Improvement of debilitating tardive dyskinesia with risperidone

This case vignette illustrates dramatic improvement of tardive dyskinesia (TD) in an elderly female with a long history of neuroleptic exposure, following treatment with low-dose risperidone. The TD continued to be in remission at 1-year follow-up. This observation calls for well-designed randomized studies to evaluate the efficacy of risperidone in treating TD.

What method should be used to define 'night' when assessing diurnal systolic blood pressure variation in the elderly?

Diurnal blood pressure (BP) variation can be assessed by cusums-derived measures and by the day-night BP difference from time-, activity- and diary-defined 'night' periods. Reproducibility of diurnal systolic BP (SBP) variation by these different methods was studied in 19 active elderly normotensives, mean age 68.5 years. Subjects underwent simultaneous 24 h BP (Spacelabs 90207) and activity (Gaehwiler wrist actigraph) monitoring on two occasions (median interval 70 days). On the first occasion, mean diurnal SBP variation was 15.1 +/- 8.1 mm Hg by fixed-time definition of 'night' (22.07). When compared with 22-07 defined 'night' period, actigraph- and diary-defined 'night-time' was significantly reduced (-60 +/- 49, and -48 +/- 51 min, respectively) and consequently diurnal SBP variation was significantly greater at 18.2 +/- 8.1 mm Hg and 17.6 +/- 8.4 mm Hg, respectively. Actigraph recordings were also used to exclude 'night' BP readings associated with activity, but this did not significantly alter the diurnal SBP variation. Cusums-derived circadian alteration magnitude resulted in the greatest value for SBP variation (23.4 +/- 6.7 mm Hg). However, reproducibility of diurnal SBP variation was poor by fixed-time method with a coefficient of variation (CV) of > 50%, and only improved to 40% with diary use. Actigraph measurements, even if used to exclude BP values associated with disturbed sleep, did not improve this further. Cusums-derived measures of diurnal variation slightly improved reproducibility with a CV of 34.6% and may be a better method in the assessment of diurnal BP variation in the elderly.

Changes in the sweatspot test with ageing and relation to cardiovascular autonomic function

The sweatspot test assesses the local sweat response to an intradermal injection of acetylcholine. It has been reported as a more sensitive indicator of autonomic dysfunction in important diabetic men than either pupillary or cardiovascular tests, and has been used to establish the presence of autonomic dysfunction in patients with idiopathic chronic constipation. However, the usefulness of this test as a simple and quick method of diagnosing autonomic dysfunction in an elderly population has not been established. This is important given the high prevalence of reduced autonomic function with ageing and hypertension. We compared the age-associated responses in the sweatspot test and its relation to cardiovascular autonomic function in elderly normotensive and hypertensive subjects. We studied eleven normotensive and 24 untreated hypertensive elderly subjects (mean age 75.7 years, range 63-85) and compared the results of the sweatspot test to a young control group (n = 11, mean age 32.0 years, range 25-41), and to a standard battery of cardiovascular autonomic function tests. The median sweatspot score was significantly lower in the elderly compared with young subjects (1.9 vs. 12.0, p < 0.0001) although there was no difference between elderly normotensive and hypertensive subjects (1.6 vs. 2.4, p = 0.8). No correlation was demonstrated between the median sweatspot score and the number of abnormal cardiovascular tests. The sweatspot test was grossly abnormal in all elderly subjects and was not correlated to changes in cardiovascular autonomic function. Its diagnostic use in the elderly is therefore of very limited value.

Spontaneous resistance to acute T-cell leukaemias in TCRV gamma 1.1J gamma 4C gamma 4 transgenic mice

The concept of tumour surveillance implies that specific and non-specific components of the immune system eliminate tumours in the early phase of malignancy. The immunological mechanisms that control growth of preneoplastic cells are, however, not known. T cells expressing gamma delta T-cell receptors (TCR) were first described as lymphocytes with reactivity against various tumour cells, which suggests that gamma delta T cells could mediate tumour surveillance. Here we show that TCRV gamma 1.1J gamma 4C gamma 4 transgenic mice are spontaneously resistant to acute T-cell leukaemias but cannot reject non-haematopoietic tumours. TCRV gamma 1.1J gamma 4C gamma 4+ hybridomas isolated from these mice react in vitro against almost all haematopoietic tumour cell lines tested. Recognition of tumour cells depends on the gamma delta TCR but is independent of major histocompatibility complex (MHC) class I, MHC class II, or TAP-2 peptide transporter expression. Ligand recognition is influenced by the murine Nromp gene, which confers resistance or susceptibility to tuberculosis, lepra and leishmaniasis. These data indicate that TCRV gamma 1.1+ T cells confer spontaneous immunity against haematopoietic tumours in vivo and link innate resistance to bacterial infections with tissue-specific tumour surveillance by gamma delta+ T cells.

The nutritional status and clinical course of acute admissions to a geriatric unit

Undernutrition of long-stay hospital patients and those in surgical units is well documented. This study was designed to determine the extent of the problem in elderly people admitted to hospital with acute medical problems and to assess the relationship between nutritional status and course of hospital stay. Sixty-nine patients underwent a nutritional assessment on admission and at intervals throughout their hospital stay and episodes of sepsis were documented. Severely malnourished patients were identified using body mass index, BMI (22%) and corrected arm muscle area, CAMA (26%). Episodes of sepsis occurred significantly more often in the severely undernourished group (p < 0.04). The median length of stay of the group was 16 days (range 2-113): during this time there was no significant change in markers of nutritional status apart from actual muscle circumference (AMC), which showed a reduction in measurement between admission and discharge which was statistically significant (p < 0.0003). This study indicated that severe malnutrition is common in elderly medical admissions, and that it is associated with an increased risk of sepsis. Additional nutritional depletion may occur during hospital stay, and is not easily recognized unless anthropometry is undertaken.

The influence of anesthetic agents on rat hepatic cytochromes P450 in vivo

The objective of this study was to identify which anesthetics when used acutely will affect cytochrome P450 (CYP) activity in male Sprague-Dawley rats in vivo. The anesthetics tested were fentanyl citrate, alpha-chloralose, ketamine, urethane (ethyl carbamate), halothane, and ether. CO2 anesthesia was used as the control comparator. Theophylline was used as a probe for CYP1A activity, phenobarbital for CYP2B/2C, flecainide for CYP2D1, and ethosuximide for CYP3A activity. All probes were administered via tail vein injection after anesthetic-induced loss of the righting reflex. Single sample probe clearances were estimated, and used as an index of CYP activity. Fentanyl citrate, alpha-chloralose, halothane, and ether did not have statistically significant effects on any of the CYP activities. Ketamine did not significantly affect CYP1 or CYP2B/2C activity. However, it decreased the clearance of flecainide (i.e. CYP2D1 activity) by 13.4% (p < 0.001) and the clearance of ethosuximide (i.e. CYP3A activity) by 17.6% (p < 0.0001). Urethane increased the clearance of theophylline by 91.5% (p < 0.0001), and decreased the clearance of ethosuximide by 40.5% (p < 0.0001) though it did not affect CYP2B/2C or CYP2D1 activities significantly. From this data, we conclude that a single dose of ketamine mildly inhibits the activity of CYP2D1 and CYP3A, and a single dose of urethane strongly inhibits CYP3A but increases CYP1A activity.

Energy intake and expenditure in elderly patients admitted to hospital with acute illness

Studies on hospitalized elderly subjects have demonstrated that negative energy balance is common during hospitalization, but have concentrated primarily on long-stay and psychogeriatric patients. There is little information on energy balance in elderly patients admitted with acute illness from the community, despite the importance of this patient group and the presence of a number of factors likely to predispose such patients to negative energy balance. In the present study energy balance was quantified in twenty patients (eight males, mean age 82 (SD 5) years; twelve females, mean age 84 (SD 6) years) admitted from the community with acute illness, and predicted basal metabolic rate (BMR) was compared with measured resting metabolic rate (RMR). Most patients were in negative energy balance during hospitalization, and median measured energy intake (EI): measured RMR ratio was 1.0 (range 0.7-1.8). The mean difference between measured EI and estimated total energy expenditure was -1.3 MJ/d (range -3.4 to +2.5 MJ/d). Estimated total energy expenditure exceeded measured EI in fifteen of the patients and there was a significant decline in mid-arm muscle circumference (paired t, P < 0.05) during hospitalization. We conclude that moderate negative energy balance is common in this patient group, and that these patients are at risk of undernutrition during their hospital stay.

Change in smoking prevalence among pregnant women 1982-93

Maternal smoking is the most prevalent risk factor for low birthweight in Canada. This study compared the prevalence of maternal smoking before and during pregnancy from 1983 to 1992. Population-based surveys of 3,296 women during six months in 1983 and 7,940 women during 12 months in 1992 were conducted in Ottawa-Carleton using a self-administered questionnaire completed in the hospital postpartum period. The proportion of women smoking after the first trimester of pregnancy decreased from 28.5% in 1983 to 18.7% in 1992. This difference was due mainly to a reduction in the proportion of women who smoked before pregnancy (37.4% to 26.4%). Another factor was that more women stopped smoking early in pregnancy (23.9% to 29.2%). Gradients in levels of smoking by age, education, marital status and poverty level still exist; however, this is true for the general population. Programs to decrease smoking in pregnancy should continue to focus on reducing smoking among women in general and among those in the preconception and early stages of pregnancy in particular.

The Hypertension in the Very Elderly Trial (HYVET). Rationale, methodology and comparison with previous trials

The Hypertension in the Very Elderly Trial (HYVET) is a multicentre, open, randomised, controlled trial. The aim of this trial is to investigate the effect of active treatment on stroke incidence in hypertensive patients over the age of 80 years. Secondary end-points include total cardiovascular mortality and morbidity. Entry criteria include a sustained sitting systolic blood pressure of 160 to 219mm Hg plus a sustained sitting diastolic pressure of 95 to 109mm Hg. Also required is a standing systolic blood pressure of at least 140mm Hg. Patients must give their informed consent, and be free of congestive heart failure requiring treatment, gout, renal failure or a recent cerebral haemorrhage. Patients are to be randomised to 3 groups-(i) no treatment; (ii) treatment with a diuretic [bendroflumethiazide (bendrofluazide)]; or (iii) treatment with an angiotensin converting enzyme (ACE) inhibitor (lisinopril). Starting dosage for bendroflumethiazide and lisinopril is 2.5 mg/day. In order to achieve goal sitting systolic and diastolic blood pressures (< 150/80 mm Hg), a doubling of the dosage is allowed. Furthermore, slow release diltiazem (120 mg/day increasing to 240 mg/day if required) may be added to the medication of the actively treated groups. These drugs have been chosen as inexpensive and appropriate representatives of their therapeutic classes. 700 patients in each group (a total of 2100) will be sufficient to detect a 40% difference in cerebrovascular events between no treatment and active treatment (alpha = 0.01, 1-beta = 0.90). These numbers will also detect a difference in total mortality of 25% and in cardiovascular mortality of 35%. The pilot phase of the trial has been started with support from the British Heart Foundation. Centres which are interested in taking part should contact C.J. Bulpitt or any of the other authors.

Primary cutaneous infection by Aspergillus ustus in a 62-year-old liver transplant recipient

We report the first case of primary cutaneous aspergillosis caused by Aspergillus ustus, a species that seldom infects human beings. The patient, a 62-year-old liver transplant recipient with end-stage hepatitis C-induced cirrhosis, was receiving the experimental immunosuppressive drug FK-506. Trauma to the skin of the right arm from tape and from an arm board holding intravenous and intraarterial catheters in place and to the left leg from an occlusive knee brace may have contributed to this unusual mycosis. The patient's cutaneous aspergillosis responded to a combination of intravenous amphotericin B and topical terbinafine cream. Although the patient died shortly thereafter from hepatic failure, there was no evidence of systemic aspergillosis.

The acute effects of a single dopamine infusion in elderly patients with congestive cardiac failure

1. Dopamine (DA) at low doses (2.5 micrograms kg-1 min-1) produces a measurable increase in glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) in young healthy subjects and has a therapeutic effect in younger patients with congestive cardiac failure (CCF). In elderly healthy subjects, DA increases ERPF but does not increase GFR in all subjects. 2. To determine the potential therapeutic use of DA in elderly subjects with CCF, we studied 17 patients (5 male) aged 79.9 years (range 68 to 93 years) admitted to hospital for inpatient treatment of CCF resistant to diuretic and angiotensin converting enzyme inhibitor therapy. The effects of a single infusion DA at 2.5 micrograms kg-1 min-1 on GFR and ERPF were assessed in a double-blind, placebo controlled prospective study. 3. There were no significant differences in GFR or ERPF between control and DA. A reduction in GFR was seen in some patients. 4. DA at low dosage was not shown to benefit elderly patients with resistant CCF, and in some patients was detrimental. Higher doses or a combination with other inotropes may be necessary for a renal effect in elderly patients.

Evidence for free radical-mediated lipid peroxidation at reperfusion of human orthotopic liver transplants

BACKGROUND

Generation of toxic oxygen metabolites at reperfusion may contribute to the injury sustained as a consequence of harvest and ischemic preservation of organ allografts. Because there is a paucity of evidence that this mechanism is operative in human beings, we measured the generation of ethane into the exhaled breath as a biomarker of free radical-mediated lipid peroxidation in human liver transplantation.

METHODS

A novel technique that increased the previous standard of sensitivity 100-fold was used to measure picomole quantities of ethane in exhaled breath of eight recipients undergoing human orthotopic liver transplantation.

RESULTS

Ethane production correlated closely with the specific events of liver transplantation including the initial reperfusion of the allografts. In every case a twofold to threefold increase in ethane production was superimposed on a stable baseline immediately after reestablishment of portal vein blood flow through the donor liver.

CONCLUSIONS

Ethane production was interpreted as evidence of hepatic lipid peroxidation, presumably mediated by toxic metabolites of oxygen occurring at reperfusion. This noninvasive approach allowed localization of the time point at which lipid peroxidation occurred and may facilitate quantification of lipid peroxidation mediated by free radicals and other toxic oxygen metabolites during operation.

Promoting first trimester prenatal classes: a survey

In June 1990, 436 women and their spouses attending prenatal classes in the Ottawa-Carleton region completed a self-administered questionnaire to identify use of and interest in first trimester prenatal classes, and possible contact points with women to encourage early prenatal class attendance. Only 23% of the women had attended classes during the first trimester, but another 39% said they would have been interested. Two major categories of deterrents to early prenatal class attendance were found: 1) low level of public knowledge about availability and usefulness and 2) low physician patient referral. Most (89.4%) women went to their physician early in pregnancy, and many (45.7%) found out they were pregnant through the drug store. Suggested approaches to promoting first trimester attendance at prenatal classes include public awareness campaigns through pharmacies, the workplace and in the general community, and education programs for physicians about the importance of referral to early classes.