A preliminary study of the feasibility of wound telecare for the elderly

We have developed a method for remote wound assessment in the elderly. Wound images were taken with a digital camera at a resolution of 640x480 pixels. JPEG compression was then used to produce images of about 100 kByte. Selected clinical data were transmitted by email, together with standardized digital images of wounds. The remote physician then read the clinical data and viewed the digital images on a 38 cm colour display monitor, at a resolution of 800x600 pixels, in 16-bit colour, using standard software. Three elderly inpatients with pressure sores or leg ulcers had both bedside and remote examinations, by different physicians. The diagnosis and therapeutic recommendations proposed after each of the two examinations were compared qualitatively. There was reasonable agreement between the two physicians in the assessment of wound size, anatomical classification, wound bed and status of infection. However, the lack of palpation represented a major limitation to remote wound assessment, despite the use of probes to delineate the depth of any opening in the wound bed.

Influence of pulsation on start-up of UASB reactors

The aim of this work is to study the influence of pulsation on the start-up of lab-scale UASB reactors. Pulsation was produced by an Elastic Membrane Pulsator (EMP). The application of this device in previous works improved the performance of continuous fixed-bed fermentors and reduced the formation of preferential pathways, the retention of gas metabolites within the bed and the resistance to mass transfer. These characteristics seem to be suitable for feeding UASB reactors. In this work, the influence of pulsation frequency was studied in two pulsed UASB reactors operated in parallel with a non-pulsed one. One of them (P1) operated at high frequencies (periods of 50 and 200 s between each pulsation) and the other (P2) at low frequencies (periods of 3600 and 900 s between each pulsation). An important improvement of the removal efficiency for pulsed reactors with respect to the non-pulsed one was obtained. The structure of the biomass was observed at the end of the process by scanning electron microscopy. In general, granulation of biomass was improved when operating in pulsing form.

[Thoracic empyema in very old patients: two types of clinical presentation]

INTRODUCTION

Primitive thoracic empyema or empyema secondary to pneumonia represents a significant medical problem necessitating prolonged hospitalizations and increasing the rates of morbidity and mortality. Average patient age is 55 years and remains rare in very old patients (> 85). We report here two observations in very old patients, pointing out the diversity of the clinical presentation.

EXEGESIS

Empyema thoracis is classically associated with underlying diseases. It is often polymicrobial but Gram-positive bacteria and anaerobes are more frequent than Gram-negative bacteria. The clinical presentation may be aspecific without any parameters in favor of infectious disease: the rapidity of pleural drainage and antibiotic therapy are the main prognostic factors.

CONCLUSION

Because of the diversity of clinical presentation in the elderly population, and because of the efficiency of rapid treatment, geriatric physicians should perform an examination of pleural fluid when pleural effusion is unknown.

Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques

BACKGROUND

The authors studied the changes in selected hemostatic variables in patients undergoing coronary surgery with on-pump coronary artery bypass grafting (CABG) or off-pump coronary artery bypass surgery (OPCAB) techniques.

METHODS

Platelet counts and plasma concentrations of antithrombin, fibrinogen, D dimer, alpha(2) antiplasmin, and plasminogen were measured preoperatively, 5 min after administration of heparin, 10 min after arrival in the intensive care unit, and 24 h after surgery in patients scheduled to undergo OPCAB (n = 15) or CABG (n = 15). To correct for dilution, hemostatic variables and platelet counts were adjusted for the changes in immunoglobulin G plasma concentrations and hematocrit, respectively.

RESULTS

Adjusting for dilution, antithrombin and fibrinogen concentrations decreased to a similar extent in patients undergoing OPCAB or CABG (pooled means and 95% confidence limits of the mean: 95.5% of baseline, 93-98%, P = 0.002, and 91.7% of baseline, 88-95%, P = 0.0001), respectively, whereas alpha(2)-antiplasmin concentrations were unchanged. Only CABG was associated with a reduction in platelet counts (76% of baseline, 66-85%, P = 0.0001), plasminogen concentrations (96% of baseline, 91-99%, P = 0.011), and increased D-dimer formation (476%, 309-741%, P = 0.004). Twenty-four hours after surgery, platelet counts were still lower in patients undergoing CABG (P = 0.049), but all the investigated variables adjusted for dilution were similar in the two groups.

CONCLUSIONS

Coronary surgery causes a net consumption of antithrombin and fibrinogen. A transient decrease in platelet counts, with plasminogen activation and increased D-dimer formation, however, is only observed with CABG. Twenty-four hours after surgery, the hemostatic profiles of patients in both groups are similar.

[Acceptability of computerized prescription writing in the hospital. Survey of 44 drug-prescribing physicians]

OBJECTIVES

The purpose of this work was to assess the acceptability of computerized prescriptions delivered by hospital prescribers.

METHODS

The study was conducted in four clinical units of the Grenoble University Hospital that have a computerized prescription system. Forty-four physicians using the system responded to a questionnaire concerning the act of prescribing and the benefits or drawbacks of the system.

RESULTS

Generally, the computerized prescription system was well accepted. The first drawback mentioned was the time spent manipulating the software. Safe prescription was noted as one of the advantages. Overall, organizational rather than technical factors appeared to condition the development of computerized prescription writing.

CONCLUSION

Optimization of computerized prescription writing requires a reorganization of the care unit. Consultation schedules and working relations between the prescriber and other healthcares and hospital pharmacies will have to be adapted.

[A French tool for evaluation of home palliative care: adaptation of the Support Team Assessment Schedule]

The authors describe the utilisation of a quality assessment tool for palliative care administered at home. The questionnaire entitled Support Team Assessment Schedule (STAS) was translated from English for this study. It was then utilised comparatively with different quality of life evaluation instruments. Only the results of the STAS are described here. The approach allows for the unresolved problems in the care to come to the surface week after week. The STAS comprises nine items pertaining to the patient and his/her family, and seven items concerning the services provided. The study exhibits the results of 107 evaluations completed from 50 patients stricken with cancer or AIDS in an advanced phase. The availability of this auto clinical audit tool, employable at home or in a hospital, constitutes an essential initial step in the field of French-speaking clinical evaluation of palliative care.

[Experience at a branch center of the National HIV Protease Inhibitor Registry]

In the present study we show our experience as one of the Centers (center 006) of the Italian Index of Protease Inhibitors (PI). In this multicentric, observational study we studied HIV-positive naive patients for antiretroviral therapy with protease inhibitors. From 8/1/97 to 31/1/98 in our department 64 patients were enrolled and followed up through an electronic medical sheet in order to evaluate efficacy, tolerability, toxicity and compliance of treatment with PI. Our results show a reduction in AIDS-related mortality and a decrease in AIDS defining diseases: in particular data show an increase in CNS pathologies in comparison with other opportunistic events. Moreover, in patients non complaints to therapy, the progression of the disease was more frequent. The side effects more frequently observed during PI treatment were hypertrigliceridaemia and lipodystrophy; gynaecomastia and hyperprolactinaemia were even present, perhaps as expression of direct metabolic action of HAART therapy.

High prevalence of low HDL cholesterol concentrations and mixed hyperlipidemia in a Mexican nationwide survey

The prevalence of lipid abnormalities revealed in a survey done in 417 Mexican cities is described. Information was obtained on 15,607 subjects, aged 20 to 69 years. In this report, only samples obtained after a 9- to 12-h fast were included (2,256 cases: 953 men and 1,303 women). The population is representative of Mexican urban adults. Mean lipid concentrations were: cholesterol, 4.80 mmol/l; triglycerides, 2.39 mmol/l; HDL cholesterol, 1.00 mmol/l; and LDL cholesterol, 3.06 mmol/l. The most prevalent abnormality was HDL cholesterol below 0.9 mmol/l (46.2% for men and 28.7% for women). Hypertriglyceridemia (>2.26 mmol/l) was the second most prevalent abnormality (24.3%). Severe hypertriglyceridemia (>11.2 mmol/l) was observed in 0.42% of the population. Increased LDL cholesterol (> or =4.21 mmol/l) was observed in 11.2% of the sample. Half of the hypertriglyceridemic subjects had a mixed dyslipidemia or low HDL cholesterol. More than 50% of the low HDL cholesterol cases were not related to hypertriglyceridemia. Insulin resistance was found in 59% of them. In conclusion, the prevalence of hypoalphalipoproteinemia and other forms of dyslipidemia in Mexican adults is very high and it is among the highest previously reported worldwide.

Tranexamic acid in off-pump coronary surgery: a preliminary, randomized, double-blind, placebo-controlled study

BACKGROUND

We evaluated the hemostatic effects of tranexamic acid, a synthetic antifibrinolytic drug, in patients undergoing beating-heart coronary surgery.

METHODS

Forty consecutive patients were in a double-blind manner, prospectively randomized into two groups: 20 patients received tranexamic acid (bolus of 1 g before skin incision, followed by continuous infusion of 400 mg/hr during surgery), and 20 patients received saline. As primary outcomes, bleeding and allogeneic transfusions were considered. D-dimer and fibrinogen plasma levels were also evaluated to monitor the activation of fibrinolysis. Major postoperative thrombotic events, as a potential consequence of antifibrinolytic treatment, were recorded.

RESULTS

The treatment group had significantly lower postoperative bleeding (median [25th to 75th percentiles]: 400 mL [337 to 490 mL] vs 650 ml [550 to 862 mL], p < 0.0001), lower need for allogeneic blood products (1,200 vs 5,300 mL, p < 0.001), and lower postoperative D-dimer plasma levels. No postoperative thrombotic complications were observed in either group.

CONCLUSIONS

In this initial series of patients undergoing off-pump coronary surgery, tranexamic acid appears to be effective in reducing postoperative bleeding and the need for allogeneic blood products.

Localization of Trichinella spiralis in muscles of commercial and parasitologic interest in pork

Trichinellosis is widespread around the world with different representatives of the genus Trichinella found in almost every continent. In Argentina the main source of transmission for the disease to humans is pig meat infected with Trichinella spiralis. The object of this work was to determine the distribution of Trichinella larvae in fresh meat cuts which are sold for human consumption and in the muscles traditionally used for the disease diagnosis at meat-packing plants. Cranial muscles to the last rib showed more Trichinella spiralis larvae than those with a caudal location (p < 0.01). No significant differences were found (p > 0.05) between bilateral left and right muscles. Significant larval concentrations were found in the neck muscles, even in carcasses with a low parasitic load; these muscles are used to prepare cold meats (boston butt). Commercial cuts of meat had a substantial larval burdens in animals experimentally infected with 500 to 5,000 Trichinella spiralis larvae, with parasite burdens similar to infection levels in muscles evaluated at the meat packing plant.

[Changes in renal function in renal transplantation. Predictive factors for functional deterioration]

Renal transplants may undergo changes secondary to the decrease of the renal mass, the effects of rejection, and various other risk factors that contribute to the progression of renal insufficiency. We have performed a prospective study of 285 cadaveric renal transplants recipients, that were receiving various maintenance immunosuppressives regimens, to study the evolution of their renal function and to evaluate the influence of various factors in the progression of renal insufficiency. All variables were analysed in a regression model of multivariate analysis. We found a progressive increase of the serum creatinine in the studied population. The mean initial creatinine was 1.70 +/- 0.84 mg/dl and final creatinine in the study 2.17 +/- 2.06 mg/dl, difference statistically significant (p = 0.000). We calculated the increase of creatinine in each patient. We observed that 113 patients (42.2%), had stable serum creatinine but the remaining 155 patients (57.8%) had a mean increase of 0.04 +/- 0.8 mg/dl/month. We analysed the patients according to various variables. Although in most the final creatinine is significantly greater than the initial, this increase of creatinine level was not present in patients with delayed graft function, in patients with no acute rejection, in the extreme age groups, in the grafts from younger donors and in those patients without initial proteinuria. The patients transplanted from younger donor had the best renal function, without any decrease in their function during the study. The advanced age of the donor has a great negative impact in the evolution of the renal transplant. According to our study, proteinuria and its quantity is a major predictor of progressive renal insufficiency. The multivariate analysis confirms that the age of the donor and initial proteinuria predict decrease of renal function. It is important to identify the factors that they could predict a greater progression to the failure of the graft. We have the possibility of acting on them, establishing immunosuppressive strategies that reduce the deleterious effects of the calcineurin inhibitors in the recipients of grafts from older donors' and to encourage the use of drugs which reduce proteinuria.

Teleconsultation in psychology: the use of videolinks for interviewing and assessing elderly patients

Although elderly people are one of the major target groups for telemedicine applications, they remain under-represented in studies of teleconsultation. Videolinks appear to be easily used by many elderly people as a means of communicating with health-care staff, including psychologists and doctors. To date, studies of psychometric teleconsultation have been confined to screening tests, or have used very small numbers of patients. There is a need to examine the reliability of more complex psychometric batteries and to use larger samples of older people. Some recommendations for conducting clinical interviews and psychometric tests are presented, based on clinical experience and a review of the literature. The importance of ergonomic considerations, patient comfort and professional preparation are explained.

Advanced monitoring and control of anaerobic wastewater treatment plants: diagnosis and supervision by a fuzzy-based expert system

A fuzzy-based expert system (ES) for the diagnosis and supervision for anaerobic digesters is presented. The system was developed in a Microsoft Windows support using fuzzy logic inference together with a rule base for the implementation of expert knowledge. The ES runs on-line through three main modules, which determine the state and trend of the process, and the best set points for the actuation on the final control elements of the plant. Two further modules run in parallel, when they are required by the operator, using off-line and on-line information for the detection of inhibition due to toxic compounds in the process and for the validation of the on-line diagnosis. The diagnosis and supervision ES was tuned up in order to adjust the membership functions describing the process, and lately tested, running on-line, to study the response of the rule base.

Tranexamic acid administration after cardiac surgery: a prospective, randomized, double-blind, placebo-controlled study

BACKGROUND

Many different doses and administration schemes have been proposed for the use of the antifibrinolytic drug tranexamic acid during cardiac surgery. This study evaluated the effects of the treatment using tranexamic acid during the intraoperative period only and compared the results with the effects of the treatment continued into the postoperative period.

METHODS

Patients undergoing elective cardiac surgery with use of cardiopulmonary bypass (N = 510) were treated intraoperatively with tranexamic acid and then were randomized in a double-blind fashion to one of three postoperative treatment groups: group A: 169 patients, infusion of saline for 12 h; group B: 171 patients, infusion of tranexamic acid, 1 mg x kg(-1) x h(-1) for 12 h; group C: 170 patients, infusion of tranexamic acid, 2 mg x kg(-1) x h(-1) for 12 h. Bleeding was considered to be a primary outcome variable. Hematologic data, allogeneic transfusions, thrombotic complications, intubation time, and intensive care unit and hospital stay duration also were evaluated.

RESULTS

No differences were found among groups regarding postoperative bleeding and outcomes; however, the group treated with 1 mg x kg(-1) x h(-1) tranexamic acid required more units of packed red blood cells because of a significantly lower basal value of hematocrit, as shown by multivariate analysis.

CONCLUSIONS

Prolongation of treatment with tranexamic acid after cardiac surgery is not advantageous with respect to intraoperative administration alone in reducing bleeding and number of allogeneic transfusions. Although the prevalence of postoperative complications was similar among groups, there is an increased risk of procoagulant response because of antifibrinolytic treatment. Therefore, the use of tranexamic acid during the postoperative period should be limited to patients with excessive bleeding as a result of primary fibrinolysis.

[Fluctuation in bilateral thalamic infarction: diffusion study using magnetic resonance]

INTRODUCTION

Bilateral paramedian thalamic infarcts are uncommon. The most frequent clinical manifestations are acute impairment of consciousness, oculomotor abnormalities and cognitive disturbances. A fluctuating course has not been previously reported.

CLINICAL CASE

A 66 year-old woman with a past history of arterial hypertension and diabetes was admitted to our hospital presenting four episodes of decreased consciousness and vertical gaze paresis. Neurological examination between episodes was unremarkable. Diffusion-weighted magnetic resonance imaging revealed high-signal lesions in both paramedian thalamic areas.

CONCLUSIONS

Fluctuating impairment of consciousness may be a clinical presentation of bilateral paramedian thalamic infarction. Atheromatous occlusion of the mouth of the paramedian thalamic penetrating artery is the most common cause. Neurological findings and diffusion-weighted images may help to define the extension and the underlying pathophysiological mechanism.

[Comparison of conductivity with sodium determination in the same sweat sample]

OBJECTIVE: To correlate sweat conductivity by Wescor with quantitative sodium determination in the same sample. METHODS: We analyzed 206 sweat samples, being 31 obtained from patients with cystic fibrosis (CF). Sweat was collected by quantitative pilocarpine iontophoresis in the Macroduct system for 30 minutes. Samples were immediately determined by Sweat-Chek analyzer (Wescor) and sodium quantification with a flame photometer. RESULTS: In non-CF subjects sweat (n=175), mean conductivity and quantitative sodium were 41mmol/L (16-75mmol/l) and 36mEq/ l (12-75mEq/l) respectively. In CF subjects (n=31), mean values of conductivity and sodium were 119mmol/L (84-155mmol/l) and 113mEq/l (80 - 146mEq/l) respectively. None of CF patients showed values lower than 80mmol/L. There was a correlation between sweat conductivity and sodium determination (r= + 0.99; p<0.0001). CONCLUSION: Sweat conductivity by Wescor simplifies the analysis with lower volumes and is well correlated to sodium concentration.

[Hematoma of the anterior rectus abdominis muscle as the first manifestation of lymphoproliferative disease after renal transplantation]

Rectus sheath hematoma results from the rupture of rectus muscle vessels by trauma, coagulation disorders or anticoagulant therapy, but it can occur spontaneously too. Its prognosis is good. On the other hand, posttransplant lymphoproliferative disorders (PTLD) are serious and potentially fatal complications in transplant recipients. Patients with PTLD have a mononucleosis-like syndrome or develop extranodal masses which involve various organs. We report the case of a renal transplant recipient who develop a rectus sheath hematoma as the first clinical feature of PTLD.

[Pneuropsychological disorders after occupational exposure to mercury vapors in El Bagre (Antioquia, Colombia)]

INTRODUCTION

The department of Antioquia in Columbia is the main producer of gold in Columbia. In the gold-producing regions the population is exposed to high levels of mercury used in the processes of extraction and purification. Studies done in Columbia on neurotoxicity underline the hazards of mercury from the environmental and occupational-health point of view, but the effect of long-term exposure on cognitive function has not been studied.

OBJECTIVE

To determine whether the miners of El Bagre (Antioquia, Columbia) have neuropsychological and/or behavior disorders as a result of occupational exposure to toxic mercury vapor.

PATIENTS AND METHODS

The sample was made up of 22 right-handed men, residents of El Bagre, aged between 20 and 45 years old who had been exposed to mercury vapor for at least three years. The control group consisted of 22 men who lived in the non-mining regions of the department and had not been exposed to mercury, paired with the cases considered for age and educational status. Neuropsychological assessment, a medical examination and behavioral performance tests were applied to all the men (in both groups).

RESULTS

In the study group alterations were seen and classified as: intellectual damage (mainly alteration of executive function and constructional praxis); emotional changes (symptoms of depression and anxiety) and neurological changes (amnesia, insomnia and tremor of the tongue). No changes were found in the control group.

CONCLUSION

Exposure to mercury causes specific neuropsychological and behavior disorders in the absence of clinically detectable physical or physiological damage.

Characterization of tpp1(+) as encoding a main trehalose-6P phosphatase in the fission yeast Schizosaccharomyces pombe

We have characterized an open reading frame of 2,454 bp on chromosome I of Schizosaccharomyces pombe as the gene encoding trehalose-6P phosphatase (tpp1(+)). Disruption of tpp1(+) caused in vivo accumulation of trehalose-6P upon heat shock and prevented cell growth at 37 to 40 degrees C. Accumulation of trehalose-6P in cells bearing a chromosomal disruption of the tpp1(+) gene and containing a plasmid with tpp1(+) under the control of the thiamine-repressible promotor correlated with tpp1(+) repression. The level of tpp1(+) mRNA rose upon heat shock, osmostress, or oxidative stress and was negatively controlled by cyclic AMP-dependent protein kinase activity. Expression of tpp1(+) during oxidative or osmotic stress, but not during heat shock, was under positive control by the wis1-sty1 (equivalent to phh1 and spc1) mitogen-activated protein kinase pathway. Analysis of Tpp1 protein levels suggests that the synthesis of trehalose-6P phosphatase may also be subjected to translational or posttranslational control.

Tranexamic acid compared with high-dose aprotinin in primary elective heart operations: effects on perioperative bleeding and allogeneic transfusions

OBJECTIVE

Since excessive fibrinolysis during cardiac surgery is frequently associated with abnormal perioperative bleeding, many authors have advocated prophylactic use of antifibrinolytic drugs to prevent hemorrhagic disorders. We compared the effects of tranexamic acid (a synthetic antifibrinolytic drug) with aprotinin (a natural derivative product with antifibrinolytic properties) on perioperative bleeding and the need for allogeneic transfusions.

METHODS

In a single-center prospective randomized unblinded trial, 1040 consecutive patients undergoing primary, elective cardiac operations with cardiopulmonary bypass received either high-dose aprotinin or tranexamic acid. The aprotinin group (518 patients) received 280 mg in 20 minutes before the skin incision, 280 mg in the priming solution of the extracorporeal circuit, and a continuous infusion of 70 mg/h throughout the operation. The tranexamic acid group (522 patients) received 1 g in 20 minutes before the skin incision, 500 mg in the priming solution of the extracorporeal circuit, and a continuous infusion of 400 mg/h during the operation. Postoperative bleeding, perioperative transfusions, and hematologic variables were evaluated at fixed times. Postoperative thrombotic complications, intubation time, intensive care unit stay, and hospital stay were recorded.

RESULTS

Postoperative bleeding was similar in the 2 groups: aprotinin 250 mL (150-400 mL) versus tranexamic acid 300 mL (200-450 mL) (median and 25th-75th quartiles), median difference of 50 mL (95% confidence intervals, 0-50 mL). The number of transfusions and the outcome did not differ.

CONCLUSIONS

Tranexamic acid and aprotinin show similar clinical effects on bleeding and allogeneic transfusion in patients undergoing primary elective heart operations. Since tranexamic acid is about 100 times cheaper than aprotinin, its use is preferable in this type of patient.

Epitope affinity for MHC class I determines helper requirement for CTL priming

We show here that priming and memory generation of antigen-specific CD8+ cytotoxic T lymphocytes (CTL) does not require help if the immunogen binds major histocompatibility complex (MHC) class I molecules with high affinity. This conclusion was based on the study of three chemically distinct optimal length CTL epitopes with high affinity for the restriction element Kb. In contrast, when two subdominant epitopes with intermediate MHC binding affinity were studied, either a class II MHC-restricted T helper cell epitope or administration of antibody to CD40 was required to obtain significant CTL priming. Depending on the epitope, one source of help was much more efficient than the other.