Geriatric assessment and medical preoperative screening (GrAMPS) program for older hernia patients.

PURPOSE: The incidence of older adults undergoing inguinal and ventral hernia repairs is increasing. Older adults are disproportionately affected by age-related risk factors, which are often under-recognized and may adversely affect surgical outcomes. These age-related risk factors often termed "geriatric syndromes," include multimorbidity, frailty, cognitive impairment, depression, obesity, functional impairment, polypharmacy, and poor subjective health. The aim of this study was to identify the prevalence of age-related risk factors in older patients undergoing elective hernia repair. METHODS: Patients aged 60 years or older with a planned elective surgical repair of a ventral or inguinal hernia were prospectively enrolled in a clinic. Subjects completed several validated screening tools for geriatric syndromes. RESULTS: Seventy patients completed preoperative assessments (mean age: 68.5 years). In total, 24 (34.3%) screened positive for previously unrecognized objective cognitive impairment (Mini-Cog) and 33 (47.1%) for a subjective memory concern. Sixty patients (85.7%) met criteria for polypharmacy. Additionally, 48 (68.6%) screened positive for either pre-frailty (37, 52.9%) or frailty (11, 15.7%), and 66 (94.3%) had multimorbidity. Twenty-five (35.7%) patients self-rated their health as "poor" or "fair," and 18 (25.7%) patients endorsed some functional impairment. CONCLUSIONS: There is a high prevalence of age-related risk factors in older patients undergoing elective hernia repair. Further, these factors are often unrecognized and underappreciated despite their potential to significantly impact informed consent and shared decision making. Additional study is required to define the impact of these age-related risk factors on surgical outcomes, which will inform preoperative risk assessment and optimization through modifiable risk reduction.

Longitudinal study of craniofacial growth in subjects with cleft lip and palate: from cheiloplasty to 8 years of age.

Craniofacial morphology was compared in 10 patients with unilateral cleft lip and alveolus (UCLA), 33 with complete unilateral cleft lip and palate (UCLP), and 14 patients with isolated cleft palate (CP). Serial lateral and posteroanterior cephalograms, obtained just before lip repair at 4 months or palatoplasty at 2 years, and at 4 and 8 years of age, were analyzed through comparisons with the means and growth increments of craniofacial dimensions. Facial forms at 8 years of age were compared with those of 33 noncleft subjects. Wider upper facial width before lip repair in the UCLP patients diminished slightly following surgery, but the condition persisted up to 8 years of age. Less forward growth of the maxilla was found in the subjects who received palatoplasty and a larger vertical growth increment in anterior maxilla occurred in the UCLP patients. Posterior maxillary height showed no significant differences in its growth increment among patients with clefts, but shorter posterior maxillary height in the UCLP patients continued. Linear dimensions of the mandible did not differ among cleft subjects, but a larger intercondylar width, a larger gonial angle, and a slightly retruded mandible in the CP patients and UCLP patients suggested compensation of the mandible to a wider and retroinclined nasomaxillary complex.

Lack of tolerance to a 24-hour infusion of S-nitroso N-acetylpenicillamine (SNAP) in conscious rabbits.

In order to design a means to preclude the development of nitrate tolerance, an in vivo model of nitroglycerin (GTN) tolerance was developed in the rabbit to examine the tolerance potential of S-nitroso vasodilators. Three separate studies were performed with 54 male New Zealand white rabbits which were instrumented for chronic infusion of vehicle or of either S-nitroso N-acetylpenicillamine (SNAP) or GTN (n = 6/group). Each vasodilator was infused for 24 hr at a dose rate of 60 nmol/kg/min. Three and 24 hr after the end of the infusion, each rabbit was anesthetized with pentobarbital and instrumented to monitor blood pressure, and dose-response curves were performed using SNAP or GTN. The dose-response curves were analyzed to determine the degree of displacement of the treated rabbit's dose-response curves compared to that of the vehicle-treated rabbit. Relative to the vehicle group, the GTN dose-response curve for systolic blood pressure in the GTN-infused rabbits was dextrally shifted 25.0-fold (P less than .05); 24 hr later the dextral shift was 0.9. The corresponding shifts in the SNAP dose-response curves were 2.7- and 0.5-fold, respectively. When SNAP was infused for 24 hr, the corresponding 3- and 24-hr dextral shifts for GTN were: 7.8- (P less than .05) and 0.7-fold; for SNAP they were: 1.9- and 0.6-fold. In a third study, N-acetylcysteine was coinfused (0.14 mg/kg/min, 200 mg/kg cumulative dose) with GTN over 24 hr.(ABSTRACT TRUNCATED AT 250 WORDS)

The hemodynamic effects of S-nitrosocaptopril in anesthetized dogs.

We studied the effects of a unique vasoactive agent, S-nitrosocaptopril (SnoCap), in an anesthetized canine preparation. We have previously demonstrated that this agent manifests the properties of both a direct nitrovasodilator and an angiotensin-converting enzyme inhibitor in vitro. The present investigation was performed to evaluate the effects of SnoCap in vivo. Intravenous administration of SnoCap produced immediate reductions in blood pressure and significantly attenuated the pressor response to angiotensin I. Equieffective doses of SnoCap had a greater duration of action after intravenous bolus administration compared with nitroglycerin (15.3 +/- 2.6 min vs. 3.2 +/- 0.5 min, respectively; P less than .01); importantly, this effect was apparent despite the relatively short plasma half-life of the compound (T1/2 alpha = 0.48 min, T1/2 beta = 5.54 min) and did not appear to be the result of inhibition of angiotensin-converting enzyme. Another unexpected property of SnoCap was that its nitrovasodilator effect was 10- to 30-fold less potent than nitroglycerin when administered as a bolus, but more efficacious when given by continuous infusion. These data support the view that SnoCap is a vasoactive substance with the properties of a nitrovasodilator and an angiotensin-converting enzyme inhibitor, as well as the unique properties of an extended duration of action and greater potency when administered by continuous intravenous infusion than by bolus injection. The clinical utility of this compound in humans and in individuals with specific disease states remains to be demonstrated.

The utero-placental circulation, eugenics and the prevention and treatment of high risk pregnancies.

Through systematic experimental and clinical studies, the physiological regulation of utero-placental circulation and the relation of the disturbance in this acirculation to pathogenic mechanisms of high risk pregnancies-Intrauterine Growth Retardation (IUGR) and Pregnancy-induced hypertension (PIH) were explored. The pharmacological effects and mechanism of a Chinese herbal medicine-Qingxintong in improving, the utero-placental circulation and the therapeutic efficacy in treatment of IUGR and PIH, both accompanied by disturbance of utero-placental circulation, were investigated as well.