Comparison of thoracic and lumbar epidural infusions of bupivacaine and fentanyl for post-thoracotomy analgesia

Epidural analgesia, via either a thoracic or lumbar route, is commonly used to provide postoperative analgesia following thoracotomy for pulmonary resection, but little data indicate which location is better in terms of postoperative analgesia, side effects, or associated complications. In this study, 45 patients, who were scheduled to have epidural analgesia and undergo a lateral thoracotomy, were randomized to receive either a thoracic or a lumbar catheter. Pain assessments and routine clinical data were recorded to determine if either thoracic or lumbar epidural catheters provided superior analgesia, fewer side effects, or fewer complications. This study found no statistical difference in pain relief or side effects between lumbar and thoracic epidural analgesia for post-thoracotomy pain. An increased infusion rate (6.4 +/- 1.9 v 5.1 +/- 1.4 mL/h, P = 0.02) was required in the lumbar group to achieve equivalent analgesic levels.

Intimal sarcoma of the superior vena cava

A case of superior vena cava syndrome caused by a primary intimal sarcoma of the superior vena cava is described. The known causes of superior vena caval obstruction are discussed, together with the difficulties in identifying the underlying lesion. The possibility of a primary superior vena caval neoplasm as a cause of superior vena caval obstruction should be considered in patients presenting with superior vena caval syndrome.

A new theory of human accommodation: cilio-zonular compression of the lens equator

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Ideational fluency in Parkinson's disease

Recent research on Parkinson's disease (PD) suggests that executive functions are impaired but that visuospatial functions may be spared. This dissociation has been attributed to dysfunction in ascending dopaminergic pathways affecting the prefrontal cortex. We investigated these ideas in a sample of intellectually intact patients with idiopathic, optimally treated PD (N = 20) and in spouse controls (N = 15); the groups were divided into young (age < 60) and old subgroups, each comparable on education, vocabulary level, and Mini-Mental State scores. Six tasks were selected from a set of factor-referenced cognitive tests to measure three abilities: (1) ideational fluency (ability to generate ideas), (2) flexibility of use (ability to shift mental set), and (3) spatial orientation (ability to perceive spatial patterns). PD patients were impaired only on the ideational fluency factor (p = .01). An age-related deficit was seen on the spatial factor (p < .05) with a trend on the flexibility factor (.05 < p < .10). No interactions were significant. The findings suggest that when age and verbal intelligence are controlled, PD patients show no deficit on purely spatial tasks; in contrast, patients seem less able to generate ideas though capable of shifting from one idea to another.

Ondansetron does not affect alfentanil-induced ventilatory depression or sedation

Ondansetron is a selective 5-hydroxytryptamine type 3 receptor antagonist effective as an antiemetic in patients experiencing post-operative or cancer chemotherapy-induced nausea and vomiting. Currently, no information is available regarding the interaction of ondansetron with opioids, although a serotonin antagonist might be expected to modify some opioid actions. This study was designed to measure the effects of ondansetron on alfentanil-induced ventilatory depression and sedation in healthy male volunteers. Ventilatory drive (measured as the end-tidal CO2 necessary to produce a minute ventilation of 15 l/min) was determined in 29 subjects using a modification of the Read rebreathing technique. Sedation was measured by asking the subjects to complete visual analog scales. Alfentanil was administered as a bolus (5 micrograms/kg) followed by a continuous infusion (0.25-0.75 micrograms.kg-1.min-1) for at least 90 min. Study medication (ondansetron 8 or 16 mg or vehicle placebo) was then administered in a randomized, double-blind manner, and the alfentanil was infused for an additional 15 min. Measurements of ventilatory drive and sedation were made at baseline, during alfentanil infusion, after study medication, and at 30-min intervals after alfentanil was discontinued. Alfentanil produced significant ventilatory depression (P less than 0.001) and sedation (P less than 0.001) in all three groups. Neither placebo nor ondansetron produced further change in the intensity of either alfentanil effect. After discontinuation of the opioid, both ventilatory depression and sedation decreased, and the rate of recovery was not significantly different between groups. The data indicate that alfentanil-induced sedation and ventilatory depression are not significantly affected by the subsequent administration of ondansetron.

Clinical correlates of high signal lesions on magnetic resonance imaging in Alzheimer's disease

The pathophysiology and clinical significance of high signal lesions, visualized on magnetic resonance imaging (MRI) in patients with Alzheimer's disease (AD), remain controversial. Since they are known to correlate with vascular disease and vascular risk factors, we reviewed the clinical correlates of periventricular high signal (PVH) and subcortical white matter lesions (WML) in a sample of 106 patients with probable AD, excluding persons with treated vascular risk factors or symptomatic cerebrovascular and cardiovascular disease. Grade 2 PVH were seen in 26 (25%) and scattered WML were identified in 29 (18%). PHV were associated with advancing age and gait disturbance. WML were associated with gait disturbance and incontinence. Neither radiologic finding was related to dementia severity. The findings suggest that these lesions are common in patients with AD even when those with evidence of cerebrovascular disease are excluded; their presence, therefore, should not preclude a diagnosis of AD. Additionally, the data suggest that HSL on MRI may be one of many risk factors associated with functional disability in persons with probable AD.

Nuisance parameters in the assessment of noncognitive manifestations of dementia

Measures of noncognitive disturbances in dementia typically rely on ratings by informants. In this study, method variance in measures of affect, behavior, and functional competence was evaluated by comparing ratings from 2 types of informants (spouse vs. child) in patients with probable Alzheimer's disease. No differences were observed on 5 variables; for 2 measures of behavior disturbance and 1 measure of functional disability, ratings obtained from child informants were significantly higher than spouse ratings for patients at comparable levels of dementia severity. Although the effect of the rater dimension was relatively small and selective, the findings suggest the need for further research on potential sources of bias in the ratings of noncognitive features of the dementia syndrome.

Nuisance parameters in the assessment of noncognitive manifestations of dementia

Measures of noncognitive disturbances in dementia typically rely on ratings by informants. In this study, method variance in measures of affect, behavior, and functional competence was evaluated by comparing ratings from 2 types of informants (spouse vs. child) in patients with probable Alzheimer's disease. No differences were observed on 5 variables; for 2 measures of behavior disturbance and 1 measure of functional disability, ratings obtained from child informants were significantly higher than spouse ratings for patients at comparable levels of dementia severity. Although the effect of the rater dimension was relatively small and selective, the findings suggest the need for further research on potential sources of bias in the ratings of noncognitive features of the dementia syndrome.

Predictors of behavioral disturbance in Alzheimer's disease

The relationship of behavioral disturbances in Alzheimer's disease to disease severity, age at onset, and the presence of extrapyramidal signs was investigated in three studies. Five categories of behavior disturbance were ascertained through structured interview with the patient's primary caregiver: apathy, agitation, psychotic symptoms, disinhibition, and irritability. In Study 1, measures of disease severity accounted for 42% of the variance in the Apathy scale but less than 20% of the variance in the remaining scales. In Study 2, the presence of extrapyramidal signs was associated with increased Apathy and moderated the association between disease severity and the Psychotic Symptoms and Irritability scales. In Study 3, age at onset was associated with the Agitation scale and moderated the association between disease severity and the Apathy, Psychotic Symptoms, and Irritability scales. The findings are discussed in terms of the clinical heterogeneity within Alzheimer's disease, the possible biological bases of these behavioral disturbances, and the psychometric issues pertinent to their measurement.

Cessation of driving and unsafe motor vehicle operation by dementia patients

We surveyed 522 consecutive patients from a dementia clinic to assess duration of driving after disease onset and instances of unsafe motor vehicle operation in the preceding 6 months. Among the 333 patients licensed to drive at the onset of dementia, the median duration of driving after onset was 28.6 months. Patients with a clinical diagnosis of Alzheimer's disease drove significantly longer than those with other dementia syndromes. Of the 93 patients still driving at the time of the survey, approximately one third were reported to have had at least one form of unsafe motor vehicle operation in the past 6 months, including 21 patients with motor vehicle accidents. Motor vehicle accidents were associated with use of prescription medications with sedative properties and with lower subjective ratings of the patient's driving ability by the informant.

Hallucinations and associated factors in Alzheimer's disease

In a consecutive sample of 230 community-dwelling patients with probable Alzheimer's disease, a structured interview yielded evidence of current hallucinations in 29.1% and misperceptions in another 11.3%. Visual and auditory modalities were similarly represented in apparent hallucinations. Hallucinations prior to the current monitoring period were rare among patients with misperceptions or with no perceptual abnormality. The probability of hallucinations was associated with the severity of cognitive dysfunction, the degree of other behavioral disturbances, and the presence of extrapyramidal signs. A logistic regression model predicting hallucinations based on these diverse clinical features accurately classified 87.0% of the sample.

Maze learning in Alzheimer's disease

Alzheimer's disease (AD) patients and normal elderly controls performed a block of 10 trials on a finger maze, followed by a 45-min period during which verbal learning measures were administered. Subjects then performed an additional 10 trials on the original maze, followed by 10 trials on a new maze. The AD patients and a subset of control subjects decreased mean completion time across Blocks 1 and 2, suggesting skill acquisition. Mean time on Block 3 was significantly less than mean time on Block 1, suggesting skill generalization. A subset of controls did not show the above pattern. The results of this study suggest that AD patients are able to acquire and generalize a cognitively mediated perceptual-motor skill.

Clinical diagnosis of Binswanger's disease

To aid in the prospective study of Binswanger's disease, a poorly understood form of vascular dementia, a standardised criteria for its antemortem diagnosis was proposed. These criteria include dementia, bilateral radiological abnormalities on computed tomography (CT) or magnetic resonance imaging (MRI), and at least two of the following three clinical findings: A) a vascular risk factor or evidence of systemic vascular disease; B) evidence of focal cerebrovascular disease; and C) evidence of "subcortical" cerebral dysfunction. These criteria were validated in two ways. First, by retrospectively applying them to a series of 30 demented patients with various pathological diagnoses. Second, by prospectively applying them to a series of 184 patients with clinically typical Alzheimer's disease. The sensitivity and specificity of the criteria appear adequate for use in clinical research.

Preserved word-stem-completion priming of semantically encoded information in Alzheimer's disease

Alzheimer's disease (AD) patients and normal elderly control subjects completed 80 standardized sentence frames with single words, yielding a measure of semantic memory. Memory for best fit sentence endings was then tested either explicitly, with a forced-choice recognition task, or implicitly, with a word-stem-completion task. The patients completed fewer sentences with best fit word endings than did the control subjects. Explicit retention was markedly defective in the AD group, but word-stem completion was normal. The preserved word-stem completion in AD is discussed in terms of encoding operations and transfer-appropriate processing.

Adrenal medullary transplant to the striatum of patients with advanced Parkinson's disease: 1-year motor and psychomotor data

We studied motor and psychomotor changes over 1 year after surgery in 7 patients with severe idiopathic Parkinson's disease (PD) who underwent intrastriatal autologous adrenal medulla transplant. Significant clinical improvements were present 1 year after surgery and primarily involved increased quantity of "on" time and increased quality of "off" time: "on" time increased from a mean 60.7% of the waking day to 82.7%, and "off" function improved. In contrast, although "on" function also improved, statistically significant improvement occurred in only 1 measure, the Unified Parkinson's Disease Rating Scale activities of daily living subscale. Medications did not change, and motor fluctuations persisted. Improvement began several weeks after surgery, was maximal at 4 to 6 months, and was sustained thereafter. There was significant group improvement in quality of life measures of sleep and rest, social isolation, and ambulation. One patient had severe, recurrent depression postoperatively. The efficacy of adrenal transplant surgery is not transient, and specific functional improvements can be prolonged.

Adrenocorticotrophin-induced hypertension in the rat: haemodynamic, metabolic and morphological characteristics

Adrenocorticotrophin (ACTH) administration has been systematically studied in man and sheep. It raises systolic blood pressure (SBP) in the rat, but this has been little studied. ACTH was injected once daily at 0.5 mg/kg for 12 days in male Sprague-Dawley rats (n = 19). Sham-injected animals were studied in parallel (n = 15). ACTH increased SBP from 94 +/- 4 to 121 +/- 4 mmHg (P less than 0.001), significantly greater (P less than 0.02) than sham injection. The SBP of ACTH-treated rats was significantly higher than that of sham-injected rats when the same animals were measured by both the tail-cuff method (ACTH, 126 +/- 3 mmHg; sham, 99 +/- 3 mmHg) and direct arterial cannulation (ACTH, 137 +/- 2 mmHg; sham, 123 +/- 3 mmHg): P less than 0.005 and P less than 0.001, respectively. There was a loss of body weight, and increased water intake and urine output in ACTH-treated animals compared with both control (P less than 0.001) and sham treatments (P less than 0.02). ACTH increased plasma [Na] (sham, 140 +/- 1 mmol/l; ACTH, 145 +/- 1 mmol/l; P less than 0.001) and urinary Na excretion compared with control (P less than 0.01) and sham injection (P less than 0.05), and also decreased plasma [K] (sham, 4.6 +/- 0.2 mmol/l; ACTH, 3.3 +/- 0.8 mmol/l; P less than 0.01) and increased urinary K excretion (P less than 0.01) compared with control. SBP in adrenalectomized animals (n = 10) was unchanged by ACTH. ACTH increased adrenal, renal, cardiac and brain weights compared with sham injection (P less than 0.05). There were no significant changes in vascular morphology, although ACTH treatment increased glomerular epithelial cell droplets and abolished the adrenal zona glomerulosa.

Preserved word-stem-completion priming of semantically encoded information in Alzheimer's disease

Alzheimer's disease (AD) patients and normal elderly control subjects completed 80 standardized sentence frames with single words, yielding a measure of semantic memory. Memory for best fit sentence endings was then tested either explicitly, with a forced-choice recognition task, or implicitly, with a word-stem-completion task. The patients completed fewer sentences with best fit word endings than did the control subjects. Explicit retention was markedly defective in the AD group, but word-stem completion was normal. The preserved word-stem completion in AD is discussed in terms of encoding operations and transfer-appropriate processing.

Involuntary smoking in Savannah's restaurants

A survey of Savannah area restaurants was conducted to determine the frequency with which nonsmoking sections are provided. Only one in five restaurants in Savannah provide nonsmoking sections, and only one in 10 tables available for dining out are reserved for nonsmokers. Restaurants associated with a national corporation are more than four times as likely to reserve space for nonsmokers than those strictly locally owned. Pertinent attitudes of restaurant personnel are presented, as is a brief discussion of the issue of involuntary smoking.

Effect of digoxin and vasodilators on left ventricular function in aortic regurgitation

In order to assess the relative value of digoxin, nifedipine and hydralazine on left ventricular performance at rest and during exercise, we studied 10 men with moderately severe chronic aortic regurgitation using two-dimensional echocardiography. Digoxin after one month at therapeutic serum levels increased resting ejection fraction as compared to control [0.54 +/- 0.08 (SD) vs 0.47 +/- 0.08, respectively, P less than 0.03]. Ejection fraction decreased during exercise but the difference between digoxin and control was maintained. Stroke volume also was higher on digoxin than control at rest (93 +/- 15 vs 83 +/- 17 ml, P less than 0.02) and the larger stroke volume on digoxin was maintained during exercise. By contrast, stroke volume was reduced by one month of therapy with maximally tolerated nifedipine doses compared to control (74 +/- 8 vs 83 +/- 17 ml, P = 0.03) and this difference was maintained during exercise. Hydralazine in doses up to 225 mg/day for one month produced no significant changes in left ventricular performance compared to control at rest or during exercise. However, compared to digoxin ejection fraction at peak exercise was significantly less on hydralazine (0.39 +/- 0.9 vs 0.52 +/- 10, P less than 0.02). These data suggest that digoxin improved left ventricular performance and may be of benefit in the treatment of patients with chronic aortic regurgitation.

Psychogenic dysphagia and globus: reevaluation of 23 patients

Despite warnings against attributing dysphagia to psychological causes, the diagnoses of "psychogenic dysphagia" or "globus hystericus" have been previously applied to 13% of patients referred to the Johns Hopkins Swallowing Center. This paper reports the results of reevaluation of 23 patients previously diagnosed as having symptoms of psychogenic origin. The Swallowing Center evaluation documented an explanation for symptoms in 15 (65%). No cause of dysphagia could be documented in eight patients. All five patients with the "globus sensation" had a documentable abnormality of swallowing. Overall, nine patients had esophageal pathology, while six had pharyngeal disease. Five had structural lesions constricting the lumen, while 10 had motor dysfunction of either the pharynx or esophagus. Review of the referral records of these patients indicates the quality of prior evaluation for patients previously labeled as having a swallowing disorder of psychogenic origin is variable, and that once attribution of symptoms to psychogenic causes is made, the diagnosis is rarely reconsidered. We conclude that attribution of the diagnosis of psychogenic dysphagia should be made with caution, and only after thorough evaluation. Any change or progression of symptoms should prompt a careful re-evaluation.

Right upper lobe obstruction with right-sided double-lumen endobronchial tubes: A comparison of two tube types

Twenty-nine patients undergoing left thoracotomy consecutively were intubated with right-sided double-lumen endotracheal tubes in the conventional "blind" fashion. The first 20 received Leyland red-rubber double-lumen tubes, and the subsequent nine received Mallinckrodt polyvinylchloride double-lumen tubes. The patency of the right upper lobe bronchial orifice was then assessed by flexible fiberoptic bronchoscopy. Right upper lobe obstruction occurred in 89% of the polyvinylchloride tube intubations and in 10% of the red-rubber tube intubations.