Acute confusion in elderly medical patients.

The acute confusional state (delirium) is a common presentation for a wide variety of medical conditions in the elderly. This paper reports a prospective study of acute confusion in elderly people admitted to general medical services in two acute care hospitals in Edmonton, Alberta. Eighty patients were studied, ranging in age from 65-91. Acute confusion was seen in one-fourth of these patients, who tended to be older, more ill, more likely to have chronic cognitive impairment and a higher mortality rate. In patients admitted with confusion, infection and congestive heart failure predominated. In those who developed confusion after hospitalization, iatrogenic disease was more common. Confusion was a sensitive sign of physical illness, and its resolution accompanied recovery. A diagnosis of the cause of the confusion state could be made in 22 of 24 cases. These findings support the aggressive investigation and treatment of acute confusion in the elderly.

Iatrogenic Campylobacter pylori infection is a cause of epidemic achlorhydria.

On a number of occasions, there have been descriptions of epidemic achlorhydria in subjects undergoing repeated gastric secretory studies, typically as part of research protocols. We observed a case in a 37-yr-old healthy man undergoing weekly gastric analyses, along with endoscopy and gastric biopsy, as part of a research protocol studying gastric adaptation to aspirin. In the middle of the 2nd wk of aspirin administration, he developed severe nausea and epigastric discomfort. Aspirin administration was discontinued, but, as per protocol, gastric analyses, endoscopies, and biopsies were continued. Compared to the week preceding the acute illness, biochemical analyses showed a transient 7.4-fold increase in basal gastric acid, 3.6-fold increase in pepsin secretion, 8.8-fold increase in DNA loss, 5.6-fold increase in mucus secretion, and 12-fold increase in gastric bleeding. Basal acid secretion was zero, and pepsin secretion was one-third of control during the 2nd wk of the infection. Endoscopy at the time of symptoms showed erosions in the gastric body and antrum, as well as numerous mucosal hemorrhages and an acute ulcer in the antrum. Endoscopy 7 days later revealed that the gastric mucosa had almost completely recovered, with only a shallow erosion seen at the site of the previous ulcer. Gastric biopsies were normal before and during the first 2 wk of aspirin ingestion. Gastric biopsies taken at the time of the acute illness (associated with increased basal acid secretion) showed marked acute inflammation of the antrum with many Campylobacter pylori bacilli. At that time, neither acute inflammation nor C. pylori were found in biopsies from the body of the stomach. Biopsies obtained 1 wk later (zero basal acid) showed acute inflammation of both the gastric body and antrum. One week later, biopsies from the gastric body showed mild focal acute inflammation, moderate chronic inflammation, and an occasional lymphoid follicle; the gastric antrum showed chronic inflammation. Antral biopsies obtained 2 yr later showed persistent chronic gastritis with prominent lymphoid follicles and scattered foci of acute inflammatory cells; C. pylori bacilli were still present, but were less apparent. We believe that the syndrome of acute (epidemic) gastritis is often iatrogenic C. pylori infection. Our case shows that increased basal acid and pepsin secretion occur before onset of basal acid hypochlorhydria in the acute phase of C. pylori infection.

Having babies at home: is it safe? Is it ethical?

Home births entail a definite small risk, of unknown magnitude. Hospital births entail a wider range of risks, whose magnitude may be large but is also unknown. The morality of home births should be decided on a case-by-case basis, according to these priorities: safety of the mother, safety of the fetus, benefit to the fetus, potential benefit to the mother.

KIE: While both home and hospital births entail risks to the pregnant woman and fetus, no evidence of significantly greater risk of home birth is currently available that would clearly tilt the scales in favor of requiring babies to be born in hospitals. Parents, the state, and physicians have an interest in deciding about home birth, but for low-risk mothers with well-trained birth attendants, home birth can be considered in the best interest of both woman and fetus cannot be considered neglectful or abusive. Since home birth does not represent a clear and present danger to the common good, it does not warrant legal prohibition; physicians, however, are not required to participate but can legitimately offer backup support. The morality of home birth should be decided on a case-by-case basis, according to the priority of safety of the mother, safety of the fetus, benefit to the fetus, and potential benefit to the mother.

Clinical manifestations of zinc deficiency.

The essentiality of zinc for humans was recognized in the early 1960s. The causes of zinc deficiency include malnutrition, alcoholism, malabsorption, extensive burns, chronic debilitating disorders, chronic renal diseases, following uses of certain drugs such as penicillamine for Wilson's disease and diuretics in some cases, and genetic disorders such as acrodermatitis enteropathica and sickle cell disease. In pregnancy and during periods of growth the requirement of zinc is increased. The clinical manifestations in severe cases of zinc deficiency include bullous-pustular dermatitis, alopecia, diarrhea, emotional disorder, weight loss, intercurrent infections, hypogonadism in males; it is fatal if unrecognized and untreated. A moderate deficiency of zinc is characterized by growth retardation and delayed puberty in adolescents, hypogonadism in males, rough skin, poor appetite, mental lethargy, delayed wound healing, taste abnormalities, and abnormal dark adaptation. In mild cases of zinc deficiency in human subjects, we have observed oligospermia, slight weight loss, and hyperammonemia. Zinc is a growth factor. Its deficiency adversely affects growth in many animal species and humans. Inasmuch as zinc is needed for protein and DNA synthesis and for cell division, it is believed that the growth effect of zinc is related to its effect on protein synthesis. Whether or not zinc is required for the metabolism of somatomedin needs to be investigated in the future. Testicular functions are affected adversely as a result of zinc deficiency in both humans and experimental animals. This effect of zinc is at the end organ level; the hypothalamic-pituitary axis is intact in zinc-deficient subjects. Inasmuch as zinc is intimately involved in cell division, its deficiency may adversely affect testicular size and thus affect its functions. Zinc is required for the functions of several enzymes and whether or not it has an enzymatic role in steroidogenesis is not known at present. Thymopoeitin, a hormone needed for T-cell maturation, has also been shown to be zinc dependent. Zinc deficiency affects T-cell functions and chemotaxis adversely. Disorders of cell-mediated immune functions are commonly observed in patients with zinc deficiency. Zinc is beneficial for wound healing in zinc-deficient subjects. In certain zinc-deficient subjects, abnormal taste and abnormal dark adaptation have been noted to reverse with zinc supplementation.

Pulmonary bile emboli. Sequelae of iatrogenic trauma.

A 58-year-old man manifested obstructive jaundice secondary to adenocarcinoma of the common hepatic duct. The markedly icteric patient underwent multiple diagnostic and therapeutic procedures, including percutaneous needle biopsy of the liver, curettage, catheterization and washing of the hepatic ducts, and percutaneous transhepatic cholangiography. Three months later the patient died of a bleeding gastric ulcer. Autopsy confirmed the presence of adenocarcinoma of the common hepatic duct. Microscopic examination of the lungs disclosed numerous bile emboli in the smaller arteries, arterioles, and in a few alveolar capillaries. Histochemical reaction of the emboli was positive for bilirubin. Organizing fibrin was seen around occasional bile emboli, but most were without microscopic reaction. Review of the literature disclosed nine cases of pulmonary bile embolism, six of which had a history of marked cholestasis and trauma to the liver, like the present patient. Bile reaches the systemic circulation through a biliary-venous fistula that, in our case, was probably iatrogenic.

The prevention of hearing loss.

Hearing loss can affect up to 20% of the adult population and prevalence increases with age. However, hearing loss in childhood may have the most profound effects because of the block to the development of communication skills. Prevention of hearing loss is of major importance as treatment is often unsatisfactory. Causes are numerous, and may be multifactorial in an individual. Important causes include trauma, including noise and air pressure changes; genetic hearing loss; infection, including rubella; drug damage, metabolic and neoplasia.

[Growing cranial fractures in infancy (author's transl)]. / Fracturas craneales evolutivas en la infancia. Revisión de 17 casos.

Seventeen cases of growing cranial fractures in infancy are presented, eleven males and six females. Seventy per cent of the cases suffered a traumatic episode before one year of life. Thirteen of the total group experienced surgical intervention in which a completely defective duramater and alterations of the leptomeninges and the subsequent cerebral cortex were encountered. Leptomeningeal cysts were found in nine patients or 70 per cent of the cases. Ventricular system revealed alterations in all cases that were studied by means of neumoencephalography or computerized axial tomography. Evolution of 15 of the cases was follow up for a period of time which varied between five months to eleven years of age. An analysis of electroencephalographical alterations and neurological sequelae is made. An uncommon form of clinical-electroencephalographic evolution is described in one of the cases.

Head injury and the dilated pupil.

The significance of the dilated pupil in head injury is discussed. History of this condition and its possible mechanisms are described. Three patient reports are presented with unilateral dilated pupil. The literature on the subject is reviewed. Finally, the diagnostic steps which may be taken to differentiate direct third nerve injury from expanding mass lesion are suggested.