Multiple Organ Dysfunction in Older Major Trauma Critical Care Patients: A Multicenter Prospective Observational Study

The objective was to explore the characteristics and outcomes of multiple organ dysfunction syndrome (MODS) in older trauma patients.

Background

Severely injured older people present an increasing challenge for trauma systems. Recovery for those who require critical care may be complicated by MODS. In older trauma patients, MODS may not be predictable based on chronological age alone and factors associated with its development and resolution are unclear.

Methods

Consecutive adult patients (aged ≥16 years) admitted to 4 level 1 major trauma center critical care units were enrolled and reviewed daily until discharge or death. MODS was defined by a daily total sequential organ failure assessment score of >5.

Results

One thousand three hundred sixteen patients were enrolled over 18 months and one-third (434) were aged ≥65 years. Incidence of MODS was high for both age groups (<65 years: 64%, ≥65 years: 70%). There were few differences in severity, patterns, and duration of MODS between cohorts, except for older traumatic brain injury (TBI) patients who experienced a prolonged course of MODS recovery (TBI: 9 days vs no TBI: 5 days, P < 0.01). Frailty rather than chronological age had a strong association with MODS development (odds ratio [OR], 6.9; 95% confidence intervals [CI], 3.0-12.4; P < 0.001) and MODS mortality (OR, 2.1; 95% CI, 1.31-3.38; P = 0.02). Critical care resource utilization was not increased in older patients, but MODS had a substantial impact on mortality (<65 years: 17%; ≥65 years: 28%). The majority of older patients who did not develop MODS survived and had favorable discharge outcomes (home discharge ≥65 years NoMODS: 50% vs MODS: 15%; P < 0.01).

Conclusions

Frailty rather than chronological age appears to drive MODS development, recovery, and outcome in older cohorts. Early identification of frailty after trauma may help to predict MODS and plan care in older trauma.

Disazo (Bishydrazone) pigments based on acetoacetanilides

Disazoacetoacetanilide pigments, more commonly known as diarylide yellows, are the most important group of yellow classical organic pigments. They were commercialized in the early 20th century many years after the introduction of the structurally related monazoacetoacetanilides (Hansa yellows). The molecules adopt the bis-ketohydrazone tautomeric form. X-ray single crystal structure investigations have provided an insight into the influence of the molecular geometry and crystal packing arrangements in the solid state on the properties of the pigments in application. The synthesis of diarylide pigments is relatively straightforward, the conditions essentially following those used for the corresponding monoazo pigments, so that the products are economically priced. In the case of these disazo pigments, suitable aromatic amines (1 mol) are bis-diazotized and the resulting bis-diazonium salts reacted with acetoacetanilide coupling components (2 mol), the two azo coupling reactions occurring at the same time. They are by far the dominant group of yellow pigments used in printing inks, well-suited for most standard process yellow inks. They were formerly important in the coloration of plastics but are no longer recommended for polymers processed above 200 °C, under which conditions toxic decomposition products are formed. Diarylide yellow pigments are characterized by high color strength, good to excellent solvent fastness, and good chemical stability, although they generally show inferior lightfastness.

Phthalocyanine green pigments

The dominant organic green pigments are polyhalogenated copper phthalocyanines (CuPcs). These pigments exhibit similar excellent coloristic and technical performance to CuPc blue pigments and are produced worldwide in large quantities. The green pigments are halogenated CuPcs. There are two pigments with CI designations. CI Pigment Green 7 is a bluish green product, in which the 16 ring hydrogen atoms of the CuPc molecule are replaced virtually completely by chlorine. Products designated as CI Pigment Green 36 incorporate a range of bromo- and bromochlorocopper phthalocyanines and are yellowish-green pigments. CuPc green pigments are manufactured by direct exhaustive halogenation of crude CuPc blue with chlorine or bromine or an appropriate mixture of the two halogens, depending on the composition of the product required. The synthesis is carried out at elevated temperatures in a suitable solvent, commonly a molten AlCl3/NaCl eutectic mixture.

Phthalocyanine pigments: general principles

This chapter describes some of the fundamental chemical and structural principles underlying the phthalocyanine system. Historically, phthalocyanines had been isolated as insoluble blue products in the early twentieth century, although the structures were not established at the time. After the serendipitous re-discovery of metal complex phthalocyanines by industry, and the elucidation of their structures, copper phthalocyanine (CuPc) pigments were introduced industrially in the 1930s to become, and remain, by far the most important blue and green organic pigments, finding almost universal use as colorants for paints, printing inks, plastics, and a wide range of other applications. The phthalocyanines have become one of the most extensively studied classes of organic compounds, because of their unique molecular structures, light absorption properties that produce strong, bright colors, and their exceptionally high stability. While their dominant use is as colorants, they are also of interest for a range of other applications, for example in electronic devices, biological applications, and as catalysts.

Perylene and perinone pigments

Perylenes and perinones are separate groups of pigments categorized within the carbonyl chemical class. The two pigment groups show similarities, for example, in their chemical structural features and, to an extent, in their technical and application properties as high-performance organic pigments. Perylenes constitute a series of firmly established high-performance pigments, offering red and violet colors, and also extending to black. Synthetically, they are derived from perylene-1,4,5,8-tetracarboxylic acid. The perylenes tend to be quite expensive pigments, but their high levels of fastness properties mean that they are suitable for highly demanding applications. In particular, they offer very high heat stability. Two perinone pigments are used commercially. In their synthesis from naphthalene-1,4,5,8-tetracarboxylic acid, they are formed as mixtures of the two isomers, which can be separated. The trans isomer, CI Pigment Orange 43, is a highly important commercial pigment, especially for plastics, while the cis isomer, CI Pigment Red 194, is bordeaux in color and is of much lesser importance. The perinone, CI Pigment Orange 43, provides a brilliant orange color and has very good fastness properties. Its commercial manufacture involves a challenging multistage procedure and consequently it is one of the most expensive organic pigments on the market.

Diketopyrrolopyrrole (DPP) pigments

Since their industrial introduction in the 1980s, DPP pigments now constitute a highly important group of high-performance carbonyl pigments. The DPP system was first discovered by accident in 1974, and was subsequently re-investigated by Ciba Geigy who recognized its potential to provide commercial organic pigments. DPP pigments exhibit strong similarities compared with quinacridone pigments, in terms of their molecular and crystal structures and their properties, including low solubility and excellent fastness properties. X-ray crystal structural analysis has demonstrated that their technical performance is the result of intermolecular hydrogen bonding and π–π stacking interactions in the crystal lattice structure. Based on a simple retrosynthetic analysis, an efficient synthetic process was developed by Ciba Geigy for their large-scale manufacture. DPP pigments currently provide orange through to reddish violet shades and have become of special importance in providing brilliant saturated red shades with the outstanding durability required for applications such as automotive paints.

Anthraquinonoid pigments

Colorants based on the anthraquinone structure are categorized as a subclass of carbonyl colorants. Anthraquinone textile dyes rank second in importance to azo dyes, especially within the vat dye application class. Vat dyes became of interest to the pigment industry because of their insolubility. This insolubility and generally excellent fastness properties inspired investigations into the selection of suitable established anthraquinonoid vat dyes for use as pigments after conversion to a physical form that is appropriate for their applications. Originally this proved difficult, but was eventually achieved following the development of appropriate conditioning after treatment processes. The structural chemistry of the various types of anthraquinonoid pigments in relation to their technical and coloristic performance is discussed. The chapter concludes with an illustrated description of the main synthetic routes and finally with a description of the principal applications of the individual commercial products. Anthraquinonoid pigments are generally regarded as high-performance products, suitable for highly demanding applications, although they tend to be expensive.

Organic pigments: general principles

This introductory chapter presents an overview of the general principles underlying the structural chemistry, manufacturing processes, and application technology of organic pigments. The coverage provides a fundamental theoretical and practical basis for the chapters that follow in this series that are devoted to specific chemical classes of industrially significant organic pigments of the azo, phthalocyanine, carbonyl, dioxazine, and metal complex classes. The initial sections cover the fundamental differences which mean that dyes and pigments are considered universally as two separate types of colorant, based on their solubility characteristics. They also provide discussions of the contrasting chemical, technological, and performance features of organic and inorganic pigments. An outline of the most important historical features in the development of the synthetic organic pigment industry is then presented, from its origins in the 19th century that followed soon after the development of the industrial synthetic dye industry, through its expansion in the 20th century, to its current position as a mature global industry. A section then follows that describes the functions that organic pigments are required to perform in their application, mainly their optical functions that include not only color properties, including hue, strength, brightness, but also the contrasting requirements for transparency or opacity as demanded by specific applications. The pigments are also required to resist the conditions and agencies that they might encounter in applications, assessed as fastness properties, such as fastness to light, heat, solvents and chemicals, amongst many others, to an extent that specific applications demand. The principles, in broad terms, of the ways in which chemical structures determine colour and performance of organic pigments are discussed, with focus not only on the influence of molecular structure, but also on the effect of the crystal structural arrangement and the particulate structure, including particle size and shape and its distribution, on application performance. This is important as these pigments are applied as a dispersion of finely divided crystalline solid particles that are insoluble and are ultimately trapped mechanically in their application medium, often a polymer. The manufacture of organic pigments is discussed in broad terms. The overall process may be considered in stages, initiated by the chemical synthetic sequence in which the pigment is formed, followed by a conditioning stage where the crude product thus obtained is modified to optimise its performance properties, and finally finishing where the product is processed into a form, or preparation, that is suitable for its intended applications. Finally, the technological principles underlying a broad range of the most important application areas for organic pigments, which are mainly in paints, inks, and plastics, are discussed.

Disazo (Bishydrazone) condensation pigments

Disazo condensation pigments were developed in the mid-twentieth century as a range of high-performance azo pigments to meet the stringent demands placed on the technical properties required for applications in growing markets such as automotive paints, plastics, and fibers. The commercial products vary in shade from yellow through red to brown. Structurally, the pigments are related to the classical yellow azoacetoacetanilides or red azonaphthols by synthetically connecting two monoazo derivatives by a condensation reaction involving an aromatic diamine. The resulting pigment molecules are of extremely large molecular size with the presence of several amide groups, factors that determine their excellent set of fastness properties. The procedures used in their manufacture involve complex and demanding multistage processes, and this explains the higher cost of these pigments. The application performance attributes provided by the individual commercial products are discussed in detail in the final section.

Monoazo (Monohydrazone) pigments based on benzimidazolones

A series of azo pigments containing the benzimidazolone ring were introduced in the mid to late twentieth century as high-performance organic pigments in the yellow, orange, red, and brown shade areas. The structures of the commercial benzimidazolone azo pigments are derived from either the monoazoacetoacetanilide or monoazonaphtharylamide classical azo pigments systems and exist in the ketohydrazone tautomeric forms. The high-performance properties of the pigments have been attributed to a network of intermolecular hydrogen bonds involving the benzimidazolone group, and efficient molecular packing, as demonstrated by X-ray crystal structure determinations. The manufacturing processes leading to the pigments involve traditional diazotization and azo coupling reaction procedures, although they require special conditioning aftertreatments to optimize their performance. Although benzimidazolone azo pigments were initially developed for the coloration of plastics, they have probably had a greater impact on the paint industry. The application properties of the benzimidazolone azo pigments are discussed for individual products.

Metal complex pigments

There are several commercially significant metal complex organic pigments that are based on first row transition metals. The most important of these are the copper phthalocyanine blue and green pigments which find virtually universal use in paints, printing inks, and plastics. These pigments are of such prime importance that they are dealt with separately in three other chapters in this series. This paper describes a group of pigments that are complexes of iron, copper, nickel, and cobalt with polydentate colored ligands of azo, azomethine, oxime, and isoindoline chemical types. The oldest metal complex organic pigment that still finds some use is CI Pigment Green 8, an octahedral oxime iron complex. In the 1970s and 1980s, there was considerable industrial research effort aimed at developing metal complex pigments based on azomethine and isoindoline structures, many of which were found to offer excellent lightfastness, good solvent resistance and thermal stability, although they exhibited rather dull colors. However, several products provide brilliant effects when used in combination with metallic and pearlescent pigments in automotive paints. Many of the pigments introduced have since been withdrawn by the original manufacturers, but a few remain on the market. The synthesis of metal complex pigments generally involves the preparation of the colored ligand, which is then complexed with the transition metal ion

Monoazo (Monohydrazone) pigments based on 2-naphthol and derivatives

This chapter describes the range of industrial monoazo pigments based on the 2-naphthol (β-naphthol) ring system. This group includes some of the earliest organic pigments introduced commercially and is also numerically the largest group of products currently described in the Colour Index. Most of the pigments within this group are red (with a few oranges), thus complementing the azoacetoacetanilides, which are mostly yellows. Three groups of monoazonaphthol-based pigments may be identified categorized according to the chemical structure of the coupling components used in their synthesis. The first group contains products based on 2-naphthol itself, a second is based on amide derivatives of 3-hydroxy-2-naphthoic acid (naphtharylamides), and the third is a series of metal salt azo pigments. The historical development of these pigments, outlined in an early section of this chapter, originated in the late 19th century with pigments described as ‘lakes’, derived from water-soluble anionic dyes absorbed on to inert colorless substrates, which were the forerunners of products now referred to as metal salt pigments. The non-ionic 2-naphthol-based pigments were introduced soon after. In the early to mid-20th century, a series of monoazonaphtharylamide (Naphthol AS) pigments were developed and introduced commercially. The pigments of this type that are currently manufactured can be sub-divided into products containing a single amide group (group 1) and higher performance products containing more than one amide or sulfonamide groups. Several group 1 pigments have diminished in importance over the years, while some higher performing group 2 pigments have grown in importance. The molecular and crystal structures of the range of pigments are presented and discussed in relation to their performance characteristics. The manufacture of the pigments involves the reaction of a diazotized aromatic amine with the appropriate 2-naphthol-based coupling component, using synthesis conditions typical of phenolic coupling components, followed by conditioning aftertreatments that are typical for azo pigments in general. Finally, there is an extensive discussion of the wide-ranging applications in which the individual pigments are used. While the pigments are especially well-suited to printing ink applications, many products also find use in paints and a few in plastics.

Quinacridone pigments

This chapter surveys the structural and synthetic chemistry and the industrial applications of quinacridones, a small but extremely important group of high-performance carbonyl (or polycyclic) organic pigments. They are based on one of the most important new chromophoric systems developed specifically for pigment applications after the introduction of the phthalocyanines, and currently occupy a prominent position in the red to violet shade areas. A historical perspective on the discovery and commercial development of the quinacridones is presented initially. There then follows an illustrated discussion of the structural chemistry of the pigments, encompassing both molecular and crystal structures. Throughout the chapter, specific features of their molecular structures and the nature of the intermolecular association within the crystals are related to their influence on the color and technical performance in application, in which they exhibit some of the highest standards of heat stability, solvent resistance, and fastness to light and weather encountered in organic pigments. Finally, a survey of the principal current applications of the specific individual commercial quinacridone pigments is presented.

Carbonyl pigments: miscellaneous types

Carbonyl pigments are characterized by the presence of one or more carbonyl (C = O) groups in their structures, generally as a component of the chromophoric grouping and as part of an extended conjugated π-electron system. Structurally, they constitute a diverse group of pigments that offer a wide range of colors throughout the spectrum, and most of them provide high levels of technical performance. This paper provides a description of the historical development of thioindigoid, isoindoline, isoindolinone, and quinophthalone pigment types, and discusses their molecular and crystal structures in relation to their properties, the synthetic procedures used in their manufacture and their principal applications. They provide some of the most important high-performance yellow organic pigments for demanding applications in paints, inks, and plastics. Separate individual chapters in this series are devoted the anthraquinonoid, quinacridone, diketopyrrolopyrrole, perylene, and perinone carbonyl pigment subclasses.

Disazo (Bishydrazone) pigments based on pyrazolones

The most important classical orange organic pigments are disazopyrazolones, also referred to as diarylide oranges. The first pigment in this series, CI Pigment Orange 13, was discovered in 1910 although it was a further 20 years before it was introduced as a commercial product. Currently, two orange disazopyrazolones are extremely important industrial organic pigments, while two red products are of lesser importance. The products are structurally analogous to the disazoacetoacetanilides (diarylide yellows), which are discussed in a separate chapter. For example, they are symmetrical compounds that exist in the bis-ketohydrazone tautomeric form. The pigments also exhibit similar technical and color properties compared with disazoacetoacetanilide pigments, for example providing high color strength and transparency, features that determine their importance as printing ink pigments. They are manufactured in a process that parallels those used for the disazoacetoacetanilide (diarylide) yellows, but with coupling components containing the pyrazolone heterocyclic system, in place of acetoacetanilides.

Dioxazine pigments

This chapter provides an overview of the structural and synthetic chemistry, and the industrial applications, of dioxazine pigments, a small group of high performance organic pigments. The color violet (or purple) has frequently assumed a prominent position in history, on account of its rarity and cost. The natural colorant Tyrian purple and the first synthetic textile dye, Mauveine, are prime examples of this unique historical feature. CI Pigment Violet 23, also referred to as Dioxazine Violet or Carbazole Violet, is one of the most universally used organic pigments, by far the most important industrial pigment in the violet shade area. Dioxazine Violet is also unique as the dominant industrial violet pigment providing a brilliant, intense violet color and an excellent all-round set of fastness properties. The pigment has a polycyclic molecular structure, originally described wrongly as a linear arrangement, and later shown to adopt an S-shaped arrangement on the basis of X-ray structural analysis. Two other dioxazine pigments are of rather lesser importance. The synthesis and manufacturing route to CI Pigment Violet 23 is described in the review. Finally, a survey of the principal current applications of the individual dioxazine pigments is presented.

Monoazo (Monohydrazone) pigments based on acetoacetanilides

The monoazoacetoacetanilide series of pigments, traditionally known as Hansa Yellows, are long-established products that entered the market in the early twentieth century. They are mostly inexpensive products offering bright colors of moderate intensity covering the entire yellow area of the spectrum, good lightfastness, but inferior solvent resistance. The technical properties of the pigments may be explained by their molecular structures, which adopt the ketohydrazone tautomeric form, and their crystal structures. Their good lightfastness is attributed mainly to intramolecular hydrogen-bonding, while their generally inferior fastness to organic solvents is explained by the relatively weak intermolecular interactions in the crystal structure. The monoazoacetanilide pigments are synthesized by the traditional two-stage process of diazotization of a primary aromatic amine, followed by an azo coupling reaction of the resulting diazonium salt with an acetoacetanilide coupling component. Their main use is in decorative paints, although a few products are suitable for printing inks.

Cationic (Basic) dye complex pigments

Cationic (or basic) dye complex pigments are classical organic pigments obtained from water-soluble cationic dyes for textiles, mainly of triarylmethine (arylcarbonium ion) types, which are precipitated using large inorganic counterions, especially those derived from heteropolyacids such as phosphotungstomolybdic acid or, to a certain extent, using the counteranion derived from copper ferrocyanide. This range of pigments includes red, violet, blue and green products, offering brilliant shades, high color strength and good transparency. They are well suited to printing ink applications, although they provide only moderate levels of fastness properties. The pigments are synthesized by treating aqueous solutions of the dyes under highly controlled conditions with solutions of the heteropolyacids, prepared in situ. The copper ferrocyanide salts are obtained by treatment of potassium ferrocyanide with sodium sulfite in water, and subsequently with solutions of the cationic dye and copper (II) sulfate. The pigments are primarily used in inks for packaging and advertising materials. However, they have little use outside printing inks. Reflex or alkali blue pigments are structurally related cationic dye derivatives which are inner salts of the dye structures and are also used in printing inks.

Azo (Hydrazone) pigments: general principles

This paper presents an overview of the general chemical principles underlying the structures, synthesis and technical performance of azo pigments, the dominant chemical class of industrial organic pigments in the yellow, orange, and red shade areas, both numerically and in terms of tonnage manufactured. A description of the most significant historical features in this group of pigments is provided, starting from the discovery of the chemistry on which azo colorants are based by Griess in the mid-nineteenth century, through the commercial introduction of the most important classical azo pigments in the early twentieth century, including products known as the Hansa Yellows, β-naphthol reds, including metal salt pigments, and the diarylide yellows and oranges, to the development in the 1950s and 1960s of two classes of azo pigments that exhibit high performance, disazo condensation pigments and benzimidazolone-based azo pigments. A feature that complicates the description of the chemical structures of azo pigments is that they exist in the solid state as the ketohydrazone rather than the hydroxyazo form, in which they have been traditionally been illustrated. Numerous structural studies conducted over the years on an extensive range of azo pigments have demonstrated this feature. In this text, they are referred to throughout as azo (hydrazone) pigments. Since a common synthetic procedure is used in the manufacture of virtually all azo (hydrazone) pigments, this is discussed in some detail, including practical aspects. The procedure brings together two organic components as the fundamental starting materials, a diazo component and a coupling component. An important reason for the dominance of azo (hydrazone) pigments is that they are highly cost-effective. The syntheses generally involve low cost, commodity organic starting materials and are carried out in water as the reaction solvent, which offers obvious economic and environmental advantages. The versatility of the approach means that an immense number of products may be prepared, so that they have been adapted structurally to meet the requirements of many applications. On an industrial scale, the processes are straightforward, making use of simple, multi-purpose chemical plant. Azo pigments may be produced in virtually quantitative yields and the processes are carried out at or below ambient temperatures, thus presenting low energy requirements. Finally, provided that careful control of the reaction conditions is maintained, azo pigments may be prepared directly by an aqueous precipitation process that can optimise physical form, with control of particle size distribution, crystalline structure, and surface character. The applications of azo pigments are outlined, with more detail reserved for subsequent papers on individual products.

A combination of transanal minimally invasive surgery and transanal technique to facilitate suturing during transanal minimally invasive surgery

Transanal minimally invasive surgery (TAMIS) is an effective option for the local excision of benign, non-invasive rectal lesions, or selected early stage rectal cancers. However, the suturing encountered in TAMIS remains technically challenging. A combination of TAMIS and transanal approach to suturing is demonstrated to address this challenge. A 64-year-old female with a T1N0 adenocarcinoma located in the anterior mid-rectum underwent TAMIS for resection of the lesion. Total operative time was 91 minutes. Free peritoneal defect was closed in two layers. The patient was discharged on postoperative day 1. Final pathology revealed a 0.7 cm T1 well-differentiated adenocarcinoma 0.8 cm from the closest resection margin. The patient remains free of systemic or local recurrence at 24 months. TAMIS is a safe and effective option for removal of benign rectal lesions or selected low grade T1 adenocarcinomas of the rectum. A hybrid TAMIS and transanal approach to suturing may often easily address the technical challenge of pure laparoscopic suturing in TAMIS.

Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact

WHAT IS KNOWN AND OBJECTIVE

Potentially inappropriate prescribing (PIP) has significant clinical, humanistic and economic impacts. Identifying PIP in older adults may reduce their burden of adverse drug events. Tools with explicit criteria are being developed to screen for PIP in this population. These tools vary in their ability to identify PIP in specific care settings and jurisdictions due to such factors as local prescribing practices and formularies. One promising set of screening tools are the STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) criteria. We conducted a systematic review of research studies that describe the application of the STOPP/START criteria and examined the evidence of the impact of STOPP/START on clinical, humanistic and economic outcomes in older adults.

METHODS

We performed a systematic review of studies from relevant biomedical databases and grey literature sources published from January 2007 to January 2012. We searched citation and reference lists and contacted content experts to identify additional studies. Two authors independently selected studies using a predefined protocol. We did not restrict selection to particular study designs; however, non-English studies were excluded during the selection process. Independent extraction of articles by two authors used predefined data fields. For randomized controlled trials and observational studies comparing STOPP/START to other explicit criteria, we assessed risk of bias using an adapted tool.

RESULTS AND DISCUSSION

We included 13 studies: a single randomized controlled trial and 12 observational studies. We performed a descriptive analysis as heterogeneity of study populations, interventions and study design precluded meta-analysis. All observational studies reported the prevalence of PIP; however, the application of the criteria was not consistent across all studies. Seven of the observational studies compared STOPP/START with other explicit criteria. The STOPP/START criteria were reported to be more sensitive than the more-frequently-cited Beers criteria in six studies, but less sensitive than a set of criteria developed in Australia. The STOPP criteria identified more medications associated with adverse drug events than the 2002 version of the Beers criteria. Patients with PIP, as identified by STOPP, had an 85% increased risk of adverse drug events in one study (OR = 1·85, 95% CI: 1·51-2·26; P < 0·001). There was limited evidence that the application of STOPP/START criteria optimized prescribing. Research involving the application of STOPP/START on the impact on the quality of life was not found. The direct costs of PIP were documented in three studies from Ireland, but more extensive analyses on the economic impact or studies from other jurisdictions were not found.

WHAT IS NEW AND CONCLUSION

The STOPP/START criteria have been used to review the medication profiles of community-dwelling, acute care and long-term care older patients in Europe, Asia and North America. Observational studies have reported the prevalence and predictors of PIP. The STOPP/START criteria appear to be more sensitive than the 2002 version of the Beers criteria. Limited evidence was found related to the clinical and economic impact of the STOPP/START criteria.

Chemical analysis of atherosclerotic plaque cholesterol combined with histology of the same tissue

Sensitive method for chemical analysis of free cholesterol (FC) and cholesterol esters (CE) was developed. Mouse arteries were dissected and placed in chloroform-methanol without tissue grinding. Extracts underwent hydrolysis of cholesteryl esters and derivatization of cholesterol followed by liquid chromatography/mass spectrometry (LC/MS/MS) analysis. We demonstrated that FC and CE could be quantitatively extracted without tissue grinding and that lipid extraction simultaneously worked for tissue fixation. Delipidated tissues can be embedded in paraffin, sectioned, and stained. Microscopic images obtained from delipidated arteries have not revealed any structural alterations. Delipidation was associated with excellent antigen preservation compatible with traditional immunohistochemical procedures. In ApoE(-/-) mice, LC/MS/MS revealed early antiatherosclerotic effects of dual PPARalpha,gamma agonist LY465606 in brachiocephalic arteries of mice treated for 4 weeks and in ligated carotid arteries of animals treated for 2 weeks. Reduction in CE and FC accumulation in atherosclerotic lesions was associated with the reduction of lesion size. Thus, a combination of LC/MS/MS measurements of CE and FC followed by histology and immunohistochemistry of the same tissue provides novel methodology for sensitive and comprehensive analysis of experimental atherosclerotic lesions.

Reactive azo dye reduction byShewanella strain J18 143

A bacterial isolate designated strain J18 143, originally isolated from soil contaminated with textile wastewater, was shown to reduce intensely coloured solutions of the reactive azo dye, Remazol Black B to colourless solutions. Phylogenetic placement based on 16S rRNA gene sequence homology identified the bacterium as a Shewanella species. Based on results from analyses of the end products of dye decoloration of Remazol Black B and the simpler molecule, Acid Orange 7, using capillary electrophoresis, UV-visible spectrophotometry and liquid chromatography-mass spectrometry, we suggest that colour removal by this organism was a result of microbially mediated reduction of the chromophore in the dye molecules. Anaerobic dye reduction by Shewanella strain J18 143 was 30 times more efficient than the reduction carried out by aerated cultures. Whole cells used a range of electron donors for dye reduction, including acetate, formate, lactate, and nicotinamide adenine dinucleotide (NADH), with formate being the optimal electron donor. The impact of a range of process variables was assessed (including nitrate, pH, temperature, substrate concentration, presence of an extracellular mediator) and results suggest that whole cells of Shewanella J18 143 offer several advantages over other biocatalysts with the potential to treat azo dyes.

Multiphoton microscopy and amyloid angiopathy

The underlying pathophysiological processes of amyloid angiopathy have been difficult to study because the vessel size affected is too smallfor imaging in the human condition, and animal models have not yet been adequately developed or characterized. Herein we present characterization of animal models of overexpression of the human AbetaPP gene, initially developed as models of Alzheimer's disease, but which fortuitously also develop marked cerebral amyloid angiopathy. We also present a novelform of microscopy that allows in vivo imaging of vessels affected by amyloid in the anesthetized, but intact, animal.

Structural and functional disruption of vascular smooth muscle cells in a transgenic mouse model of amyloid angiopathy

The deposition of amyloid Abeta peptide in the wall of cerebral vessels (cerebral amyloid angiopathy), can lead to weakness and rupture of the vessel wall, resulting in hemorrhagic stroke. The Tg2576 transgenic mouse line, overexpressing mutant amyloid precursor protein in an age-dependent manner, forms amyloid angiopathy morphologically similar to that seen in the human. We report here the structural and functional disruption of smooth muscle cells (SMCs) in the walls of pial vessels affected by amyloid deposition in the Tg2576 mouse. We demonstrate, using multiphoton imaging, that the arrangement of SMCs becomes disorganized before the onset of cell death, and that these disorganized SMCs are unable to respond appropriately to application of endothelial-dependent and endothelial-independent vasodilators in a closed-cranial window preparation.

Recurrent varicose veins: patterns of reflux and clinical severity

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

Aggregation and disaggregation of senile plaques in Alzheimer disease

We quantitatively analyzed, using laser scanning confocal microscopy, the three-dimensional structure of individual senile plaques in Alzheimer disease. We carried out the quantitative analysis using statistical methods to gain insights about the processes that govern Abeta peptide deposition. Our results show that plaques are complex porous structures with characteristic pore sizes. We interpret plaque morphology in the context of a new dynamical model based on competing aggregation and disaggregation processes in kinetic steady-state equilibrium with an additional diffusion process allowing Abeta deposits to diffuse over the surface of plaques.

Lack of association of trinucleotide repeat polymorphisms in very-low-density lipoprotein receptor gene with Alzheimer's disease

Inheritance of the apolipoprotein E epsilon 4 allele is a risk factor for Alzheimer's disease (AD). A recent report studying Japanese patients suggested that a polymorphism of a trinucleotide repeat in the 5' untranslated region of an apolipoprotein E receptor, the very-low-density lipoprotein receptor, is genetically associated with AD, with overrepresentation of the allele containing five copies of the repeat. We determined the allele frequencies of the very-low-density lipoprotein receptor in 3 white populations totaling 469 individuals. In contrast to the previous report, we found no differences in allele frequencies between case patients and control subjects. The discrepancy could be due to differences in Japanese and white populations. Nonetheless, these data weaken the likelihood that this polymorphism in the very-low-density lipoprotein receptor gene is strongly associated with AD.

Laparoscopic excision of distal pancreas including insulinoma

A case of sporadic occult insulinoma treated by laparoscopic distal pancreatectomy using a laparoscopic ultrasound probe to facilitate localization of the insulinoma and a laparoscopic surgical stapler to transect the pancreas is presented. This is believed to be the first case description of a laparoscopic pancreatic resection.

The use of video image analysis for the measurement of venous ulcers

The accurate measurement of the size of skin wounds and ulceration is important for comparing the efficiency of treatment modalities and for monitoring progress in the individual patient. Although various methods of differing sophistication are in use, many of the common simpler techniques lack accuracy and reliability. We describe a new technique of ulcer measurement which uses video image recording, capture and computer analysis. A method of correcting for limb convexity in a two-dimensional image is presented. The method has an overall accuracy of 1.82% and a clinical precision of 3.41%, both of which are significantly better than acetate tracings or photographic methods. The technique is simple and rapid, and once established it incurs minimal ongoing costs.

Anatomic and physiologic characteristics of venous ulceration

PURPOSE

The purpose of this study was to describe the combination of physiologic and anatomic changes present in limbs with venous ulceration.

METHODS

Limbs with venous ulceration (chronic venous insufficiency [CVI] class 3) were assessed prospectively by air plethysmography and color-flow duplex scanning. Findings were compared with clinically normal contralateral limbs and normal control limbs (CVI class 0), as well as with limbs without skin changes (CVI class 1).

RESULTS

Of the 120 ulcerated limbs studied, only 28% had deep system incompetence. Reflux at the saphenofemoral or saphenopopliteal junctions without perforator incompetence was present in 40%. Raised venous filling indexes (> 2 ml/s) and high residual volume fractions (> 20%) were present in 90% and 95%, respectively. Although levels of these parameters were significantly different from the other groups (p < 0.05), absolute ejection volumes and outflow parameters were the same (p > 0.05). One third of contralateral "normal" limbs (class 0) had abnormal duplex scanning findings. The ratio of venous filling time to residual volume fraction produced a useful discriminating index for the ulcerated limb.

CONCLUSION

The ulcerated limb was characterized by high rates of reflux and high residual volumes that were independent of the site of reflux. This study highlights the important association of venous ulceration and isolated superficial venous system incompetence.

Evidence that pepper mottle virus and potato virus Y are distinct viruses: analyses of the coat protein and 3' untranslated sequence of a California isolate of pepper mottle virus

Pepper mottle virus (PepMoV) is a member of the large and complex genus Potyvirus, and is classically distinguished from other members of the genus by differential host range and cytopathology as well as serology of the coat protein and cytoplasmic inclusion body proteins. Here we report the deduced amino acid sequence of the coat protein of a California potyvirus identified by a variety of classical methods as PepMoV (PepMoV C). Comparison of the 3' untranslated nucleic acid sequence and the deduced coat-protein amino acid sequence of the PepMoV C isolate with those of PVY and other potyviruses indicates that PepMoV C is sufficiently diverged to be considered a distinct virus species. Thus, comparative sequence analyses of the PepMoV C isolate support earlier serological and biological evidence that PepMoV and PVY are distinct viruses.

Prenatal ethanol exposure alters immune capacity and noradrenergic synaptic transmission in lymphoid organs of the adult mouse

Clinical and experimental evidence indicates that exposure to alcohol in utero is associated with altered immune capacity. The mechanisms underlying such abnormalities are not clear. However, the suggestion that reciprocal interactions between the immune and the nervous systems are necessary for a competent immune response may be relevant. This work examined the consequences of prenatal ethanol exposure on cellular immune responses and noradrenergic synaptic transmission in lymphoid organs of the adult C57B1/6 mouse. Pregnant mice were fed a liquid diet containing 25% of the calories as ethanol (4.8% w/v) or pair-fed an isocaloric equivalent of this diet throughout gestation, followed by foster-nursing the neonates on normal dams. As young adults, mice exposed to ethanol prenatally displayed immunologic and selective neurochemical changes: (1) depressed ability to produce cellular immune responses, including contact hypersensitivity and a local graft-vs-host response, and (2) altered noradrenergic synaptic transmission, including enhanced norepinephrine turnover, and a reduction in norepinephrine levels and beta-adrenoceptor density in the thymus and spleen, but not the heart. However, both the integrity and compartmentation of noradrenergic nerve fibres in the spleen were intact. It is suggested that altered noradrenergic synaptic transmission selectively in lymphoid organs may contribute to the impaired immune capacity associated with fetal alcohol exposure.

Analytical study of a Rift Valley fever epidemic

Three epidemiological investigations were carried out during and after the 1987 Rift Valley fever (RVF) epidemic in South Mauritania: a case control study, a cross-sectional study in the town of Rosso and a cross-sectional study of villages and encampments around Rosso. The case control study showed an association between epizootic and epidemic outbreaks. The study in Rosso town showed housing and district effects. Also, a medical survey of hospital staff showed the absence of interhuman contamination. The cross-sectional study of villages and encampments around Rosso showed heterogeneity corresponding to a village and ethnic effect. The human epidemic was linked to epizootic disease, but the "vectors" of the disease are not as yet known.

Carotid artery exteriorisation in the red deer

A technique for the surgical relocation of the carotid artery, to permit repeated percutaneous puncture, in red deer, is described. An incision was made through the skin distal to the ramus of the jaw parallel to and dorsal to the superficial jugular vein. The brachiocephalicus muscle was divided by blunt dissection to reveal the carotid artery. The carotid artery was dissected free of connective tissue and the vagus nerve and enclosed in a polythene prosthesis. The brachiocephalicus muscle was sutured dorsal to the now enclosed artery. The wound was closed taking care that the line of sutures did not overlie the prosthesis. Repeated percutaneous puncture of the artery was possible for periods of up to 18 months.

Scimitar syndrome

Three patients with the scimitar syndrome represented an incidence at the King Faisal Specialist Hospital and Research Centre of one per cent of patients who underwent cardiac catheterization. In one of the patients the anomalous pulmonary venous return and the pulmonary hypoplasia was on the left. The syndrome is usually benign. Its recognition may save the patient from unnecessary additional diagnostic procedures.

Lesch-Nyhan disease: clinical experience with nineteen patients

The clinical phenotype in Lesch-Nyhan disease has been analyzed in 19 patients studied in hospital. In each case the diagnosis was made on the basis of inactivity of the enzyme hypoxanthine guanine phosphoribosyltransferase in erythrocyte lysates. All had hyperuricemia, and the presence of 'orange sand' in the diaper was a prominent early complaint. All had self-mutilative behavior, of which the most characteristic form was biting the fingers or lips. All had the neurological syndrome of spasticity and choreoathetoid involuntary movements. All but one had less-than-normal intelligence.