Early postoperative mortality in the elderly: a pilot study

BACKGROUND

As the population ages and as surgical and anaesthetic techniques advance, more elderly people will be referred for surgery. Postoperative mortality and morbidity are certainly associated with increasing age; however the severity of coexisting medical conditions is an equally important risk factor. In the present study we tried to look into the aetiology of early postoperative morbidity of elderly patients following major surgery, in relation to their medical history.

FINDINGS

Fifty patients aged 70 to 95 years of age were enrolled in the study. All patients had undergone major elective orthopedic procedures due to either osteoarthritis of femoral head or femoral neck fracture. Patients were followed up by telephone interview one month following their discharge. 8 out of 50 patients (16%) were reported dead at follow up. For the majority of the patients who died, the cause of death was directly related to their previous medical history.

CONCLUSION

Despite the detailed preoperative evaluation, and the intensive intraoperative and early postoperative anaesthetic care, most patient's deaths were related to their previous medical history.

Neuromuscular control and performance in shot-put athletes

AIM

The aim of this study was to investigate the relationship between the activation level of certain protagonist muscles of the upper and lower body during the shot-put with the shot-put performance in skilled athletes.

METHODS

Eight experienced right-handed shot-putters, performed the shot-put with the linear technique. They also performed a maximum (1RM) squat and a 1RM incline bench-press strength test. Electromyographic (EMG) signals were recorded from the m. quadriceps vastus lateralis (VL), m. gastrocnemius internus, m. pectoralis major (PEC) and the m. triceps brachii (TRI) of the right side during all efforts. The level of EMG during the shot-put was normalized relatively to that measured during the respective maximum strength test.

RESULTS

Shot-put performance was significantly correlated with 1RM squat (r=0.76, P<0.05) and 1RM bench-press (r=0.75, P<0.05) as well as with the average EMG from VL and PEC after taking the power position (r=0.91, P<0.01 and r=0.75, P<0.05, respectively). A close negative relationship was also found between shot-put performance and the time to reach peak activation of right TRI during the explosive strike of the throwing arm (r=-0.70, P<0.05).

CONCLUSION

These results suggest that, besides the importance of absolute muscle strength, an important parameter for shot-put performance is the level of activation of the VL and the PEC during the delivery phase. Furthermore, these data suggest that the TRI should be activated fast in order to be an effective contributor to the shot-put performance.

Prevalence of overweight and obesity in a national representative sample of Greek children and adolescents

OBJECTIVE

The aim of this study was to examine the prevalence of overweight and obesity in Greek school age children and adolescents.

DESIGN

Nationwide representative survey.

SETTING

Primary and secondary schools all over Greece.

SUBJECTS

In all, 6448 students (50.4% boys, 49.6% girls) 6-17 years old.

METHOD

A nationwide multistage procedure was followed to obtain a representative sample of youths. Body mass and height were measured by trained personnel. Data were collected between October 1990 and May 1991.

RESULTS

According to the 12-month-International Obesity Task Force cutoff values, the overall prevalence of overweight was 17.3% (16.9% for boys, 17.6% for girls). The rate of obesity was 3.6% (3.8% for boys, 3.3% for girls). The prevalence of overweight and obesity was decreasing with age in girls (6-9 years: 23.2 and 6.7%, respectively, 10-17 years: 14.8 and 1.6%, respectively). In boys, the prevalence of overweight was higher in 10-17 years (19.3 and 2.7%, for the rate of overweight and obesity, respectively) than in 6-9 years (12.1 and 5.9%, respectively).

CONCLUSION

The prevalence of overweight and obesity in Greek children and adolescents is comparable to that reported for most European countries.

Add-on topiramate in the treatment of refractory partial-onset epilepsy: clinical experience of outpatient epilepsy clinics from 11 general hospitals

An open, prospective, observational study was performed to assess efficacy and adverse-event profile of topiramate as add-on therapy in epilepsy. Outpatient neurology clinics from 11 general hospitals in Greece participated in the study. In total, 211 patients with treatment resistant partial-onset seizures who met the inclusion criteria, were studied. After baseline evaluation, topiramate was given at a target dose of 200mg/day over a 1-month titration period. In the subsequent maintenance period, the topiramate dose could be varied according to the clinical results. Patients were followed for in total 6 months, with monthly visits and regular physical, neurological and laboratory examinations. Seizure frequencies decreased to 35--40% of baseline values following 3 months of treatment and remained relatively constant thereafter. The average monthly seizure frequency over the 6-month study period was 4.61, compared to 9.21 at baseline. The number of responders (patients with at least 50% reduction in seizure frequency) followed a similar pattern, i.e., increase during the first 3 months levelling off at a final 80--85% response rate. Of those completing the study, 30% had been seizure-free for at least 3 months and 12% for 5 months. Topiramate was well tolerated, no deviations in laboratory values were found. Adverse events appeared to occur less frequently, and antiepileptic effects were more pronounced in this prospective open-label study than in earlier reports from randomised controlled trials. The nature of the patient population and the application of individualised dose optimisation are proposed as contributing factors to explain the favourable results of this study.

Meningococcal Purpura Fulminans in a Patient with Systemic Lupus Erythematosus: A Mimic for Catastrophic Antiphospholipid Antibody Syndrome?

Purpura fulminans (PF) is a life-threatening disorder characterized by acute onset of progressive cutaneous hemorrhage, necrosis, and disseminated intravascular coagulation. Acute infectious PF occurs most commonly in the setting of meningococcal sepsis. When PF occurs in the setting of systemic lupus erythematosus (SLE), the catastrophic antiphospholipid antibody syndrome (CAPS) must be ruled out because urgent therapy is required. Plasmapheresis is effective in both cases, but immunosuppression (high-dose corticosteroids plus cyclophosphamide), although beneficial in patients with CAPS, could be harmful in patients with meningococcal PF. The authors report here a patient with SLE who presented to the intensive care unit with meningococcal PF, acute renal failure, and acute respiratory distress syndrome and discuss clinical similarities and laboratory differences from CAPS.

Relationship between shot put performance and triceps brachii fiber type composition and power production

It is commonly accepted that shot put performance is mainly determined by the ability of the lower body to produce power. The purpose of the present study was to investigate the relationship between shot put performance and triceps brachii muscle fiber type composition and strength capacity. Thirteen male physical education students were selected to participate in the study based upon their shot put performance after 5 weeks of shot put technique instruction. At the completion of this technique-instruction period, they performed the following tests: shot put with a 6-kg shot, isokinetic torque measurements of the elbow extensors at 0, 0.52, 1.04, 1.57, 2.09, 3.14, and 4.19 rad.s(-1), maximal strength (1 RM) and explosive-throwing bench-press tests, one-arm seated shot put with 1-, 2-, 3-, 4-, 5- and 6-kg shot. Whole-body and dominant upper-arm bioimpedance measurements were used to estimate whole-body and upper-arm muscle mass. Muscle biopsy samples from the long head of the dominant triceps brachii were obtained and analyzed for fiber type composition with ATPase histochemistry. Shot put performance was significantly correlated with type II fiber area ( r=0.70, P<0.01), one-arm seated shot put (range r=0.60 to r=0.79, P<0.05), elbow extensors' isokinetic torque (range r=0.65 to r=0.78, P<0.05), bench-press tests ( r>0.86, P<0.01) and estimated arm muscle cross-sectional area ( r=0.68, P<0.05). These results suggest that fiber type composition and the functional capacity of triceps brachii muscle (e.g., isokinetic torque) explain a part of shot put performance. The magnitude of the correlation coefficients between shot put and the upper-body power tests suggests that other body parts (e.g., lower extremities) may play a significant role in this event.

Fulminant Mycoplasma pneumoniae infection with multi-organ involvement: a case report

A 50-year-old man with no medical history was admitted because of progressive respiratory distress, aseptic meningitis, disseminated intravascular coagulation, cholestatic hepatitis, and renal failure. Mycoplasma pneumoniae infection was confirmed serologically. The patient was treated with erythromycin and showed a favorable recovery. Although M. pneumoniae infection is usually a benign, self-limited acute respiratory disease, on rare occasions it can manifest itself with a fulminant course and multi-organ involvement, even in normal healthy individuals.

Peritoneal cancer index: a prognostic indicator of survival in advanced ovarian cancer

AIM

The peritoneal cancer index (PCI) has been used for the detailed evaluation of the peritoneal spread in tumors of gastrointestinal origin and has been found to be a prognostic indicator of survival. The aim of this study was the identification of the significance of the peritoneal cancer index in advanced ovarian cancer.

METHODS

From 1990 to 2001, 60 women, mean age 65+/-10.84 (41-86), were treated for advanced ovarian cancer. The performance status (Karnofsky performance scale), age, prior surgery score (PSS), peritoneal cancer index (PCI), tumor volume, tumor grade, residual tumor, the presence of ascites, treatment with adjuvant chemotherapy, histopathologic subtype and FIGO stage were retrospectively correlated to survival using univariate model of statistical analysis.

RESULTS

Hospital mortality and morbidity were 11.7 and 16.7% respectively. The recurrence rate was 23.3%. Overall 5-year survival rate was 41% and mean survival 63+/-8 months. The peritoneal cancer index was related to survival (P=0.0253). The other favorable clinical prognostic indicators of survival were low grade and small volume tumors, treatment with adjuvant chemotherapy and complete cytoreductive surgery (P<0.05).

CONCLUSIONS

The peritoneal spread in advanced ovarian cancer can be assessed in detail using the peritoneal cancer index. It is a significant prognostic factor of survival and is useful in identifying subgroups.

Presumed localized tetanus in two cats

In this report two cases of localised tetanus in two young (<1 year) intact male and outdoor DSH cats, which had been missing, are described. Clinical examination revealed severe muscular spasms on the right (case 1) or both thoracic limbs (case 2). In the latter cat, wrinkling of the forehead and mild trismus were also seen. The routine diagnostic workup (CBC, survey radiographs of the spine, CSF analysis) did not reveal any abnormalities in both cats. EMG testing on the affected muscles in the second animal showed persistent spontaneous motor unit potentials, strongly indicating tetanus. The treatment, that was symptomatic (diazepam, metronidazole) and supportive (physical therapy, assist feeding and intravenous fluid therapy) resulted in the progressive improvement of limb rigidity and the restoration of motor dysfunction in a period of 5- (case 1) and 2- (case 2) month duration.

Group B streptococcal prosthetic joint infections

We report 6 cases of group B streptococcal prosthetic joint infections seen in our institution and review 8 previously reported cases. These 14 patients (6 men and 8 women) had an average age of 69. Seven hip joints and 7 knee joints were affected. Only 4 patients had risk factors for prosthetic joint infection (diabetes mellitus in 2, cancer in 1, and myelodysplasia in 1). The average time from surgery to onset of symptoms was approximately 4 years (range, 5 months to 10 years). Pain in the affected joint was the chief complaint. Six patients had bacteremia. Seven patients had known or suspected foci of infection, which were genitourinary tract (1), skin and soft tissue trauma sites (1), gastrointestinal tract (1), and oropharynx (1). Nine patients required prosthesis removal in addition to antibiotic therapy. Two patients had apparent cure of the infection with retention of the prosthesis. Group B streptococcal prosthetic joint infections appear to be a late complication of prosthetic joint replacement surgery.

beta-thalassemia and gonadal axis: a cross-sectional, clinical study in a Greek population

beta-thalassemia (beta-thal) is characterized by disturbances of the reproductive system. The aim of the present study was: 1) to assess the hypothalamic- pituitary-gonadal axis in patients with beta-thal in relation to their phenotype and 2) to determine prognostic features of current gonadal status. We studied 135 patients (67 males and 68 females) with beta-thal through history, physical examination, spermiograms and GnRH test. These patients were divided into beta-thal major (51 males and 62 females) and beta-thal intermedia phenotypes (16 males and 6 females). Male patients with beta-thal major were subdivided into three groups a) eugonadal (35%, Tanner's stage V, normal testicular volume, normal spermiograms, normal basal and stimulated hormone values), b) patients with hypogonadotrophic hypogonadism (HH) of late onset (24%, Tanner's stage II-V, low-normal testicular volume, abnormal spermiograms, normal basal gonadotrophin values and abnormal response to GnRH test) and c) patients with HH of early onset (41%, Tanner's stage I, small testicular volume, abnormal spermiograms, abnormal basal and stimulated hormone values). Female patients with beta-thal major were subdivided into: a) eugonadal (32%, Tanner's stage V, regular menstruation, normal basal and stimulated hormone values), b) patients with hypogonadotrophic hypogonadism (HH) of late onset (34%, Tanner's stage II-V, secondary amenorrhea, subnormal basal and stimulated gonadotrophin values) and c) patients with HH of early onset (34%, Tanner's stage I, primary amenorrhea, subnormal basal and stimulated hormone values). Patients with beta-thal intermedia were subdivided into eugonadal (75% of males, 33% of females) and hypogonadal (25% of males, 67% of females). Current gonadal status could not be predicted by means of transfusion or chelation parameters. In conclusion, beta-thal patients could be eugonadal or develop early or late onset HH. trade mark-thal intermedia patients have a more favorable profile than beta-thal major individuals. Current gonadal status of beta-thal patients cannot be predicted by means of history, clinical or laboratory parameters.

Amantadine sulfate infusion effect on N30 somatosensory evoked potentials in Parkinson's disease

The purpose of this study was to evaluate the effect of amantadine sulfate infusion on the N30 component of the median nerve short-latency somatosensory evoked potentials (SSEPs) in patients with Parkinson's disease (PD). Twenty patients with advanced PD and severe motor fluctuations received a 6-day course of amantadine sulfate infusion (400 mg/day) plus their usual levodopa medication. Patients were assessed clinically by means of the Unified Parkinson's Disease Rating Scale (UPDRS-III and -IV). SSEPs to median nerve stimulation were recorded from the parietal and frontal regions before and after the 6-day course of amantadine infusion. Mean UPDRS motor score during the ON and OFF phase improved after amantadine infusion, as did motor fluctuations. SSEP changes resulting from amantadine sulfate treatment were observed in the P20-N30 amplitude as follows: Mean P20-N30 amplitudes before and after treatment were 2.15 +/- 1.11 microV and 3.06 +/- 1.19 microV respectively (p = 0.000), whereas mean N30-P40 amplitude increased from 2.7 +/- 1.6 microV to 3.9 +/- 1.3 microV after treatment (p = 0.000). Our results indicate that coincident to its clinical impact, amantadine infusion in patients with PD affects electrophysiologic parameters as well.

Abnormality of N30 somatosensory evoked potentials in Parkinson's disease: a multidisciplinary approach

PURPOSE OF THE STUDY

Assess the N30 component of median nerve somatosensory evoked potentials (SEPs) in patients with Parkinson's disease (PD) and correlate its parameters with the severity of the disease, general cognitive ability and regional cerebral blood flow (rCBF).

PATIENTS AND METHODS

Twenty-three non-demented, non-depressed PD patients (at stage II and III of the disease) and 23 age- and education-matched normal controls were enrolled in the study. SEPs were elicited by median nerve stimulation. PD patients' cognitive ability was assessed by means of: 1) Raven's Colored Progressive Matrices (RCPM); 2) the Test of Non-Verbal Intelligence (TONI-2); and 3) the Wisconsin Card Sorting Test (WCST). The patients' rCBF was evaluated by HMPAO SPECT.

RESULTS

There was no difference between SEP N30 latency in PD patients and controls (P > 0.05). The P20-N30 peak-to-peak amplitude was lower in PD patients bilaterally (P < 0.05), and the amplitude of N30-P40 was lower on the right side only (P < 0.05). A significant increase in the amplitude ratio P14-N20/P20-N30 was observed in PD patients (P < 0.05). The correlation of these findings with the clinical parameters of the disease, and notably motor signs, was not significant. Of the three neuropsychological tests only the RCPM showed a positive relation to right P20-N30 amplitude. Regression analysis between SEP parameters and rCBF showed a correlation of N30 amplitude with blood flow in parietal cortical areas, but not in frontal regions.

Linear and nonlinear analysis of pressure and flow during mechanical ventilation

OBJECTIVE

Linear modeling as a method of exploring respiratory mechanics during mechanical ventilation, was compared to nonlinear modeling for flow dependence of resistance in three distinct groups of patients, those with: (a) normal respiratory function (NRF), (b) chronic obstructive pulmonary disease (COPD), or (c) adult respiratory distress syndrome (ARDS).

DESIGN AND PATIENTS

Airways opening pressure (Pao), flow (V'), and volume (V) signals were recorded in 32 ICU mechanically ventilated patients, under sedation and muscle relaxation (10 NRF, 11 COPD, 11 ARDS). All patients were ventilated with controlled mandatory ventilation mode at three levels of end-expiratory pressure (PEEPe): 0, 5, and 10 hPa. Data were analyzed according to: (a) Pao = PE + Ers V + Rrs V' and (b) Pao = PE + Ers V + k1V' + k2¿V'¿V'; where Ers and Rrs represent the intubated respiratory system (RS) elastance and resistance, k1 and k2 the linear and the nonlinear RS resistive coefficients, and PE the end-expiratory pressure. The model's goodness of fit to the data was evaluated by the root mean square difference of predicted minus measured Pao values.

RESULTS

NRF data fit both models well at all PEEPe levels. ARDS and particularly COPD data fit the nonlinear model better. Values of k2 were often negative in COPD and ARDS groups, and they increased in parallel with PEEPe. A gradual increase in PEEPe resulted in better fit of ARDS and COPD data to both models.

CONCLUSIONS

The model of V' dependence of resistance is more suitable for the ARDS and particularly the COPD groups. PEEP tends to diminish the V' dependence of respiratory resistance during the respiratory cycle, particularly in the COPD group, probably through an indirect effect of the increased lung volume.

Masticatory and skeletal muscle myositis in canine leishmaniasis (Leishmania infantum)

Twenty-four dogs with a parasitologically and serologically established diagnosis of leishmaniasis were studied to investigate the atrophy of the masticatory muscles which commonly occurs in this disease, and to compare the lesions in the masticatory muscles with those in the cranial tibial muscles. The 24 animals were divided into three groups of eight, group A dogs with no muscular atrophy, group B dogs with different degrees of atrophy in the masticatory and skeletal muscles, and group C dogs with similar degrees of atrophy in the masticatory and skeletal muscles. Increased activities of creatine phosphokinase and lactate dehydrogenase were recorded in only some of the dogs in groups B and C, but there were no significant differences between the mean activities in the three groups. Electromyographic changes indicating myopathy and involving both the temporalis and cranial tibial muscles, were observed in two of the dogs in group A, seven of those in group B, and in all the dogs in group C. Muscle histopathology revealed a variable degree of muscle fibre necrosis and atrophy, mononuclear infiltrates and neutrophilic vasculitis in all the dogs except two in group A. Leishmanial amastigotes were found within macrophages and myofibres in 16 of the dogs, some in each group. IgG immune complexes were detected in muscle samples, and circulating antibodies against myofibres were detected in serum samples from all the 24 dogs.

A phase I clinical trial of dextromethorphan in intractable partial epilepsy

We conducted an open-label pilot study of dextromethorphan (DM) in intractable partial epilepsy with the following objectives: a preliminary evaluation of the drug's safety and efficacy in the epileptic patient and a definition of a concentration range which can be safely achieved in future studies. Sixteen patients with drug-resistant, localization-related epilepsies entered the trial. After an 8-week baseline period, DM was added to the existing antiepileptic drugs at a dose of 40 and 50 mg every 6 h (160 and 200 mg/day). Each treatment period lasted 8 weeks. Seizure control improved after administration of DM, especially in the group of intermediate and slow metabolizers. Two patients, however, experienced increased seizure frequency and withdrew from the study. Adverse effects during DM administration were mild and transient. DM was well tolerated even in patients with high plasma levels of the drug (up to 15020 ng/dl). Our results indicate that DM is safe and effective in the treatment of comedicated patients with intractable partial epilepsies.