Prevalence of delirium in a geriatric convalescence hospitalization unit: patient's clinical characteristics and risk precipitating factor analysis

The aim was to evaluate the prevalence of delirium among patients discharged from an acute care hospital and admitted to a geriatric convalescence unit (GCU), and to analyze patient's characteristics and risk precipitating factors. Sixty-eight patients were analyzed during a 2-week period. The confusion assessment method (CAM) was used to detect delirium. The precipitating factors evaluated were: major surgery-intensive care unit(ICU) stay, pulmonary and heart failure, acute infections, metabolic disorders/anemia,psychoactive medications, other drugs, severe pain, changing environmental influences and others. According to CAM, fifteen patients presented delirium (22%), and in 14 of them(93.3 %) the delirium was developed before admission at GCU. The precipitating factors in the studied population were the following: changing environmental influences in 66 patients(97%) (15 with delirium and 51 without delirium); other drugs 56 (82.3 %) (11 vs. 45);others 56 (82.3%) (9 vs. 24); psychoactive medications 50 (73.5%) (12 vs. 38); acute infections 48 (70.5 %) (13 vs. 35); metabolic disorders/anemia 40 (58.8 %) (9 vs. 31); major surgery-ICU stay 28 (41 .1%) (8 vs. 20); severe pain 26 (38.2%) (6 vs. 20); pulmonary and heart failure 22 (32.3%) (5 vs. 17). The univariant analysis showed that, none of the precipitating factors studied was significantly related to delirium. Seventy-two patients (91.1%) had simultaneously >3 precipitating factors. There were 16 patients with >6 precipitating factors, 7 of 15 with delirium and 9 of the 53 without delirium (46.6 % vs 16.9 %) (p < 0.05). The prevalence of delirium has been 22 %. Most of the patients had developed delirium before the admission at GCU. A high proportion of patients had >3 precipitating factors. In the study the presence of > 6 precipitating factors simultaneously has been significantly related to delirium.

Liquid formulation of the biocontrol agent Candida sake by modifying water activity or adding protectants

AIMS

To evaluate the effect of modification of water activity (aw) and the addition of protective substances in the preservation medium of liquid formulations of the biocontrol agent Candida sake stored at 4 and 20 degrees C.

METHODS AND RESULTS

The aw of the preservation medium of C. sake was modified from 0.72 to 0.95 by adding glycerol or polyethylene glycol (PEG). Moreover, several protectant substances at different concentrations were evaluated. Modification of lower aw-levels (0.721-0.901) with glycerol did not maintain the viability of the yeast cells. Higher aw-levels (0.93-0.95) with either glycerol or PEG improved the viability but not at acceptable viability levels. C. sake cells maintained viabilities >60% when sugars, such as trehalose, and polyols, such as glycerol and PEG were used as protectants in liquid formulations. Moreover, liquid formulations of C. sake stored at 4 degrees C showed higher number of viable counts than at 20 degrees C. When different sugars were tested, all of them, except 10% fructose, resulted in a viability higher than 50% of the C. sake formulations. Biocontrol of liquid formulation treatments was similar to fresh cells in controlling Penicillium expansum on wounded apples.

CONCLUSIONS

Sugars such as lactose and trehalose could be considered as good protectants in order to obtain liquid formulations of C. sake cells as they maintain the viability >70% for 4 months at 4 degrees C.

SIGNIFICANCE AND IMPACT OF STUDY

This study shows that a suitable liquid formulation for commercial application can be produced with high viability and conservation of biocontrol efficacy. Moreover, if 10% lactose is the protectant used in the formulation, the economic costs would not be limiting for industrial production.

Phase III randomized pilot study comparing interferon alpha-2b in combination with radiation therapy versus radiation therapy alone in patients with stage III-B carcinoma of the cervix

This randomized pilot study was designed to determine whether the addition of interferon alpha-2b to standard radiation therapy offered an advantage in loco-regional control and survival over radiation therapy alone in a homogeneous group of patients with stage IIIB carcinoma of the cervix. Thirty-six patients were treated with a combination of interferon alpha-2b plus radiation therapy, and 38 patients were treated with radiation therapy alone. Patients with evidence of ureteral obstruction were excluded from the study. Evaluation of loco-regional response was determined by pelvic examination, cervical cytology, biopsies and CT scans when indicated. Survival time was measured from initiation of treatment to date of death or last follow-up. Patient characteristics were comparable between both study arms. The objective complete response rate was 67% in the combined therapy group and 55% in the radiation alone group (P = 0.454). With a median follow-up of 17 months for all patients and 31 months for live patients, 50% of the combined group survived vs. 39.5% of the radiation alone group (P = 0.424). We conclude that the addition of interferon alpha-2b to standard radiation therapy did not significantly improve loco-regional response or survival, although such a trend was noted. We encourage the design of a larger randomized study with sufficient power to detect meaningful differences to prove whether the tendency observed in the present investigation holds any promise to improve the outcome of these patients.

Phase III randomized pilot study comparing interferon α- 2b in combination with radiation therapy versus radiation therapy alone in patients with stage III-B carcinoma of the cervix

This randomized pilot study was designed to determine whether the addition of interferon α-2b to standard radiation therapy offered an advantage in loco-regional control and survival over radiation therapy alone in a homogeneous group of patients with stage IIIB carcinoma of the cervix. Thirty-six patients were treated with a combination of interferon α-2b plus radiation therapy, and 38 patients were treated with radiation therapy alone. Patients with evidence of ureteral obstruction were excluded from the study. Evaluation of loco-regional response was determined by pelvic examination, cervical cytology, biopsies and CT scans when indicated. Survival time was measured from initiation of treatment to date of death or last follow-up. Patient characteristics were comparable between both study arms. The objective complete response rate was 67% in the combined therapy group and 55% in the radiation alone group (P = 0.454). With a median follow-up of 17 months for all patients and 31 months for live patients, 50% of the combined group survived vs. 39.5% of the radiation alone group (P = 0.424). We conclude that the addition of interferon α-2b to standard radiation therapy did not significantly improve loco-regional response or survival, although such a trend was noted. We encourage the design of a larger randomized study with sufficient power to detect meaningful differences to prove whether the tendency observed in the present investigation holds any promise to improve the outcome of these patients.

Six years of experience in laparoscopic surgery of esophageal achalasia

BACKGROUND

We show the experience of 6 years in laparoscopic surgical therapy of esophageal achalasia, performing of the Heller-Dor or Heller-Toupet operation, with particular regard to the technical aspect.

METHODS

One hundred and ten laparoscopic interventions were done between November 1995 and December 2001. We studied operative time in hiatus approach, esophagocardiomyotomy, transoperative endoscopy, and anti-reflux procedure. We also analyzed the relation between complications and clinical evolution of disease with clinical stage.

RESULTS

The mean surgical time of the intervention is 138 min, and it is significantly increased by transoperative endoscopic control; conversion to open surgery was not necessary. Clinical results are classified as excellent in 103 patients. Morbidity was 6%.

CONCLUSION

This surgical procedure is a first line in the treatment of esophageal achalasia. It is necessary to have special care in early diagnostic cases to avoid electrosurgical injury.

Antinerve growth factor treatment prevents intestinal dysmotility in Trichinella spiralis-infected rats

Nerve growth factor (NGF) could be involved in the development of hyperalgesia as well as in nervous remodeling consequence of inflammation. Both dysmotility and increase of visceral sensitivity have been described in functional gastrointestinal disorders such as irritable bowel syndrome. Trichinella spiralis-infected rats show an exacerbated spontaneous motility and a significant increase of the excitatory response to cholecystokinin (CCK), both associated with a reversible inflammatory process and the hypertrophy of the muscle layers. In this study we determined the intestinal expression of NGF mRNA by polymerase chain reaction and NGF by enzyme-linked immunosorbent assay. We implanted serosal strain gauge transducers on duodenum, jejunum, and ileum of anesthetized Sprague-Dawley rats to record circular muscle contractions. The experimental protocol included the evaluation of intestinal spontaneous motor activity (SMA), the response to CCK-8, and the ascending contraction induced by electrical mucosal stimulation. This protocol was performed in healthy and infected nontreated rats, in healthy rats with an NGF antibody treatment (1.6 mg/rat i.p.), and in infected rats with the same treatment applied at 0 or 3 days postinfection. NGF and NGF mRNA levels in the bowel were increased during inflammation. Although anti-NGF treatments did not prevent or reverse inflammatory response, the treatment was effective in preventing the motor alterations induced by the T. spiralis infection, i.e., inhibited increased SMA, reversed altered response to CCK, and reversed in part exacerbated response to electrical stimulation.

Effect of package and storage conditions on viability and efficacy of the freeze-dried biocontrol agent Pantoea agglomerans strain CPA-2

AIMS

To reduce concentrations of protective and rehydrating media and to evaluate the effect of storage temperature, packaging and atmosphere conditions on the stability of freeze-dried Pantoea agglomerans cells. Efficacy against Penicillium digitatum of freeze-dried cells in orange fruits was also evaluated.

METHODS AND RESULTS

Several concentrations of protective and rehydration media were tested to reduce processing costs. Freeze-dried cells were packed in glass vials or plastic bags under vacuum or nitrogen conditions at 4 and 25 degrees C. After 1 and 3 months, efficacy of freeze-dried P. agglomerans against P. digitatum was tested.

CONCLUSIONS

The results indicate that it is possible to reduce the concentration of non-fat skimmed milk as a rehydration medium from 10% to 1%, maintaining viabilities of 100%. Moreover, freeze-dried cells could be stored in glass vials or in high barrier plastic bags at 4 degrees C for 3 months while maintaining high viabilities and efficacy against P. digitatum.

SIGNIFICANCE AND IMPACT OF THE STUDY

The major obstacle in the commercialization of biocontrol products is the development of a shelf-stable formulated product that retains biocontrol activity at a level similar to that of fresh cells. This study suggests that it is possible to maintain viability and efficacy of freeze-dried P. agglomerans cells for at least 3 months.

Mast cells induce upregulation of P-selectin and intercellular adhesion molecule 1 on carotid endothelial cells in a new in vitro model of mast cell to endothelial cell communication

It is suggested that mast cells contribute to cell recruitment in inflammation through the upregulation of endothelial adhesion molecules. P-selectin and intercellular adhesion molecule(ICAM)-1 are two key adhesion molecules that have been associated indirectly with mast cell activity. The canine C2 mastocytoma cell line and primary cultures of canine carotid endothelial cells were used to establish a new in vitro model to help study the interaction between mast cells and endothelial cells. Carotid endothelial cells were incubated with mast cell mediators to uncover their effect on endothelial ICAM-1 and P-selectin expression. To assess the relative contributions of tumour necrosis factor (TNF)-alpha and histamine to such effect, an H1 antihistamine and a TNF-alpha blocking antibody were used. Prior to activation by mast cell mediators, P-selectin was expressed only within the cytoplasm, and ICAM-1 was constitutively expressed on the surface of the canine carotid endothelial cells. Both adhesion molecules were enhanced significantly and strongly upon mast cell activation at various time points. Unstored TNF-alpha was fully responsible for ICAM-1 upregulation. P-selectin was up-regulated by both preformed and newly synthesized mast cell mediators, but neither histamine nor TNF-alpha accounted for such an effect. Therefore,a new model is proposed in which the pro-inflammatory effect of mast cells on endothelial cells can be studied in vitro. In this model, it has been demonstrated that only TNF-alpha accounts for the overexpression of ICAM-1 induced by mast cells, and that mast cells up-regulate P-selectin expression through a histamine-independent mechanism.

Human Raphe Magnus Nucleus: a morphometric Golgi-Cox study with emphasis on sex differences

The number and proportion of neurons according to their type and size in the Raphe Magnus Nucleus stained by the Golgi-Cox and Nissl methods were compared in male and female infants. Four female/male pairs aged from 2 to 150 days were studied. While females showed more neurons than males, males showed a higher proportion of large multipolar (more than 40 microm) and fusiform neurons (more than 20 microm) but not of ovoid neurons (more than 15 microm). These differences varied according to the type of cells and age of infants. Some of these results are similar to those found in the human Median Raphe Nucleus with the same methods.

Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium

The DRS-R-98, a 16-item clinician-rated scale with 13 severity items and 3 diagnostic items, was validated against the Cognitive Test for Delirium (CTD), Clinical Global Impression scale (CGI), and Delirium Rating Scale (DRS) among five diagnostic groups (N=68): delirium, dementia, depression, schizophrenia, and other. Mean and median DRS-R-98 scores significantly (P<0.001) distinguished delirium from each other group. DRS-R-98 total scores correlated highly with DRS, CTD, and CGI scores. Interrater reliability and internal consistency were very high. Cutoff scores for delirium are recommended based on ROC analyses (sensitivity and specificity ranges: total, 91%-100% and 85%-100%; severity, 86%-100% and 77%-93%, respectively, depending on the cutoffs or comparison groups chosen). The DRS-R-98 is a valid measure of delirium severity over a broad range of symptoms and is a useful diagnostic and assessment tool. The DRS-R-98 is ideal for longitudinal studies.

Heliotropium huascoense resin exudate: chemical constituents and defensive properties

From the resinous exudate of Heliotropium huascoense a new compound, rel-(8R,9R)-carrizaloic acid, (1) (3-[rel-(8R,9R-9-hydroxy-9,13,13-trimethyl-12-oxo-10-cyclohexenyl)methyl]-4-methoxybenzoic acid), and three known flavonoids, [3-methylgalangin, 3,7-dimethylgalangin, and (-)-alpinone] have been isolated. The structure of 1 was determined by spectral and chemical methods. Several plant defensive properties of 1 (insecticidal and antifungal) have been evaluated.

Worsening of post-traumatic stress disorder symptoms with cognitive decline: case series

We present three cases of post-traumatic stress disorder (PTSD) symptoms associated with cognitive decline. Patient age ranged from 57 to 70 years old and all patients had war-related PTSD. In each case, the patient had a history of PTSD that was under fairly good control until the onset of cognitive impairment due to Alzheimer's disease or vascular or alcohol-related dementia. These cases suggest that neurodegeneration of memory pathways may disinhibit symptoms of PTSD.

[Fever of unknown origin in HIV positive patients]

OBJECTIVES

To describe the clinical presentation of FUO in patients infected with HIV and to asses the diagnostic usefulness in this population of several test usually recommended in the study of FUO.

PATIENTS AND METHODS

We studied the clinical charts of all patients with HIV that required admission to our Hospital during a 23-month period. FUO was defined according to Petersdorf's modified criteria. Fifty-four patients fulfilled study criteria during the entry period.

RESULTS

A cause of fever was identified for 48 patients (89%). Tuberculosis, disseminated atypical mycobacteriosis and Leishmaniasis can explain 68% of them. Examination of bone marrow aspirates, lymph node aspirates and biopsy, and culture of clinical specimens for mycobacteria were the procedures with the highest diagnostic yield.

CONCLUSIONS

Mycobacterial infection should be considered as a first-line diagnosis in HIV-patients with FUO. It is possible to predict the diagnosis of tuberculosis infection with a high level of confidence (90.5%) through a logistic regression model based on easily obtainable parameters.

Cell-volume changes and ion conductances in amphibian gallbladder epithelium

Cell-volume regulation after hyposmotic swelling is common in transporting epithelial cells. Acute regulatory volume decrease is mediated in several cell types by loss of K(+) and Cl(-) via channels either activated by the swelling phenomenon or active in the cell membrane prior to swelling. In the last two decades, it has become clear that many features of cell-volume regulation mediated by ion fluxes vary considerably among cell types. In some instances, the ion channel activation, although demonstrable, is insufficient to account, on the basis of ion fluxes, for the measured cell volume changes. Here we review the case of a salt-transporting epithelium in which hyposmotic cell swelling activates plasma membrane K(+) channels, but at the same time inhibits Cl(-) channels, thus preventing an acute volume-regulatory response. The sequence of events following cell swelling appears to be as follows: K(+) channels are activated by membrane stretch, the cell membrane hyperpolarizes (the voltage moves closer to the K(+) equilibrium potential) and this hyperpolarization reduces the Cl(-) conductance, likely by a reduction in open probability of voltage-sensitive Cl(-) channels. The significance of this phenomenon may be related to the preservation of intracellular Cl(-) rather than cell volume, or to a physiological 'need' to prevent shrinkage of cells stimulated by hormones or other mediators.

Translaparoscopic jejunal approach for benign stricture of Roux-en-Y hepaticojejunostomy

Although the Roux-en-Y hepaticojejunostomy is the most common surgical procedure for the treatment of bile duct strictures, providing durable long-term results in most patients, when a stricture is present, the management is more difficult, and a reoperation generally will be proposed. However, balloon dilation and endoscopic stenting using the percutaneous transhepatic or transjejunal approach under fluoroscopic guidance have been suggested as the first step or even as definitive management in treating these patients. We present a case report of a patient with a benign biliary stricture as a consequence of a Roux-en-Y hepaticojejunostomy, who was managed through a translaparoscopic jejunal approach because of an unfixed Roux-en-Y loop. In conclusion, we recommend this strategy as the first step for managing the restricture of Roux-en-Y hepaticojejunostomy in patients with an unfixed Roux-en-Y loop.

[Prevalence of risk for mental disorders among undergraduate medical students at the Medical School of the Catholic University of Chile]

BACKGROUND

Stress caused by the high physical, intellectual and emotional demands imposed to medical students, renders them specially susceptible to the development of mental disorders.

AIM

To assess the prevalence of risk for mental disorders among undergraduate students at the Medical School of the Catholic University of Chile.

MATERIAL AND METHODS

The Twelve Item General Health Questionnaire (GHQ 12) was voluntarily answered by medical students from the first to the fifth year.

RESULTS

Sixty eight percent of the total population (305 students) answered the questionnaire. Forty one percent of students were at risk, defined as scoring five or more points in the GHQ 12. The average score was 3.9 +/- 2.2. First year students had a higher score than fourth year students (4.6 +/- 2.2 and 3.4 +/- 2.1 points respectively, p < 0.05). No gender differences were observed.

CONCLUSIONS

Our results are similar to those of other publications concerning psychiatric risk among medical students.

Mutation screening of the Wolfram syndrome gene in psychiatric patients

Wolfram syndrome, a rare autosomal recessive neurodegenerative disorder, was originally described as a combination of familial juvenile-onset diabetes mellitus and optic atrophy. It was later demonstrated that Wolfram syndrome patients were highly prone to psychiatric disorders. Mutations in exon 8 of the Wolfram syndrome gene account for 88% of the patients with Wolfram syndrome. To examine whether the gene responsible for causing Wolfram syndrome is involved in psychiatric disorders, we screened exon 8 of the Wolfram syndrome gene for mutations in 119 patients with schizophrenia, one patient with schizoaffective disorder, 12 patients with bipolar disorder and 15 patients with major depression, using sequence analysis. In Wolfram syndrome patients, this gene has been shown to have primarily nonsense or frameshift mutations, which would result in a premature truncation of the protein. None of the psychiatric patients screened in this study carried these types of mutations. We identified, however, 24 new variations whose significance remains to be determined.

Sexual dimorphism in number and proportion of neurons in the human median raphe nucleus

The number and proportion of neurons in the median raphe nuclei stained by the Golgy-Cox and Nissl methods was compared in males and females infants. When subjects are matched by age and cause of death the number and proportion of fusiform, ovoid and multipolar cells differs significantly between sexes at different ages.