. The Amazing Pop-up Music Book (Petty, 1999), Zin! Zin! Zin! A Violin (Moss, 1995), and Look Closer: Art Masterpieces Through The Ages (Desnoettes, 2006) are imaginative and original books that encourage students to learn about music and art, and they are engaging in their design and interactivity. Children’s literature promotes the development of students’ internal imaginations.
Children’s literature is of value because it fosters personality and social development. Children are very impressionable during the formative years, and children’s literature can help them develop into caring, intelligent, and friendly people. Developmental psychologist Jean Piaget says that when students move from the pre-operational to the operational stage of cognitive development, they become less egocentric. Whereas students in preschool and kindergarten may be entirely focused on themselves, as students grow older they begin to take into account the feelings and viewpoints of others. Being able to understand other people’s viewpoints and to not be selfish are important skills that adults must nurture in children, as Norton says that “acceptable relationships require an understanding of the feelings and viewpoints of others” (2010, p. 27). Children’s literature can foster social development by encouraging students to accept other people and their differences. Books like And Tango Makes Three (Parnell & Richardson, 2005), Molly’s Family (Garden, 2004), Heather Has Two Mommies (Newman & Souza, 1989) and Daddy’s Roommate (Wilhoite, 2000) present situations that might encourage students to become more open-minded to different types of families and understand that love is the most important thing in a family. Children’s literature can also encourage students to develop relationships with people, encouraging social contact. An atypical friendship is depicted in Loop the Loop (Dugan, 1992), where a young child and an elderly person become good friends and share the common joy of playing with yo-yo’s. In A Couple of Boys Have the Best Week Ever (Frazee, 2008), the boys learn to think of the needs of others when they build a diorama for the grandpa who is fascinated with penguins. Literature encourages students to be considerate and friendly people, and these traits may be consistent with developing students into quality citizens.
Finally, children’s literature is of value because it is a timeless tradition, one in which “books are the major means of transmitting our literary heritage from one generation to the next” (Norton, 2010, p. 3). Classic stories like Dr. Seuss’ And to Think That I Heard it on Mulberry Street (Geisel, 1989) and The Cat in the Hat (Geisel, 1957) are important books to read to children because of their literary heritage. For a younger audience, children could build their cognitive and language skills through exposure to Mother Goose rhymes. One example of a good collection of these classic rhymes is Hey Diddle Diddle and Other Mother Goose Rhymes (dePaola, 1998). Children in older grades can learn to appreciate the classic plays and messages of William Shakespeare in picture books that aim to make the plays more accessible. Many versions of Shakespeare’s works are available in abridged and picture book formats, including Romeo and Juliet (Coville, 1999) and The Tempest (Mayer, 2005). Children are only young for a short time, and so we must give them access to a basic literary heritage of timeless books. Quality children’s literature has the great power to captivate audiences for many generations.
Children’s literature is extremely valuable in both the school setting and at home. Teachers and parents should both be able to differentiate between quality and mediocre literature, in order to give students access to the best books to encourage these important values of literature and considering developmental domains. Children’s literature is valuable in providing an opportunity to respond to literature, as well as cultural knowledge, emotional intelligence and creativity, social and personality development, and literature history to students across generations. Exposing children to quality literature can contribute to the creation of responsible, successful, and caring individuals.
Bauer, S. (2002). Selma. La Jolla, CA: Kane Miller Book Publishers, Inc.
Bunting, E. (1996). Going home. NY: HarperCollins.
Chen C – Y. (2004). Guji Guji. La Jolla, CA: Kane Miller Book Publishers, Inc.
Coville, B., reteller, & Nolan, D. (1999). William Shakespeare’s Romeo and Juliet. NY: Dial Books.
dePaola, T., reteller. (1998). Hey diddle diddle and other Mother Goose rhymes. NY: Puffin.
Desnoettes, C. (2006). Look closer: Art masterpieces through the ages. NY: Walker & Company.
Dugan, B., & Stevenson, J. (1992). Loop the loop. NY: Greenwillow Books.
Frazee, M. (2008). A couple of boys have the best week ever. Orlando, FL: Harcourt.
Garden, N., & Wooding, S. (2004). Molly’s family. NY: Farrar Straus Giroux.
Geisel, T. (1989). And to think I heard it on Mulberry Street. NY: Random House.
Geisel, T. (1957). The cat in the hat. NY: Random House.
Jeffers, S. (1991). Brother Eagle, Sister Sky. NY: Dial.
Lehmann, B. (2004). The red book. Boston, MA: Houghton Mifflin.
Liu, J. S. (1987). The yellow umbrella. La Jolla, CA: Kane Miller Book Pub.
Martin, R., reteller, & Shannon, D. (1992). The rough-face girl. NY: G. P. Putnam Sons.
Mayer, M., reteller, & Bywaters, L. (2005). William Shakespeare’s the tempest. San Francisco, CA: Chronicle Books.
Morrison, T., & Potter, G. (1999). The big box. NY: Jump at the Sun.
Moss, L., & Priceman, M. (1995). Zin! Zin! Zin! A violin. NY: Simon & Schuster.
Moundlic, C., & Tallec, O. (2007). The scar. Somervillle, MA: Candlewick Press.
Newman, L., & Souza, D. (1989). Heather has two mommies. Boston, MA: Alyson Wonderland.
Norton, D., & Norton, S. (2010). Through the eyes of a child: An introduction to children’s literature (8th ed.). Boston, MA: Prentice-Hall.
Parnell, P., Richardson, J., & Cole, H. (2005). And Tango makes three. NY: Simon & Schuster.
Petty, K., & Maizels, J. (1999). The amazing pop-up music book. NY: Dutton Children’s Books.
Raschka, C. (2011). A ball for Daisy. NY: Schwartz & Wade Books.
Swanson, S. M., & Krommes, B. (2008). The house in the night. Boston, MA: Houghton Mifflin, Co.
Tan, S. (2009). Eric in S. Tan (2009), Tales from outer suburbia. NY: Arthur A. Levine Books.
Exercise Stress Test
A stress test, sometimes called a treadmill test or exercise test, helps a doctor find out how well your heart handles work. As your body works harder during the test, it requires more oxygen, so the heart must pump more blood. The test can show if the blood supply is reduced in the arteries that supply the heart. It also helps doctors know the kind and level of exercise appropriate for a patient.
- is hooked up to equipment to monitor the heart.
- walks slowly in place on a treadmill. Then the speed is increased for a faster pace and the treadmill is tilted to produce the effect of going up a small hill.
- may be asked to breathe into a tube for a couple of minutes.
- can stop the test at any time if needed.
- afterwards will sit or lie down to have their heart and blood pressure checked.
Heart rate, breathing, blood pressure, electrocardiogram (ECG or EKG), and how tired you feel are monitored during the test.
Healthy people who take the test are at very little risk. It's about the same as if they walk fast or jog up a big hill. Medical professionals should be present in case something unusual happens during the test.
A physician may recommend an exercise stress test to:
- Diagnose coronary artery disease
- Diagnose a possible heart-related cause of symptoms such as chest pain, shortness of breath or lightheadedness
- Determine a safe level of exercise
- Check the effectiveness of procedures done to improve coronary artery circulation in patients with coronary artery disease
- Predict risk of dangerous heart-related conditions such as a heart attack.
Depending on the results of the exercise stress test, the physician may recommend more tests such as a nuclear stress test or cardiac catheterization.
Written by American Heart Association editorial staff and reviewed by science and medicine advisers. See our editorial policies and staff.
Management of CKD
There is limited information for evidence-based guidelines and recommendations for managing CKD in the elderly. Geriatric issues such as frailty, quality of life, life expectancy, end of life issues, pharmacokinetics and pharmacodynamics of drugs and treatment complications must be addressed when planning the management of CKD in the elderly. AKI may be precipitated by nephrotoxic antibiotics, radio-contrast exposure, combinations of ACEI and angiotensin receptor blockers (ARB), NSAID diuretics and must be recognized and avoided .
Using the general approach to CKD management, the unique issues of CKD management in the elderly are emphasized. The goal of CKD management is to halt or retard disease progression. As shown in Table 1 , interventions, which become additive as disease progresses, have been designed for each stage of CKD. In stages 1 and 2, the strategy requires strict control of comorbidities including CVD and as complications emerge, they are addressed in stages 3𠄵. Preparation for renal replacement therapy is imminent in stage 4 leading to renal replacement in stage 5. The management of CKD can be summarized by the acronym BE ACTIVE (Box 1).
The general management of hypertension and considerations in the elderly has been addressed elsewhere . It has long been recognized that control of blood pressure is extremely important in efforts to slow the progression of CKD. The use of an angiotensin converting enzyme inhibitor (ACEI) or an ARB seems to have theoretical advantage because of the role of angiotensin in progression of CKD, and their proven beneficial effects on proteinuria. One of the earlier papers to demonstrated retardation of CKD progression using ACEI in patients with Type 1 diabetes was by Lewis et al. . In that study, Type 1 diabetics were treated with Captopril or placebo and other blood pressure medication so that both groups had virtually equivalent blood pressure control. Lewis found that patients on Captopril were significantly less likely, p < 0.007, to have a doubling of serum creatinine, and concluded that ptopril protects against deterioration in renal function in insulin-dependent diabetic nephropathy and is significantly more effective than blood-pressure control alone.” Similar observations were later conformed in nondiabetic renal disease [35,36]. What the ideal blood pressure is for such patients is not clear. The original targets for BP control were less that 125/75 mmHg for patients with diabetic nephropathy and less than 130/80 mmHg for nondiabetic CKD  however, Upadhyay  found in a systemic review of over 2000 patients, that there was no evidence that those values were any better that 140/90 mmHg, except in patients with proteinuria.
More recently, a large cohort study of mortality of veterans (mean age 73.8 ± 9.7 years) with CKD showed that at low blood pressure levels, mortality actual rose . They concluded that the ideal BP for CKD patients seemed to be between 130 mmHg systolic and 70 mmHg diastolic. The current 2013 KDIGO (Kidney Disease Outcome Global Imitative) guidelines recommend blood pressure less than or equal to 140/90 mmHg if albuminuria is less than 㰰 mg/day and BP less than or equal to 130/80 mmHg if albuminuria is more than 㸰 mg/day. The guidelines also recommend the use of ACEI or ARB in diabetics if albuminuria 㸰 mg/day, and nondiabetics if albuminuria mg/day.
The recommended dose for the use of erythropoiesis-stimulating agents (ESAs) for the treatment of the anemia of renal disease is also in flux. Anemia usually develops in stage 3 CKD, and the availability of erythropoietin and its analogs has made an important improvement in many aspects of patients with CKD, including less need for blood transfusion, better quality of life and improvement in left ventricular hypertrophy. The target hemoglobin for dialysis patients was between 11 and 12 g/dl. However, two studies, the CHOIR  and the TREAT  study (median age: 68 years) revealed an increased risk of cardiovascular events at hemoglobin levels greater than 13 g/dl. Therefore, the 2012 KDIGO guidelines recommend to not start ESA in CKD patients with Hgb 㸐 g/dl.
Because of impaired ammonia excretion in CKD, patients develop acidosis, beginning in stage 3. A recent study by deBrito-Ashurst treating 134 stage 3𠄴 patients with metabolic acidosis randomized to either usual care or replacement with oral sodium bicarbonate for 2 years showed that patients receiving the drug had a significantly slower progression of CKD and better nutritional parameters . Even in early CKD stage 2 patients, the use of bicarbonate was associated with retarding progression compared with controls .
Cardiovascular risk assessment
Patients with CKD have many of the traditional risk factors for CVD including diabetes mellitus and hypertension, and cardiac disease is very prevalent in that population. CKD patients are more likely to have the metabolic syndrome, elevated C-reactive protein levels and abnormal mineral metabolism, especially calcium. CKD and proteinuria are considered independent risk factors of CAD and cardiovascular mortality is increased in patients with CKD. The Rotterdam study investigated whether the level of renal function, estimated by GFR, was associated with the risk of incident myocardial infarction among 4484 apparently healthy subjects (mean age: 69.6 years). The study showed that a 10 ml.min -1 /1.73 m 2 decrease in glomerular filtration rate was associated with a 32% increased risk of myocardial infarction (p < 0.001), and that renal function is a graded and independent predictor of the development of myocardial infarction in an elderly population . The KDIGO recommendations for CVD risk reduction in CKD include interventions to slow the loss of GFR regardless of age, therapeutic lifestyle change (such as smoking cessation, weight loss, increased physical activity), specific use of ACEI or ARBs in combination with other agents to control blood pressure and management of diabetes and other cardiovascular risk factors. It should however be noted that the use of ACEI and ARB in older patients (age: 㹕 years) with diabetes and high cardiovascular risk may result in complications such as worsening renal function, dialysis, hyperkalemia or death and therefore the combination should be avoided in the group .
In CKD patients who are clearly progressing, discussion about options in renal replacement therapy should start in late stage 3, depending on the individual patient. Referral to a transplant program is considered for those who are surgical candidates. In stage 4, for those electing dialysis, access for either hemodialysis or peritoneal dialysis should be discussed, and vein mapping done for those electing hemodialysis. Vascular access should usually be placed at that stage. There is no clear consensus as to when to actually start dialytic therapy. KDOQI suggests starting when eGFR is less than 14 ml/min/m 2 in patients who have symptoms. In those who are symptom free, start at an eGFR of less than 6 ml/min/m 2 . Cooper et al. conducted a randomized control study of 828 stage 5 patients. There was an rly start’ group, eGFR 10 ml/min/m 2 , and a late start group, eGFR 5𠄷 ml/min/m 2 . There was no difference in survival or adverse outcomes, although many of the ‘late start’ group started earlier because of fluid overload and other complications .
When iron deficiency is diagnosed in CKD, a search must be initiated for any sources of blood loss. Unlike in hemodialysis patients, there is no clear advantage shown with intravenous versus oral administration in CKD patients therefore both routes of administration are options. CKD population differs from hemodialysis patients in the extent of blood loss, with hemodialysis patients losing much more blood during the procedure. Oral iron therapy may be a more reasonable option  unless oral therapy previously failed given the difficulty with parenteral injections in CKD patients. Iron should be considered in all patients with iron deficiency and in patients receiving ESAs. The goal of therapy is to have an iron saturation of more than 25%, and a serum ferritin of between 300 and 500 ng/ml.
Insulin & glucose control with oral agents
Several studies suggest controlling blood sugar to goal retards progression of microvascular complications including diabetic CKD. The United Kingdom Prospective Diabetes Study Group, showed a risk reduction of 11% in all diabetic end points including renal failure over a 10-year period in patients who had ‘tight’ control, HgbA1c 7.0% compared with those with conventional control HgbA1c 7.9% . Similarly, The VADT study showed that intensive glucose control in patients with poorly controlled Type 2 diabetes had no significant effect on the rates of major cardiovascular events, death or microvascular complications, with the exception of progression of albuminuria (p = 0.01) . Finally, the ACCORD study in 2010 looked at 10,251 patients either treated intensively HgbA1c less that 6%, versus a group with a mean HgbA1c of 7.0𠄷.9%. While the tight control delayed the onset of albuminuria, the study was ended early because of high mortality in the intensively treated group .
Vitamin D & bone disease
Bone disease in CKD is extensive, and a full review is beyond the scope of this article. However, bone disease usually starts to become evident in stage 3 and 4 and serum levels of calcium, phosphorus and intact parathyroid hormone (PTH) should be measured at these stages. Abnormalities in these levels can lead to vascular and other soft tissue calcification, renal osteodystrophy, increased fractures, cardiovascular events, increased mortality and calciphylaxis. Recommendations for treatment include use of oral phosphate binders to control serum phosphorus and the use of vitamin D or analogs or calcimimetic to suppress PTH levels and to replace vitamin D deficiency.
Whether or not a low protein diet is beneficial in slowing the progression of CKD remains to be proven. There was some suggestion that a low-protein diet, which is 0.50 g protein/kg of body weight, had a minimal effect on slowing the progression of CKD in the MDRD, Modification of Diet in Renal Disease Study . A more recent study in which 423 patients were assigned to two diets, 0.5 or 0.8 g/kg of protein found that the BUN increased significantly in the higher protein diet, and serum phosphate and PTH levels remained the same. Those patients on the lower protein diet needed less phosphate binders, less diuretics and less sodium bicarbonate replacement. There was no difference in adverse effects between the two groups .
Pancreatic Cancer in the Older Patient
Pancreatic cancer is a disease seen predominantly in elderly patients. Compared to younger patients, older patients are more likely to present with early-stage disease and, therefore, may be candidates for aggressive local
ABSTRACT: Pancreatic cancer is a disease seen predominantly in elderly patients. Compared to younger patients, older patients are more likely to present with early-stage disease and, therefore, may be candidates for aggressive local treatment. Little published information exists on treatment outcomes for elderly patients with potentially resectable disease or those with locally advanced or metastatic pancreatic cancer. The limited information available suggests that elderly patients are as likely to benefit from surgery, radiation, and chemotherapy as younger patients. Despite this apparent benefit, elderly patients appear to have a worse long-term outcome. This may be due to the failure to offer them aggressive treatment or to comorbid conditions. Nevertheless, further studies need to be conducted in this area, and greater emphasis needs to be placed on including elderly patients in clinical trials. For elderly patients with terminal disease, there should be better use of palliative measures that may be of benefit. Each of these issues is discussed in detail. [ONCOLOGY 15(7):926-937, 2001]
By 2030, 20% of the population will be over 65 years of age. As the elderly population increases, oncologists will be faced with a progressively larger number of older patients with cancer. Pancreatic cancer is seen predominantly in older people, with incidence peaking from age 70 to 79 years. According to the National Cancer Database, 68.5% of pancreatic cancers were diagnosed in those over age 65 years. Overall, it is the fourth most common cause of cancer death, with an estimated 28,200 deaths in 2000. However, this is mainly because it is the fourth most common cause of cancer death in patients over age 55 years.
Older patients are more likely to have earlier-stage disease, but are less likely to undergo pancreatectomy. A recent report showed that in those under age 55 years, 22.5% underwent pancreatectomy, compared to 13.5% in those aged 70 to 74 years, 10.7% in those aged 75 to 79, and 6.3% in those over age 80. Older patients are also less likely to receive chemotherapy than younger patients. Although some of these patients are poor candidates for aggressive therapy, there is evidence from other tumor types that elderly patients do not receive appropriate treatment based on age alone.[5-8]
Despite the fact that the majority of patients with pancreatic cancer are elderly, there are very few data in the literature specific to this group of patients. Most of the existing data come from clinical trials, in which elderly patients are vastly underrepresented.[9,10] More research is needed to expand our knowledge of the treatment of pancreatic cancer in elderly patients, as the size and life expectancy of this population is ever increasing. This article will review the existing literature on the presentation and surgical and medical treatment of pancreatic cancer in elderly patients.
Characteristics of Pancreatic Cancer in the Elderly
Disease-Specific 5-Year Survival of 44,438 Patients With Pancreatic Adenocarcinoma, 1985-1990
Several studies have shown that older patients are less likely to be staged than younger patients.[2,3] Among those who are staged, it appears that older patients present with earlier-stage disease. Despite this fact, older patients have a worse overall 5-year survival compared to younger patients (Table 1). This may be due to less aggressive treatment of elderly patients, as well as deaths due to comorbid conditions. However, no studies are available that adequately address this issue.
Kamisawa et al examined the pathologic features of pancreatic cancer in 89 elderly patients (> 70 years) and compared them to 184 younger patients. With advancing age, proportionally more women were diagnosed. There were no differences in the grade or location (head/body/tail) of tumors in younger vs older patients, and there was no difference in the incidence of local spread. Elderly patients, however, did have fewer hematogenous metastases than younger patients.
In another study, it appeared that older patients had more diploid tumors, and younger patients had more aneuploid tumors (which may help explain the difference in hematogenous spread).
Various events have been implicated in the pathogenesis of pancreatic cancer, such as K-ras mutation and p53 tumor-suppressor gene mutation. Sato et al studied the expression of p53 mutations in paraffinized tumors by using monoclonal antibodies to products of the p53 gene, DO-1-p53. Overexpression of this product was significantly associated with a worse prognosis and was more common in older patients, independent of stage. The authors suggested that p53 mutations may be more common with aging. More research is needed to determine how aging is involved in the pathogenesis of pancreatic and other cancers.
The only potentially curative approach for pancreatic cancer is resection. Recent studies report 5-year survival rates ranging from 20% to 25% for those undergoing surgical resection.[2,14] Unfortunately, less than 20% of patients are considered resectable. With improvements in surgical techniques, the mortality for pancreaticoduodenectomy has diminished, and many centers are now reporting operative mortality rates of less than 5%. Although elderly patients present with earlier-stage disease, fewer of them undergo surgical treatment.
A number of centers have reported their experience in elderly patients, and have shown that pancreatic resection can be performed in elderly patients without excess mortality, even in those over age 80 years. Fong et al compared the outcomes of patients under age 70 to those age 70 and older undergoing pancreatic resections. Overall perioperative mortality was 6%. Although fewer patients over age 80 were scheduled for surgery, this group actually had fewer complications and no perioperative mortality. There was no difference in the length of hospital stay, complication rates, mortality rates, or rate of admission into the intensive care unit between age groups.
Recent Reports of Morbidity and Mortality in Patients Undergoing Pancreatic Resection
Univariate analysis showed that a history of cardiopulmonary disease, abnormal ECG, or abnormal chest x-ray preoperatively predicted for complications in elderly patients. Elderly patients did have a slightly lower median (18 vs 24 months) and 5-year survival (21% vs 29%). Other authors report similar survival rates for elderly patients compared to younger patients after surgery.[16-20] Morbidity and mortality data from recent surgical series in older patients are summarized in Table 2.[15-27]
Even less data are available for octogenarians. Sohn et al compared the outcomes of 46 patients over age 80 undergoing pancreaticoduodenectomy with 681 patients younger than 80. Mortality was similar for the older and younger groups (4.3% vs 1.6%, respectively, P = NS), however, there were more postoperative complications and longer hospital stays among the older patients. Median survival for patients with pancreatic adenocarcinomas was no different between age groups (17 vs 18 months in the younger group). Elderly patients who undergo pancreaticoduodenectomy are a highly selected group however, these studies show that this procedure can be performed without excess morbidity or mortality, and with a 5-year survival greater than 20%.
Combined-Modality Treatment in the Adjuvant Setting
For patients who have undergone surgical resection, radiation and chemotherapy are often given in an attempt to prolong survival. A Gastrointestinal Tumor Study Group (GITSG) trial showed an improvement in median survival in those treated with fluorouracil (5-FU) and radiation vs observation after resection (20 vs 11 months). The median age of patients in this study was 64 years for those treated and 59 years for controls. No specific toxicities or benefits of treatment were reported for older patients. However, age was not a significant prognostic factor for survival only initial performance status and extent of tumor were predictive of survival.
In another nonrandomized study, Yeo et al offered patients a choice between three adjuvant regimens: standard 5-FU/radiation, intensive 5-FU/radiation plus maintenance 5-FU, or no therapy. There were no differences between these groups in regard to sex, tumor characteristics, race, or intraoperative factors. However, patients receiving adjuvant therapy were younger than those observed. Patients who had longer postoperative stays and more complications were less likely to choose adjuvant therapy. It is not clear whether more of these patients were elderly. In multivariate analysis, only the size of the tumor, intraoperative blood loss, and use of adjuvant therapy were predictive of survival. More recent studies report that 5-FU given as a prolonged intravenous infusion is better tolerated and allows for greater dose intensity than bolus 5-FU in patients with advanced pancreatic cancer.
While most studies involving radiation include older patients, the specific toxicities and benefits of therapy for the elderly are not reported. Radiation therapy has been studied in elderly patients in other diseases, such as head and neck cancer, breast cancer, and prostate cancer.[31,32] In general, older patients tolerate radiation treatment as well as younger patients, although older patients being treated for bladder or rectal cancer may experience more toxicity.
There are very few data, however, on tolerance of abdominal radiation in elderly patients. In general, the toxicities of abdominal radiation include nausea, vomiting, diarrhea, and anorexia. Elderly patients may be more susceptible to dehydration, electrolyte disturbances, and infection, and may require multiple medications for symptom control while undergoing radiation therapy. Also, elderly patients often have problems with transportation, which makes completing therapy more difficult. Further investigations are needed to define the tolerance and benefit of radiation for pancreatic and other abdominal cancers in elderly patients.
Combined-Modality Treatment for Locally Advanced Disease
The combination of chemotherapy and radiation is often used for unresectable pancreatic cancer. The most common toxicities associated with the use of this combined modality therapy are nausea, vomiting, diarrhea, anorexia, and hematologic toxicity. Gastrointestinal bleeding has also been reported.[34-37] A GITSG trial established 5-FU and radiation as the treatment of choice, with improved survival over radiation alone. The median age of patients in each of the groups in this study was 54 years and 61 years, respectively. In a multivariate analysis, age was not predictive of survival. The most common prognostic factors were good performance status (Eastern Cooperative Oncology Group [ECOG] 0 or 1), and pretreatment carcinoembryonic antigen (CEA) levels < 5.0 ng/mL. The most common toxicities were hematologic and nausea/vomiting. The rates of infection and mucocutaneous toxicity were quite low. However, there were no specific data on the tolerance of treatment in older patients.
A small study performed by ECOG randomized patients to 5-FU alone vs 5-FU and radiation. This study did not show a survival benefit with combined-modality therapy. Toxicity was more common in the combined-modality group, mostly leukopenia with sepsis. Again, there was no comment made on toxicity in older patients. One phase I study did report toxicities in elderly patients receiving 5-FU/leucovorin and radiation for locally advanced pancreatic cancer. Patients were treated with 40 Gy in 20 fractions (split course) 5-FU (300 to 375 mg/m 2 /d) and leucovorin (20 mg/m 2 /d) were given as a bolus on days 1 to 5 of radiation, and repeated the first 5 days of the second half of radiation. Of the 27 patients in the study, 4 were over age 70, and 11 were aged 55 to 69. Patients over age 70 and patients with poor performance status experienced more grade 3/4 toxicity. Two treatment-related deaths were reported (both infections)-a patient aged 44 years and a patient aged 80 years.
Recently, other radiosensitizing agents have been used with radiation in an attempt to improve on the results seen with 5-FU. Blackstock reported a phase I trial of twice-weekly gemcitabine (Gemzar) with concurrent radiation in patients with advanced disease. The median age of patients was 61 years (range: 39 to 83 years). Again, there was no comment made on older patients’ tolerance of therapy. Dose-limiting toxicities were thrombocytopenia, neutropenia, and nausea/vomiting. Three patients achieved a partial response, and the other assessable 12 patients had stable local disease. Median survival was 11 months, and because of these favorable results, a phase II study is planned.
Paclitaxel (Taxol), another radiosensitizing agent, is being evaluated in the treatment of patients with unresectable pancreatic cancer. A recent phase II study of concurrent paclitaxel and radiation reported a 33% partial response rate, and 39% stable disease rate. How the elderly patient population tolerates these new regimens awaits further study.
Chemotherapy for Advanced Disease
Numerous single-agent trials have failed to demonstrate any significant benefit for patients with advanced disease. Fluorouracil has long been the standard of care, with limited benefits in terms of survival or improved quality of life. Combination chemotherapy, such as FAM (5-FU, doxorubicin [Adriamycin], mitomycin-C [Mutamycin]) and SMF (streptozocin [Zanosar], mitomycin-C, 5-FU), has not resulted in any significant improvement in survival.
Gemcitabine, a pyrimidine antagonist, has recently been shown to confer both clinical benefit and a small improvement in survival compared to 5-FU. In a phase III study, 126 patients with unresectable pancreatic cancer were randomized to either weekly 5-FU at 600 mg/m 2 or gemcitabine at 1,000 mg/m 2 /wk for 7 weeks, then every 3 of 4 weeks. At study entry, most patients had impaired performance status and pain. The median age of enrollees was 61 to 62 years (range: 36 to 79 years). Clinical benefit, defined as improvement in performance status, narcotic requirements, and weight, was seen in 23.8% of patients receiving gemcitabine compared to 4.8% of those receiving 5-FU. Among those receiving gemcitabine, this response took an average of 7 weeks to attain, and lasted a mean of 18 weeks.
Most patients who received gemcitabine had stable disease, but three achieved a partial response (overall response rate: 5.4%). No responses were seen in the 5-FU group. The median survival was 5.65 months with gemcitabine and 4.41 months for those receiving 5-FU. Toxicities reported in both arms of the study were minimal. Grade 3/4 hematologic toxicity was observed in 26% of those receiving gemcitabine. Other common toxicities of gemcitabine included fever (grade 1/2, 30%), rash (grade 1/2, 24%), and nausea/vomiting (grade 3/4, 9.5%). The authors did not comment on any age-related differences in toxicity or clinical benefit.
Some small measure of clinical benefit with gemcitabine was also seen in a large compassionate-use protocol involving over 3,000 patients. The median age of patients was 65 years, and the majority had metastatic disease. Patients were treated with doses as described in the Burris trial above. Median survival was 4.8 months, median time to progression was 2.7 months, and the overall response rate was 12%. Improvement in disease-related symptoms was measured by monitoring pain scores, analgesic use, and Karnofsky performance status. By the end of four cycles, 18.4% of patients had achieved improvements in disease-related symptoms. The authors did report that age had no effect on any patient outcomes.
Other studies using gemcitabine in elderly patients have confirmed its tolerability. It has been used extensively in the treatment of lung and bladder cancer.[44-47] The most common toxicities are mild hematologic toxicity, transient elevation in liver function tests, mild nausea/vomiting, rash, peripheral edema, and fever/flu-like symptoms.
Two studies of gemcitabine in patients with lung cancer have specifically commented on age-related toxicities. In a group of 361 lung cancer patients receiving gemcitabine at 800 to 1,250 mg/m 2 /wk for 3 weeks in the setting of a clinical trial, there was no difference in grade 3/4 hematologic or nonhematologic toxicity between patients younger than age 65 and those age 65 and older. Grade 3/4 neutropenia occurred in 25% and grade 3/4 thrombocytopenia in 1.9% of older patients. The most common grade 3/4 nonhematologic toxicity was nausea/vomiting, seen in 16% of older patients and 22% of younger patients. The authors also looked at dose delivery and found that elderly patients received dose reductions and omissions similar to younger patients.
Ricci et al reported a phase II trial of single-agent gemcitabine given at 1,000 mg/m 2 /wk for 3 weeks in 46 patients over age 70 years with advanced lung cancer. Grade 3/4 neutropenia occurred in only 0.5% of patients, and no grade 3/4 thrombocytopenia was observed. The most common nonhematologic toxicity was a skin rash, seen in 4.3%. Patients over age 75 years received a median of three cycles, compared to four cycles in younger patients.
In a review of the safety of gemcitabine, Tonato et al reported on the toxicities seen in 790 patients enrolled in phase II studies using doses of 850 to 1,250 mg/m 2 /wk for 3 weeks, followed by 1 week of rest. Patients over age 65 years did not experience excess toxicity, with the exception of more peripheral edema (25.3% vs 15.3%). Older patients actually had less nausea and vomiting. Grade 3/4 leukopenia was seen in only 8.6% of patients, and grade 3/4 thrombocytopenia in 4.7%, with age having no apparent effect. Martin et al reviewed the same database and found that the subset of patients over age 70 years did not experience any greater toxicity than those > 65 years old.
Older patients may have more chronic renal insufficiency. Venook et al recently conducted a phase I trial of gemcitabine in patients with advanced cancer and either liver or renal dysfunction. Median age in this study was between 64 and 66 years for each of the three cohorts studied. Gemcitabine was administered starting at 800 mg/m 2 /wk for 3 consecutive weeks of every 4-week cycle, with dose escalations as tolerated. The range of renal dysfunction seen included a creatinine level of 1.6 to 3.2 mg/dL the range of hepatic dysfunction included a serum aspartate aminotransferase (AST) level of 37 to 530 U/L and total bilirubin from normal to 5.7 mg/dL.
The group with renal dysfunction experienced more skin toxicity, and the group with increased total bilirubin had transient hyperbilirubinemia. Interestingly, no hematologic toxicity was observed, and there were no differences in the clearance of gemcitabine among the patients. The authors recommended that patients with elevated bilirubin levels should be started at a reduced dose of gemcitabine (800 mg/m 2 /wk), whereas patients with elevated transaminases or renal dysfunction do not need an initial dose reduction.
Other forms of chemotherapy, as well as novel agents, are being assessed in an ongoing series of phase II and III trials. Several trials are attempting to enhance the activity of gemcitabine with other drugs such as oxaliplatin or novel agents such as pemetrexed (Alimta) and ISIS 2503. A phase III trial is currently evaluating the activity of 9-nitrocamptocin (RFS2000) compared to gemcitabine. Each of these trials is designed to include patients of all ages. However, in general, no assessment of tolerability by age groups is included as part of the primary analysis of these trials.
Because most patients with pancreatic cancer present with incurable locally advanced or metastatic disease, palliative care is important in their management. Most patients require pain control, and many will need treatment for jaundice and duodenal/gastric obstruction.
In general, elderly patients with cancer pain are undertreated,[53,54] and many of these patients underreport their pain.[54-56] Also, there are misconceptions about an older patient’s tolerance of pain and ability to use opioids safely.[54,55] Because the majority (> 80%) of patients with pancreatic cancer suffer from pain, frequent assessment and treatment of pain is extremely important. Untreated pain leads to a decreased quality of life, depression, diminished performance status, and sleep disturbances.[57,58]
In many cases, pain can be treated effectively with oral narcotics, but in treating elderly patients with narcotics, a few points need to be emphasized. Older patients are often more sensitive to opioids, and may require lower initial dosing and longer intervals between dosing.[54,55,59] Elderly patients often receive multiple medications that may exacerbate side effects, such as mental status or behavioral changes. Also, patients with renal impairment have decreased clearance of morphine, and require careful dosing and monitoring.
Certain opioids are not recommended for older patients. These include meperidine, methadone, and propoxyphene. Elderly patients, especially those with impaired renal function, may have more side effects with these drugs due to prolonged half-life or accumulation of metabolites. Transdermal fentanyl (Duragesic) should also be used with caution, especially in those with poor fat stores, muscle wasting, or abnormal liver or kidney function. This drug should be avoided in opioid-naive patients. Elderly patients can be treated successfully with narcotics, but require more careful dosing and frequent assessments of their pain.
Celiac Block for Pain Control
Another option available for control of pain is celiac plexus block, performed either at the time of laparotomy or percutaneously. In a randomized study of alcohol splanchnicectomy vs placebo in patients undergoing exploration for pancreatic cancer, those receiving a block had no increase in mortality or morbidity, but did report lower pain scores for up to 6 months. The mean age of patients in this study was 64 years. A percutaneous celiac block can also be used, and is associated with success rates of 80% to 90%.[61,62-64] Many patients experience pain relief for up to 6 months, thus decreasing the amount of narcotics they use, and diminishing the side effects of these drugs.
Side effects of the procedure include hypotension, increased bowel motility, spread of the neurolytic solution to adjacent structures, and perforation of other organs. Paralysis has rarely been reported.[62,64] Elderly patients with comorbid diseases may be more susceptible to a hypotensive episode. However, this procedure has very little overall morbidity, and should be considered in patients with pain related to their pancreatic cancer.
Palliation of Biliary and Duodenal Obstruction
Obstructive jaundice is seen in up to 70% of newly diagnosed patients. Untreated, patients will suffer from liver failure, anorexia, nausea, malnutrition, and often intractable pruritus.[61,63] Biliary obstruction can be palliated surgically or with stent placement. Most patients are treated successfully with an endoscopically placed stent, with resolution of obstruction in 90% of patients. Stent placement has been shown to improve symptoms of obstruction, as well as quality of life.[65,66]
Complications occur in roughly 20% of patients, but procedure-related mortality is low (1.3%). Complications of stent placement include infection, pancreatitis, duodenal ulceration, stent dislocation, and occlusion of the stent. Older age was found to be an unfavorable prognostic factor for stent patency in one study that used plastic stents. Newer metal expandable stents provide longer patency (> 6 months) and are associated with fewer complications than plastic stents.[67,69-71] If these stents become occluded, another stent can be placed or a variety of cleaning procedures may open the stent.
For patients in whom stent placement is unsuccessful, percutaneous stent placement is an option. This can be internalized in most patients. Surgical biliary bypass is usually a last option for patients in whom stent placement is unsuccessful. A cost-effective analysis showed that endoscopic stenting provides equivalent survival with lower costs and shorter hospital stays when compared to surgical palliation.
Duodenal obstruction occurs in about 20% of patients who do not undergo initial gastric bypass. Patients may be treated with prophylactic gastrojejunostomy at the time of initial laparotomy without increased mortality. For those who develop gastric outlet obstruction, palliative gastric bypass can be performed. Metal stents have also recently been used with success in palliating malignant gastric outlet obstruction.[73,74] Elderly patients with reasonable life expectancy should be offered these palliative procedures.
Oncologists will be faced with treating an increasing number of older patients with pancreatic cancer. Older patients present with earlier-stage disease, and may have less hematogenous metastasis than younger patients. In older patients who are surgical candidates, a pancreaticoduodenectomy can be performed without undue morbidity or mortality. Adjuvant chemotherapy with concurrent radiation should also be considered in older patients. However, there are very few data on the tolerability of combined-modality treatment in older patients in either the adjuvant or advanced setting. More research needs to be conducted in this area.
Palliative chemotherapy, specifically gemcitabine, can be administered safely to elderly patients. It is well tolerated and provides temporary palliation for some patients with advanced disease. Initial dose reductions are not needed based on age alone, but may be required for those with elevated bilirubin levels. Future studies utilizing newer agents should include older patients, and the elderly should be encouraged to participate in clinical trials whenever possible. Supportive care is extremely important in patients with advanced disease. Pain control can be accomplished safely with careful administration of narcotics. Celiac plexus blockade can also be extremely helpful in pain control. Obstructive jaundice can usually be managed successfully with endoscopic stent placement, and gastric outlet obstruction with either stenting or surgical bypass. There is a paucity of data regarding the tolerance of these palliative procedures in older patients, and more research efforts are needed to improve the care of the elderly.
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