Postprandial hypotension and orthostatic blood pressure responses in elderly Parkinson's disease patients.

OBJECTIVE: To investigate the change in systolic blood pressure (SBP) induced by meals and to compare their impact on the orthostatic SBP response in elderly Parkinson's disease with that in control patients. DESIGN: Ten elderly patients suffering from Parkinson's disease were compared with 10 age-matched elderly control patients. METHODS: The postprandial SBP change was measured by means of ambulatory blood pressure monitoring with the patient in the supine position. Orthostatic SBP responses were measured the next day by means of active standing and passive head-up tilting tests performed before and after the patients had their lunch. RESULTS: In Parkinson's disease patients, a postprandial SBP drop of 27 mmHg in the supine position was found compared with a drop of 8 mmHg in controls. In Parkinson's disease patients, that drop was moderately correlated to the orthostatic SBP responses and significantly correlated to the preprandial supine baseline SBP level. The orthostatic fall in SBP was greater with passive than with active standing and with both it was greater in Parkinson's disease patients than in the control subjects. The fall in orthostatic blood pressure was reduced by a previous meal. In contrast, there was no difference in orthostatic heart rate responses between the patients and the controls. CONCLUSIONS: Parkinson's disease patients demonstrated a significant postprandial drop in SBP and a tendency towards orthostatic hypotension, which was not worsened by the meal, probably owing to a stronger sympathetic activation. Postprandial supine SBP change and orthostatic SBP responses were only moderately associated in Parkinson's disease patients. In addition to autonomic dysfunction, an increased baseline SBP level might contribute to both phenomena.

Absence of significant bacteremia during urinary catheter manipulation in patients with chronic indwelling catheters.

The objective of this study was to quantify the microorganisms present in blood at urinary catheter removal and at reinsertion in patients with chronic indwelling urinary catheters. This was a prospective study during a 4-month period at a university-affiliated geriatric medical center. Our subjects were 33 patients with chronic indwelling urinary catheters and positive urinary cultures; the urinary catheter was usually changed once a month. A peripheral vein line was used for blood withdrawal and urinary cultures and quantitative blood cultures (Isolator) were performed during and shortly after urinary catheter removal and insertion. All patients had significant bacteriuria (greater than 10(5) cfu/mL) with an average of 2.3 microorganisms. Among the 46 sequential quantitative blood cultures performed, only two patients had bacteremia from the urinary source and at a very low concentration; one patient had 0.13 cfu/mL Str. faecalis in blood 5 minutes after removal of the urinary catheter, and the other 0.1 cfu/mL Proteus mirabilis 5 minutes after reinsertion of a new urinary catheter. None of the patients had any subjective or objective clinical problem during the 36 hours after the urinary manipulation. Clinical symptoms and bacteremia are rare events, and prophylactic antibiotics do not appear necessary during urinary catheter removal and reinsertion in elderly institutionalized patients. Further studies are necessary to identify risk factors in the rare instances of patients with bacteremia.

Effects of plant and animal lipids rich in docosenoic acids on the myocardium of Cynomolgus monkeys.

Cynomolgus monkeys (Macaca fascicularis) were fed diets containing 25% rapeseed oil (RSO), partially-hydrogenated herring oil (PHHO) or a 3:1 mixture of lard/corn oil as control (CON) for 4 months. The RSO contained approximately 25% of the fatty acids as erucic acid (cis-docos-13-enoic, 22:1w9) while the PHHO contained a similar concentration of mainly cetoleic acid (cis-docos-11-enoic, 22:1w11). The CON contained no 22:1 acids. The monkeys developed the expected myocardial lipidosis, somewhat more pronounced in the RSO than the PHHO group, but small foci of mononuclear cell infiltration, while infrequent, occurred in all three groups. Significant intergroup differences in biochemical or hematologic measurements of serum constituents were an increase in serum cholesterol concentration in the RSO group and an increase in serum glutamicoxaloacetic transaminase activity in both RSO and PHHO groups at certain intervals. The shorter proportion of M. fascicularis life span represented by this experiment may account for the absence of clear intergroup differences such as are reported in rats used in similar studies.

Acute spinal intradural extramedullary hematoma: a nonsurgical approach for spinal cord decompression.

The authors present the case of a 60-year old man with a spontaneous spinal intradural hematoma in the thoracic and lumbar region, which was caused by anticoagulant therapy and led to a severe progressive transverse lesion. After substitution of coagulation factors, a small catheter was inserted into the subarachnoid space via a lumbar puncture. By alternating irrigation and suction removal of the blood clot, restoration of the cerebrospinal fluid passage was possible along with a marked improvement in the neurological deficits. At 8 months' follow-up, the patient had completely recovered from the severe paraparesis and bladder dysfunction.

Reflex activity and axonal conduction in the L-7 spinal cord segment following experimental compression trauma.

In cats in which the spinal cord was transected at C-1, the exposed L-7 spinal cord segment was compressed with an electromagnetically driven rod applied to the dorsal surface of the segment. With the magnitude of compression constant at 3 mm, the cord was compressed for durations of 50 msec, 0.5 sec, or 1.0 sec. Polysynaptic reflex discharges integrated in the injured segment and action potentials conducted in dorsal column axons traversing the same region were electrophysiologically measured before, during, and for 41/2 hours after trauma. Structural changes were evaluated on frozen serial sections obtained both from compressed segments and from tissue adjacent to the injury. At a compression duration of 50 msec, the amplitude of evoked reflex activity decreased abruptly, and dorsal column axonal conduction was blocked for 1 minute following compression. This early-phase response was followed by partial recovery of both functions which persisted until the end of the experiment. Prolonging compression to 0.5 sec brought about a further decrease of polysynaptic reflex activity. Axonal conduction was also decreased, but not significantly. With compression lasting 1.0 sec, no significant changes in reflex discharges and axonal conduction occurred compared with those measured at 0.5 sec. Neither function was abolished, even after the longest compression time. Prolongation of compression significantly increased both the intensity and the spread of edema, whereas changes in hemorrhage were not significant. Thus, a plateau rather than a progressive increase in severity of functional and structural posttraumatic changes was reached by increasing the duration of compression. This injury model reduces the sources of variability found in other experimental compression trauma models and permits the quantitative assessment of basic spinal cord mechanisms and correlated histopathological changes in the same preparation following trauma.

Medical care and social support for the elderly in Switzerland: imbalance and mix.

Medicalization refers to the current practice of providing medical solutions to broad social problems facing the old. This approach is destined to bring about serious economic and sociocultural dilemmas in the coming decades due to the aging trends in Switzerland. On the one hand, additional bed requirements will double, really jeopardizing the present federal savings policy on health and welfare. On the other side, ignoring the specific needs of nearly 20% of the population (as the 65 and over age group are expected to reach in the year 2010), will provoke unwielding social/political tensions. Assigning medical answers to social needs is both expensive and inadequate. This proposition is illustrated by two aspects of Geneva's medical care system for the aged: At the University Geriatric Hospital a large proportion of the patients are admitted for purely social reasons ('home maintenance impossible'). The long term bed stays, medically unjustified, constrains the optimal functioning of this acute care and rehabilitation hospital. The prolonged length of institutionalization reduces the capacity of the elderly out-patients to carry on autonomously. This observation is confirmed by many Swiss medical and sociological surveys which reveal that institutionalization is rarely necessary or desirable in the 10 to 20 first years of post-retirement provided there is an adequate system of social and primary care services available. The drug prescription to those 65 and over consulting at the out-patient department of the Geneva University Medical Policlinic typically amounts to excessive prescription for women and especially of psychoactive drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart mitochondrial metabolism after feeding herring oil to rats and monkeys.

Heart mitochondrial oxidation of palmityl CoA and pyruvic acid was studied in rats and in the monkey Macaca fascicularis to determine the effects of feeding partially hydrogenated herring oil. Herring oil glycerides contain cetoleic acid (cis-11-docosenoic) which could have a similar effect to erucic acid (cis-13-docosenoic) in causing a rat cardiomyopathy. The initial rat heart mitochondrial response to dietary cetoleic acid (67% cis, 33% trans) was an in vitro decrease in palmityl CoA oxidation. Pronlonged feeding of cetoleic acid mixture was associated with a significant metabolic adaptation, increasing pyruvate and palmityl CoA oxidation above control levels. In vitro addition of cetoleyl CoA (pure cis isomer) stimulated pyruvate dehydrogenase activity, a possible response to decreased B-oxidation. There was no significant adaptive change in pyruvate or palmityl CoA use in monkeys after prolonged feeding of partially hydrogenated herring oil. Cetoleyl CoA was a good substrate for monkey heart carnitine acyl transferase even in the presence of palmityl CoA. These observations suggest that C22 fatty acids may be metabolized more rapidly in monkey heart than in rat heart. Metabolic differences argue against using the rat as an experimental model for studying possible cardiotoxic effects of docosenoic acids in primates.

The intraarterial route of drug delivery in the chemotherapy of malignant brain tumours.

This review is based on literature data and own experiences in 79 patients with malignant brain tumours using intraarterial delivery of cytostatic agents as adjuvant therapy. A survey is given of the pharmacological rationale of this therapeutic approach, of the drugs which have been used and of the related experimental and clinical experiences. Advantages and limitations are discussed and clinical conclusion drawn. Experience so far suggests that in anaplastic astrocytomas and oligodendrogliomas intraarterial ACNU might be as effective as intravenous BCNU against the tumours but causes less systemic side-effects.

Traumatic, spontaneous and postoperative CSF rhinorrhea.

CSF fistulas are a major complication of head injury but also occur spontaneously or symptomatically in connection with tumours of the skull base, empty sella syndrome, ethmoidal encephalomyelocele, intracranial hypertension or postoperatively in connection with operations on skull base tumours or ENT operations. Their main risk is the possibility of meningitis. The main clinical symptom is CSF leakage from the nose, but meningitis may be the first manifestation. Isotope cisternography and metrizamide CT cisternography are the most important methods for precise localization, sometimes also for verification of a suspected fistula. Most traumatic CSF fistulas of the frontal and ethmoidal region have to be treated operatively. The method of choice is the transfrontal approach and the closure of the fistula opening using a pedicled pericranial flap or fascia lata graft. Most sphenoidal fistulas have to be treated by packing the sphenoidal sinus with muscle. The treatment methods of the rare spontaneous and symptomatic CSF fistulas are also described. The results of operative treatment are satisfactory. About 6% recurrences, which as a rule can be cured by reoperation, and a mortality rate of about 1-3% seem to be an acceptable price for prevention of an otherwise unavoidable and oftenly deadly meningitis. Future efforts are necessary to improve the operative technique in order to reduce the incidence of anosmia. Our descriptions and advice are based not only on literature reports but also on our own experiences with a combined material of 237 cases operated on for rhinorrhea.

Acute effects of dexamethasone on normal and on posttraumatic spinal cord polysynaptic reflex activity and axonal conduction.

The effects of a single intravenous injection of a high dose of dexamethasone (4 mg/kg) on polysynaptic reflex activity and axonal conduction were measured for 5 hours in the intact and in the compression-injured L-7 spinal cord segment of high spinal cats. The segment was injured by a transient compression of preset degree and duration. In the uninjured preparation, dexamethasone administration significantly reduced polysynaptic reflex size for 2 hours. Axonal conduction was unaltered. One group of injured animals was given dexamethasone 30 minutes after trauma, whereas another was not treated. The acute posttraumatic changes in both parameters did not differ significantly in treated and untreated animals. Histopathologically, differences in the amount of segmental edema and hemorrhage between untreated and treated animals were not significant.

Increased functional vulnerability to acute compression injury of a spinal cord segment under barbiturate anesthesia.

Posttraumatic changes in polysynaptic reflex activity and axonal long-tract conduction were measured after transient compression of the L-7 spinal cord segment of cats, either made high spinal and unanesthetized or left intact under pentobarbital anesthesia. The severity of acute post-injury changes increased significantly in the anesthetized animals. Partial recovery and stabilization of functional deficits were observed in the spinal cat, but not in the anesthetized one. These findings suggest that, at least in the acute postinjury stage, pentobarbital anesthesia may enhance functional damages after experimental spinal cord compression.

Acute changes in somatosensory evoked potentials following graded experimental spinal cord compression.

Amplitude and latency of cortical somatosensory potentials evoked in cats by peripheral nerve stimulation were measured before, during, and for 5 hours after injury of spinal cord segment L-7 by a predetermined degree and duration of compression. An amplitude decrease, slight and transitory, was first observed after compression reduced the segmental cross section by 60%. After an 80% compression, amplitude reduction was initially larger and lasted longer, but recovered 2.5 hours after injury to a level that did not differ statistically from control values. After total (100%) compression, evoked responses disappeared abruptly and did not recover significantly. Latency was unaltered at all degrees of compression. Structural damage increased with the degree of compression. In this model, evoked potential changes neither reflect nor predict the magnitude of acute incomplete spinal cord injury.

The paradoxes of quality of life and its phenomenological approach.

Although evaluation scales for quality of life (QOL) represent considerable progress in medicine, clinical experience shows striking discrepancies between QOL as evaluated by caregivers and QOL from the patient's point of view. Such paradoxes of QOL are analyzed and discussed. Autonomy is universally advocated but may be denied, especially in the hospital setting, where caregivers, family members, and doctors act as a pressure group. Circumstances that deepen the contradictions in QOL assessment include (a) a high degree of patient dependence, (b) a professional judgement that a patient is incompetent (c) professional values being placed over a patient's values, (d) a multidisciplinary team acting as a pressure group, (e) a lack of effective communication with the patient, and (f) a determination to minimize the symptoms at evaluation. QOL is multidimensional, complex, difficult to measure in clinical practice, and sometimes paradoxical.

Is there a relationship between psychological well-being and patient-carers consensus? A clinical pilot study.

Does communication with terminal cancer patients about their disease influence their psychological well-being? The degree of patient-carer consensus about the disease was compared to psychological well-being related to acceptance of the disease, emotional state, and hope. These were evaluated and scored from 6 (good) to 0 (poor) through a semi-structured interview of 10 open-ended questions. Nineteen palliative care patients were studied, 18 of whom were suffering from advanced cancer. Overall, 57 interviews were conducted with the patients, staff nurses, and medical doctors. The answers of the carers (staff nurses and doctors) were compared to the patients' answers to determine the degree of consensus in terms of communication about disease, aim of treatment, and ultimate objective of hospitalization. The consensus between patients and carers was scored from 6 (satisfactory) to 0 (unsatisfactory). A significant positive correlation between the scores of consensus and those of psychological well-being (r = 0.90, p < 0.001) was found. These results suggest that good and truthful communication may improve patients' psychological well-being.

[Selective sacral nerve blockade in the treatment of detrusor hyperreflexia of the bladder]. / Die selektive Sakralnervenblockade zur Behandlung der Detrusorhyperreflexie der Harnblase.

Hyperreflexive detrusor instability causes severe impairment of the patients private and professional life. Involuntary detrusor contractions lead to incontinence. The results of previous pharmacological and operative therapeutic procedures are unsatisfactory. 22 cases with idiopathic hyperreflexive detrusor instability were cured by selective local anaesthesia of both sacral roots S3. The follow-up period ranges from 4 months to 2 years. In case with neurogenic detrusor instability local anaesthesia of the sacral roots S3 has no permanent effect. But in 4 such cases it was possible to reach continence by permanent interruption of the roots S3 using phenolglycerin injections. Unavoidably this success, which enables social rehabilitation, results in voiding disturbance of the bladder which makes voiding by manual bladder compression or even catheterization necessary.