Prevalence and Risk Factors of Postprandial Hypotension among Elderly People Admitted in a Geriatric Evaluation and Management Unit : An Observational Study

OBJECTIVES

To explore the prevalence and potential risk factors of postprandial hypotension (PPH) among elderly patients in an acute geriatric ward.

DESIGN

A prospective observational study.

SETTING

Geriatric Unit in a Belgian tertiary-care University Hospital.

PARTICIPANTS

Seventy-six hospitalized elderly patients after stabilization of their acute conditions.

MEASUREMENTS

PPH and orthostatic hypotension (OH) measured by a non-invasive automated blood pressure device, demographic data, Katz's Basic Activities of Daily Living (ADL) and Lawton's instrumental ADL, Short Physical Performance Battery, Charlson Comorbidity Index, Mini Nutritional Assessment-Short Form, Timed Up and Go test, Get-up Early test, grip strength and 7 classes of drugs.

RESULTS

Overall, the prevalence of PPH was 46% (n=35/76), and it was symptomatic in 31% of the patients (n=11/35). PPH is associated with OH in one-third of the cases (n=12/35). Two-thirds of the patients with HPP had a significant drop in systolic blood pressure within the first 75 minutes after a meal. In univariate analyses, risk factors of PPH were nursing home residence, alpha-blocker consumption, help needed for eating and a good level of global functional status. However, patients with a good functional status were at increased risk of alpha-blocker exposure. In multivariate analyses, only alpha-blocker consumption and help needed for eating remained statistically significant.

CONCLUSION

PPH is frequent among hospitalized elderly people in a Geriatric Evaluation and Management Unit, affecting nearly one out of two people. The use of alpha-blockers is an important risk factor and may alert clinicians to the risk of PPH.

Estimation de la fréquence des atteintes plantaires à dermatophytes

BACKGROUND

Plantar dermatophytosis frequently goes unnoticed and can cause relapse or re-infestation at other sites. The purpose of this study was to evaluate the incidence of plantar dermatophytosis in association with onyxis and intertrigo involving dermatophytes.

PATIENTS AND METHODS

This was a retrospective study in patients seen at mycology consultations between January 2002 and December 2003 and for whom culture revealed dermatophytes on the soles, interdigital spaces and/or toe nails. Gender, age and culture data were record from the laboratory workbooks.

RESULTS

716 patients were included, giving 1291 samples. The sex ratio M/F was 1.5 with a mean age of 48 years. Samples of toe nail were obtained from 591 patients, with plantar samples from 433 patients and intertrigo samples from 267 patients. Plantar dermatophytosis was seen in 66.6% of patients with interdigital-plantar signs, in 75.1% of those with ungual involvement and in 73.9% of cases involving both. T. rubrum was the most frequently isolated dermatophyte.

DISCUSSION

Combine involvement of the sole, nail and/or interdigital space was seen in more than 2/3 of cases. Despite the retrospective nature of our study and the evident bias, our results suggest that plantar dermatophytosis is common and should be sought. The sensitivity and specificity of clinical screening methods merit investigation in a prospective study.

[Recommended techniques for obtaining nail specimens and mycologic diagnosis of onychomycosis]

The diagnosis of onychomycosis requires an assessment of both clinical and laboratory features. The laboratory diagnosis is essential to confirm the fungal origin of the onyxis. Various types of onychomycosis need different methods to obtain a nail specimen. It requires a direct examination to confirm the presence of fungi, and a fungal culture to identify the specific genus and species of the pathogen. A good interpretation of these results is necessary to adapt the therapeutics.

[Profuse scabies: kinetic curves of parasitologic cure with an association of benzyl benzoate and sulfiram]

BACKGROUND

In vitro exposure to benzyl benzoate (25 p. 100) kills Sarcoptes scabiei within three hours. The aim of our study was to determine in vivo elimination of Sarcopte scabiei with a benzyl benzoate-sulfiram association.

METHODS

Medical charts of patients hospitalized for disseminated scabies from 1993 to 1999 were reviewed retrospectively. The diagnosis of scabies was confirmed by microscopic determination. Parasitological examinations were conducted every day or every two days until negative results. Patients were treated by successive applications of benzyl benzoate until parasitological cure.

RESULTS

Twenty patients were included in the study. The median delay of parasitological cure was seven days. After 15 days, 95 p. 100 of patients were cured. Two cutaneous side-effects were reported.

DISCUSSION

Despite immediate in vitro efficacy, benzyl benzoate action is delayed in vivo. The time of parasitological negativation after one application of benzyl benzoate is unknown. Therefore, it is not currently possible to determine whether our therapeutic regimen was excessive or not.

Pharmacological profile of SL 59.1227, a novel inhibitor of the sodium/hydrogen exchanger

1. The NHE1 isoform of the Na(+)/H(+) exchanger plays an important role in the regulation of intracellular pH and in cardiac cell injury caused by ischaemia and reperfusion. SL 59.1227 is a novel imidazolypiperidine Na(+)/H(+) antiport inhibitor which is structurally unrelated to previously described acylguanidine inhibitors such as cariporide. 2. Recovery of pH(i) following an intracellular acid load was measured in CCL39-derived PS120 variant cells, selectively expressing either NHE1 or NHE2 isoforms of the Na(+)/H(+) exchanger. pH(i) recovery was potently and selectively slowed by SL 59.1227 in NHE1-expressing cells (IC(50) 3.3+/-1.3 nM) versus NHE2-expressing cells (2.3+/-1.0 microM). The respective IC(50) values for cariporide were 103+/-28 nM (NHE1) and 73+/-46 microM (NHE2). 3. In anaesthetized rats following left coronary artery occlusion (7 min) and reperfusion (10 min) SL 59.1227 (10 - 100 microg kg(-1) min(-1) i.v.) inhibited ischaemia-mediated ventricular tachycardia (71 - 100%) and reperfusion-induced ventricular fibrillation (75 - 87%) and prevented mortality. Bolus i.v. administration of SL 59.1227 (1 mg kg(-1)) produced anti-arrhythmic effects when administered either before or during ischaemia. 4. Cardiac infarct size was determined in anaesthetized rabbits following left coronary artery occlusion (30 min) and reperfusion (120 min). Infarct size measured as a percentage of the area at risk was 36.2+/-3.4% (control group) versus 15.3+/-3.9% (SL 59.1227 0.6 mg kg(-1) i.v.). 5. SL 59.1227 is the first example of a potent and NHE1-selective non-acylguanidine Na(+)/H(+) exchanger inhibitor. It possesses marked cardioprotective properties.

[Tinea capitis in Creteil. Trends over ten years]

INTRODUCTION

We analyzed tinea capitis data in a Paris suburban area over a 11-year period from (1985-1995) to evaluate epidemiology trends.

PATIENTS AND METHODS

The following data were collected for patients seen at the Créteil myco-dermatology clinic with cultures positive for tinea capitis: sex, age, ethnic origin, fungal culture.

RESULTS

Tinea capitis was observed in 336 cases (56 p. 100 females). Eight percent of the patients were under the age of 10 years and 11 p. 100 over 20 years. Trichophyton soudanense was isolated in 45 p. 100 of the patients. Anthropophilic agents rose over the 10 year period while the number of zoophilic agents remained stable. Specific dermatophytes appeared to predominate in populations of different ethnic origin. There was a two-fold increase in the number of tinea capitis cases in the 1990-1995 period compared with the five previous years.

DISCUSSION

The percentage of adults with tinea capitis (11 p. 100) is higher than the 5 p. 100 reported in the literature. The rise in the number of anthropophilic tinea capitis cases resulted from an increase in T. soudanense (originating in Africa), probably related to the increasing immigrant population. This agent was identified in 95 p. 100 of the patients of African origin. Differing lifestyles and transmission between school children makes it quite difficult to interpret the correlation between ethnic origin and specific dermatophytes.

Tinea capitis in adults: misdiagnosis or reappearance?

BACKGROUND

According to the literature, tinea capitis in adults is supposed to be rare; we have recently observed a significant increase in cases.

METHODS

Epidemiological, clinical and mycological features were studied in all adult tinea capitis diagnosed over 1 year in our department.

RESULTS

Eight cases were observed: 75% of them were women, 50% never traveled and 62.5% had an underlying immunosuppressive disease. Scalp scaling and alopecia were the most frequent clinical features. A zoophilic dermatophyte was recovered in 50% of cases.

CONCLUSION

These cases represent 11% of all tinea capitis observed in the same period of time (higher than the 3-5% observed in the literature). Secretion of sebum and colonization by Pityrosporon orbiculare are supported to protect the scalp against dermatophytic invasion after puberty, but an immune defect may also facilitate hair invasion. The erroneous notion of the disease being uncommon and the frequent atypical clinical presentation require a high degree of clinical suspicion.

Plasmodium falciparum: detection of P-glycoprotein in chloroquine-susceptible and chloroquine-resistant clones and isolates

Recent studies have suggested the potential involvement of multidrug resistance (mdr) genes in resistance to quinoline-containing compounds in Plasmodium falciparum parasites. Three different antibodies were used to detect the malarial mdr 1 protein product by indirect immunofluorescence and/or immunoblot in fresh clinical isolates and clones of P. falciparum from different geographic origins. A 160-kDa protein was detected in all five parasite clones by immunoblot and around the food vacuole by IFA, regardless of the level of sensitivity to chloroquine and the modulation by desipramine of chloroquine accumulation. Our results suggest that chloroquine resistance is not correlated with the presence of the Pfmdr1 product.

Histone-poly(A) hybrid molecules as tools to block nuclear pores

Histone-poly(A) hybrid molecules were used for transport experiments with resealed nuclear envelopes and after attachment of a cleavable cross-linker (SASD) to identify nuclear proteins. In contrast to histones, the hybrid molecules cannot be accumulated in resealed nuclear envelopes, and in contrast to poly(A), the export of hybrids from preloaded nuclear envelopes is completely impaired. The experiments strongly confirm the existence of poly(A) as an export signal in mRNA which counteracts the nuclear location signals (NLS) in histones. The contradicting transport signals in the hybrid molecules impair translocation through the nuclear pore complex. The failure to accumulate hybrid molecules into resealed nuclear envelopes results from the covalent attachment of polyadenylic acid to histones in a strict 1:1 molar ratio. This was demonstrated in control transport experiments where radiolabeled histones were simply mixed with nonlabeled poly(A) or radiolabeled poly(A) mixed with nonlabeled histones. In comparison, control uptake experiments with histones covalently linked to a single UMP-mononucleotide are strongly enhanced. Such controls exclude the conceivable possibility of a simple masking of the nuclear location signal in the histones by the covalent attached poly(A) moiety. Photoreactive histone-poly(A) hybrid analogs serve to identify nuclear envelope proteins--presumably in the nuclear pore--with molecular weights of 110, 80, and 71.4 kDa.

Haloallylamine inhibitors of MAO and SSAO and their therapeutic potential

Based on mechanistic understandings, molecular modeling and extensive quantitative structure-activity relationships, appropriately substituted haloallylamine derivatives were designed as potential mechanism-based inhibitors of MAO and/or SSAO. Potent inhibition of MAO-B and SSAO occurred with fluoroallylamines whereas chloroallylamines, such as MDL 72274A ((E)-2-phenyl-3-chloroallylamine hydrochloride), were selective and potent inhibitors of SSAO. MDL 72974A (E)-2-(4-fluorophenethyl)-3-fluoroallylamine hydrochloride is a potent (IC50 = 10(-9) M) inhibitor of both MAO-B and SSAO, with 190-fold lower affinity for MAO-A. In clinical studies, oral doses as low as 100 micrograms produced substantial inhibition of platelet MAO-B. Essentially complete inhibition occurred at 1 mg with the effect lasting 6-10 days. One or 4 mg MDL 72974A given daily for 28 days to 40 Parkinson's patients treated with L-dopa produced statistically significant reductions in the Unified Parkinson's Disease Rating Scale. MAO-B inhibitors, such as MDL 72974A and L-deprenyl, offer the potential of being neuroprotective in Parkinson's Disease and other neurogenerative disorders. Concommitant inhibition of SSAO may provide additional, but as yet unproven, advantages over pure inhibitors of MAO-B.

Covalent attachment of ribonucleic acids to proteins

As a prerequisite for the synthesis of affinity labels, we describe methods to couple histones to ribonucleic acids. For the synthesis of these covalent hybrid molecules, we used a population of histones H1, H2A, H2B, H3, and H4 from calf thymus and polyadenylic acid with an average chain length of up to 260-280 bases, representing the size of poly(A)-tails from mature mRNAs. Three methods were investigated. (a) Poly(A) containing an 8-N3-A residue was cross-linked to histones by ultraviolet irradiation. (b) The 3'-end of the polynucleotide was connected to a mononucleotide containing an aliphatic amino group, and the resulting poly(A)-derivative was coupled to histones via derivation with a bromoacetyl group. (c) The 3'-end of the polynucleotide was oxidized with sodium periodate and bound covalently to an amino group of the polypeptide. To demonstrate the RNA content of the hybrid molecule, the poly(A) was removed with RNase T2.

[Contribution of molecular genetics to the understanding of chemoresistance of Plasmodium falciparum]

Resistance to pyrimethamine and proguanil is due to a single point mutation in the gene that codes for dihydrofolate reductase. A single mutation gives rise to resistance to only one of the drugs. Resistance to both drugs results from several mutations. Chloroquine resistance phenotype is due to a rapid efflux of the drug from the parasite's digestive vacuole. This efflux is associated with a transmembrane permeability glycoprotein, or P-gp, which is similar to the protein implicated in the multidrug resistant phenotype of some cancer cells. However, one or several other poorly understood major gene(s) may be involved. Drugs which can inhibit the supposed affinity of P-gp for chloroquine are under study.

Effects of a standardized meal on the pharmacokinetics of the new cardiotonic agent piroximone

The influence of food on the pharmacokinetics of piroximone (MDL 19.205, CAS 84490-12-0) was evaluated in two groups of 6 healthy male volunteers receiving either 25 or 50 mg of the drug. Single doses were administered intravenously and orally under fasting conditions or orally with a standard breakfast on 3 different days with a washout period of at least 3 days in-between doses, according to an open, 3-way crossover, randomized design. Pharmacokinetic parameters (Cmax, tmax, AUC, t1/2, Cl, aVd, UEx) were not affected by food administration, but significant differences were found in t1/2 calculated from the decay of plasma concentrations in response to oral administration of 25 mg and 50 mg treatment doses. The urinary excretion of piroximone was significantly reduced after oral administration, when compared with the values obtained after intravenous application. In addition, extra-renal clearance was significantly reduced in the 50 mg treatment group, when compared with the values obtained in response to 25 mg. Bioavailability of piroximone calculated from AUC data compared favorably with data obtained from urinary recovery results.

Piroximone, dobutamine and nitroprusside: comparative effects on haemodynamics in patients with congestive heart failure

Four intravenous doses of piroximone, an imidazolone derivative, were administered to 12 patients with congestive heart failure to produce a four-point dose-response curve. The haemodynamic effects were compared with those of dobutamine and nitroprusside, the substances being given sequentially and in randomized order. Piroximone and dobutamine significantly and similarly increased cardiac index (CI) and stroke volume index (SVI). Nitroprusside produced no such effect. By contrast, piroximone and nitroprusside significantly and similarly decreased mean pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP) and pulmonary vascular resistance (PVR), while such changes were not seen following dobutamine. Direct comparisons between the agents were made at doses that lowered systemic vascular resistance (SVR) to the same extent. The major difference between dobutamine and piroximone was an apparent additional vasodilator activity displayed by piroximone as demonstrated by a significantly greater decrease in MPAP, PCWP and RAP for a matched reduction in SVR and a similar increase in CI. The major difference between nitroprusside and piroximone was the significantly higher increase in CI and SVI elicited by piroximone for a matched reduction in SVR and a similar decrease in PCWP and RAP. The changes in loading conditions being equivalent, the higher increase in CI is likely to be accounted for by a direct inotropic activity.

Long-term treatment with piroximone in patients with chronic heart failure

The safety and efficacy of long-term oral piroximone therapy was assessed in 12 patients with chronic heart failure. Of these 12 patients, two died suddenly, and a further two were withdrawn because of worsening heart failure within 6 months while 8 completed the 1-year follow-up period. In 7 of these 8 patients, clinical evaluations showed sustained benefit, as demonstrated by significant increases in exercise tolerance. The remaining patient experienced a recurrence of severe heart failure at the end of follow-up. Twenty-four hour ambulatory electrocardiograms were compared in 9 patients before and during piroximone therapy. Aggravation of existing arrhythmias was observed in 3 patients, an amelioration in one with no change in the remaining 5. In the 5 patients in whom the hemodynamic effects of a single oral dose of 25 mg of piroximone were studied, the first dose resulted in a 20% increase in mean cardiac index and a 30% decrease in mean pulmonary capillary wedge pressure. This responsiveness to single-dose administration was maintained after 1-year follow-up. Likewise, comparison of the hemodynamic effects of four intravenous doses of piroximone revealed no significant difference in the response (n = 7), although the effects tended to be less marked at the end of follow-up. The present results suggesting that piroximone is effective and safe as adjunctive therapy in the management of patients with chronic heart failure will need to be confirmed in longer controlled trials.

Deployment of Indonesian migrants in the Middle East: present situation and prospects

"This paper examines the Indonesian overseas employment program. It is limited to overseas deployment through the official channels, i.e. organised by licensed labour suppliers and approved by government authorities. The main destination of this official labour migration is the Middle East. Indonesian officials have indicated that the government aims to increase overseas employment and to shift deployment from houseworkers to better skilled workers. It is argued in the paper that, in view of a shrinking labour market for migrants, even limited realisation of these hopes would depend upon some distinct changes in the overseas employment program."