The effects of wine and tobacco consumption on cognitive performance in the elderly: a longitudinal study of relative risk.

BACKGROUND: Evidence relating to the potentially protective effect of smoking and alcohol consumption in relation to senescent cognitive decline and Alzheimer's disease is inconclusive. METHODS: The relationship between wine and tobacco consumption and cognitive change was assessed within a longitudinal study of normal elderly people showing recent instability in cognitive functioning using an extensive battery of cognitive tests. RESULTS: While moderate wine consumption was found to be associated with a fourfold diminishing of the risk of Alzheimer's disease (OR = 0.26), as found in other studies, this effect was found to disappear when institutionalization was taken into account. Wine consumption was associated with an increased risk of decline over time in attention and in secondary memory. No protective effect for Alzheimer's disease was found for smoking, although smoking was associated with a decreased risk for decline over time in attentional and visuospatial functioning. No clear combined effect of smoking and drinking was found, even though smoking was found to increase the risk of decline in language performance when adjusted on wine consumption. CONCLUSIONS: There is no evidence to suggest that wine and tobacco consumption may protect against Alzheimer's disease.

Effect of age on glucose utilization and responsiveness to insulin in forearm muscle.

To determine the effect of age on responsiveness to insulin, 35 healthy subjects (age range, 22--73 years) were studied. A glucose-clamp technique was used to obtain a range of values for steady-state arterial glucose and arterial insulin concentrations; total body glucose utilization was estimated from the rate of glucose infusion needed to maintain the steady state; and the uptake of glucose and insulin by forearm muscle was determined by a forearm perfusion procedure. The results were examined by multiple regression analyses. The rate of glucose utilization by the whole body as well as by forearm muscle was dependent upon the insulin concentration. Age had no apparent effect on body glucose utilization, the uptake of glucose or insulin by muscle, or the steady-state insulin concentration in response to hyperglycemia. It is concluded that the abnormal glucose tolerance commonly associated with increased age is not due to a decrease in either insulin secretion or insulin stimulation of glucose uptake.

Factors affecting tube dwelling time after percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: Little is known about the impact of nephrostomy tubes on morbidity and quality of life. PATIENTS AND METHODS: The tube dwelling time and the factors influencing it were determined in 165 patients undergoing percutaneous nephrolithotomy (PCNL). RESULTS: The mean tube dwelling time was 21+/-30 days. The duration of tube drainage after PCNL was 13+/-17 days. Most of this time was preoperative when the tube was inserted for urgent reasons--obstruction or sepsis (31+/-33 days). On multivariate analysis, the number of secondary PCNLs and postoperative complications were the most significant factors affecting tube dwelling time. Age correlated with intubation time but did not reach statistical significance (P < 0.09). Neither the stone's side and type nor the patient's sex had a significant influence. CONCLUSIONS: A significant factor affecting the duration of tube drainage is preoperative medical evaluation and patient preparation, and these steps should be completed expeditiously in order to minimize the time to PCNL. Completion of PCNL in one session should shorten the postoperative intubation time.

Predicting CAP in patients with intermediate PSA using modified PSA indices.

OBJECTIVES: To test a new PSA index: peripheral zone fraction PSA (PSA-PZ) and evaluate its' predictive value in patients with intermediate PSA. METHODS: Fifty seven of 273 patients with serum PSA 4-10 ng/ml had CAP (21%). Total prostate volume and transition zone volume were calculated. Different cut-off points were used to calculate specificity, sensitivity, efficacy, positive and negative predictive values for PSA, PSAD, PSA-TZ and PSA-PZ (PSA-PZ= serum PSA((Total gland volume-TZ volume)/(Total gland volume)) RESULTS: The distribution of PSA-PZ is presented. PSA-PZ is shown to be effective in DRE negative patients with serum PSA 4-10 ng/ml. For patients with PSA-PZ (1.5 ng/ml the biopsy may be spared with no cancer being missed. CONCLUSIONS: The mathematical formula for PSA-PZ is straightforward and easy to use. Its application is convenient in the clinical setting. We suggest the use of PSA-PZ mainly in DRE negative patients having large glands and serum PSA between 4-10.

The efficacy of integrating "smart simulated casualties" in hospital disaster drills.

INTRODUCTION: Full-scale disaster drills are complex, expensive, and may involve hundreds or thousands of people. However, even when carefully planned, they often fail to manifest the details of medical care given to the casualties during the drill. OBJECTIVE: To assess the feasibility of integrating physicians among the simulated casualties of a hospital disaster drill. METHODS: A total of 178 physicians graduating an Advanced Trauma Life Support (ATLS) course participated in eight hospital disaster drills during 1994 as "Smart Victims." The participants were given cards with descriptions of their injury and detailed instructions on how to manipulate their medical condition according to the medical care provided in the hospital. They also were given coded questionnaires to fill out during the process of the drill. Conclusions were drawn from analysis of the questionnaires and from a roundtable discussion following each drill. RESULTS: The "smart casualties" made comments on the following topics: 1) triage (over-triage in 9%, and under-triage in 4%); 2) treatment sites; 3) medical equipment usage (i.e., shortage of ventilators and splinting devices); 4) medical knowledge and care rendered by the hospital staff; 5) evacuation and escorting of the wounded; 6) management of patients with post-traumatic stress disorder; and 7) medical documentation. Their comments contributed valuable information on the quality of medical care and organization, and identified obstacles that otherwise would have been overlooked. The "smart casualties" were very cooperative and indicated that their participation in the drill contributed to their understanding of disaster situations in hospitals. CONCLUSION: Integrating physicians among the simulated casualties in a hospital disaster drill may contribute to achieving the objectives of hospital disaster drills and add to disaster management education of the simulated casualty physicians.

Cryosurgical ablation for prostate cancer: preliminary results of a new advanced technique.

BACKGROUND: Cryosurgery is a minimally invasive treatment option for prostate cancer. OBJECTIVES: To report on the first series of cryosurgical ablation for prostate cancer performed in Israel. METHODS: Cryosurgical ablation of the prostate was undertaken in 12 patients aged 53-72 diagnosed with adenocarcinoma of the prostate. The procedures were performed percutaneously and were monitored by real-time trans-rectal ultrasound. The CRYOHIT machine applying Argon gas was used with standard or ultra-thin cryoprobes. The average follow-up was 12.8 months postsurgery (range 1-24 months). RESULTS: No rectal or urethral injuries occurred and all patients were discharged from hospital within 24-48 hours. The duration of suprapubic drainage was 14 days in 10 patients and prolonged in 2. Early complications included penoscrotal edema in four patients, perineal hematoma in three, hemorrhoids in two and epidydimitis in one. Long-term complications included extensive prostatic sloughing in one patient and a perineal fistula in another, both of whom required prolonged suprapubic drainage. Minimal stress incontinence was noted in two patients for the first 8 weeks after surgery. None of the patients has yet regained spontaneous potency. A prostate-specific antigen nadir of less than 0.5 ng/ml was achieved in eight patients and an undetectable PSA level below 0.1 ng/ml in five patients. CONCLUSION: Cryoablation for prostate cancer is safe and feasible, and the preliminary results are encouraging. Further study is needed to elucidate the efficacy of the procedure.

[Dynamics of asthma mortality in France: seasonal fluctuations and peak mortality in 1985-87]. / Dynamique de la mortalité asthmatique en France: fluctuations saisonnières et crise de mortalité en 1985-87.

In the face of an observed increase in asthma mortality since the end of the 70's an analysis of the time series of the deaths for the period 1979-89 was conducted; which shows a peaking of mortality between 1985 and 1987. A different seasonal component of asthma mortality has been identified for the age group 5-34 and over 34 group. For the later, mortality was found to peak during winter and dropping to the lowest point in summer, well synchronised with the mortality due to respiratory infection. For the former, mortality usually peaks during summer and troughs during the winter, independently of the mortality due to respiratory infection. A bimodal repartition of deaths was observed in the age group 5-34 with a main peak in summer (July) and a secondary peak in autumn (October). Modeling of the deaths series by season shows a dramatic rise in mortality during the years 1985, 1986 and 1987 affecting both age groups. During these 3 years, the global over-mortality is 21%. The increase has affected all the seasons allowing for seasonal variations of each age group. Factors responsible for the death seasonality in each age group are discussed. The temporary action of a non-specific factor was proposed to explain the cross-sectional character of the mortality crisis in the population; namely the influenza epidemics during the 1985 and 1986 winters.

[Past and present asthma mortality: towards a shift in the secular trend?]. / Le passé et le présent de la mortalité asthmatique: vers une rupture de la tendance séculaire?

In recent years disconcerting observations have been published concerning changes in mortality from asthma in France and other countries. These conclusions are difficult to assess due to uncertainty regarding the underlying asthma mortality trends. We have attempted to address this question by constituting a statistical series of asthma deaths from 1925 to 1989. The 1925 to 1989 mortality trend is clearly decreasing. This decrease follows the same rhythm as the general mortality decline, since the proportion of asthma in total deaths remained between 3 to 4/1000. Three periods are emphasized: from 1925 to 1965 where the decreasing trend is interrupted by an important crisis in mortality, from 1965 to 1980 where the decrease is regular, and the last period since 1980 with an important crisis in 1985 and 1986; crisis applying to all genders and ages. The latest trend is uncertain. Careful epidemiologic surveillance will decide between a change in the secular trend or a transitory crisis and thus determine the cause(s). An effect due to the reinclusion by ICD 9 of a fluctuating component in asthma mortality cannot be excluded.

Establishing the limits and characteristics of normal age-related cognitive decline.

BACKGROUND: Research into ageing-related pathology relies not only on exploration of disease aetiology, but also a clear understanding of the normal ageing process. The present study aims to examine the characteristics of elderly subjects who lie on the borderline between normal and pathological ageing. METHOD: Cognitive functioning is examined using computerized neuropsychometric assessment in a population of 833 normal elderly from which a cohort of 397 subjects with sub-clinical cognitive impairment are followed over three years. Subjects receive a standardized neurological examination and ApoE genotypes are established. RESULTS: Analysis of covariance revealed no cross-sectional age differences for syntax comprehension (p = 0.19), articulation (p = 0.46), semantic matching (p = 0.12), reading (p = 0.79), and implicit memory (p = 0.21) while explicit memory, language skills and visuospatial skills were found to deteriorate both in the cross-sectional age comparisons and across time. An overall intellectual ability factor, derived from Principal Components Analysis, was found by regression to decline principally in persons with low education, and a high initial IQ level was observed to provide a protective effect over age 75. Persons with higher levels of education show relative stability over time on language and secondary memory tasks but deteriorate as rapidly as persons with low education on visuospatial tasks. Five separate patterns of sub-clinical cognitive deficit were isolated by cluster analysis. Two groups, with differing clinical profiles (of which only one manifested the ApoE4 allele), were found to have an increased risk of developing senile dementia (OR = 4.4 and 3.9). A third group had a high prevalence of depressive illness, and the remaining two showed very little change. CONCLUSION: Ageing does not affect all cognitive functions uniformly: a high initial education level slowing rate of decline for certain tasks. Separate patterns of cognitive change are observed in early senile dementia, benign change and changes related to depressive illness. Results suggest the need for more stringent selection of normal control groups.

Traumatic arm amputation, an uncommon parachuting injury.

Parachuting is a unique method of deploying troops. Accidents in parachuting are common, but usually carry minimal risk for severe injury. Most accidents occur during landing and injuries often affect the lower limbs and spine. Traumatic amputation of a limb is an extremely rare event in parachuting. We present a case of a parachutist who suffered a traumatic amputation of the left hand during jumping off the plane.

The trimodal death distribution of trauma victims: military experience from the Lebanon War.

INTRODUCTION: Mortality in war is traditionally divided into two categories: killed in action and died of wounds. Mortality in civilian trauma is generally divided into three categories: immediate death (50%), early death (30%), and late death (20%). Can we identify a trimodal death distribution among war victims? METHODS: We analyzed data for casualties in the Lebanon War from June 6 to September 20, 1982. During this period a total of 1,950 soldiers were injured; 351 (18%) of them died. Time of injury and time of death of the victims was determined from real-time recordings during the battle and from hospital files. RESULTS: Analyzing the time of death revealed that 329 of the soldiers (93.7%) died within the first hour after injury, 7 soldiers died 1 to 4 hours after injury (2%), and 15 soldiers died 24 hours to 75 days after injury (4.3%). The most common causes of death during the first hour after injury were central nervous system (CNS) injuries 31%, exsanguination 30%, incineration 21%, and combined CNS injury and exsanguination 10.9%. Exsanguination was the leading cause of death 1 to 4 hours after injury (86%). CNS injury was the most common cause of late death (60%). Only 1.1% of the soldiers who reached the hospital alive died of their wounds. CONCLUSIONS: A trimodal mortality distribution with different causes of death in each peak can be identified in the mortality pattern of Israeli soldiers during the Lebanon War. The relative height of the different peaks and the causes of death in the third peak are different from those found in civilian trauma. We believe that prompt medical treatment and expeditious evacuation from the battle zone led to a very low death rate among the wounded soldiers who had reached the hospital alive. The same factors may have increased the relative portion of CNS injuries as a cause of late death.

Intravenous line diameter: is bigger really better?

OBJECTIVE: To determine whether the size of an intravenous catheter influences the cannulation success rate and procedure duration among military medics. METHODS: According to a prospective, randomized, controlled crossover study design, 114 military medic cadets were paired and inserted 14-gauge (14G) and 16G intravenous catheters into veins in the antecubital fossa. Success rate and procedure duration were determined. RESULTS: The overall success rate for 14G and 16G catheters was 80 and 86%, respectively. Average procedure duration was 33 +/- 14.7 and 35.2 +/- 14.9 seconds, respectively. No significant differences were found in either success rate or procedure duration between the examined catheter sizes. CONCLUSION: Successful intravenous cannulation was unaffected by catheter size. Therefore, 14G intravenous catheters are recommended for use by military medics on the battlefield.

[Multicenter French cohort of adults with HIV infection. Description and course after 4 years of follow-up. SEROCO]. / Cohorte francaise multicentrique d'adultes infectés par le VIH. Description et évolution après 4 ans de suivi. SEROCO.

OBJECTIVES: A prospective multicentric epidemiological study (SEROCO) of subjects with a diagnosis of human immunodeficiency virus (HIV) infection was started on January 1, 1988 in order to better understand the natural history of HIV infection and factors related to outcome. Observations after 4 years of follow-up are reported here. METHODS: After authorization by the French national ethics committee and the national commission for personal freedom, 18 French centres included non-haemophiliac volunteers who were asymptomatic, had had non anti-HIV treatment and whose HIV positivity had been known less than 1 year at inclusion. These last three criteria were not required for patients whose precise date of contamination was known within a range of +/- 3 months. RESULTS: On July 15, 1992, there were 1453 infected subjects in the cohort (1063 males, 417 females; age range at inclusion 18-75 years; mean age 31.3 +/- 9.4). Globally, 2.7% of the subjects were symptomatic at inclusion. Mean CD4 lymphocyte count at inclusion was 508/mm3. Clinically, 51.5% of the patients had a history of sexually transmitted disease at inclusion. After 4 years (on July 15, 1992) mean follow-up was 28 +/- 12.9 months for a total of 3428 patient-years. Disease progression to stage IV was observed in 439 patients including 202 who developed the acquired immuno-deficiency syndrome (AIDS). Among these 202 patients, 113 had died at the end-point of this report. The first manifestation of AIDS was Kaposi sarcoma in 44, pulmonary pneumocystosis in 38 and cerebral toxoplasmosis in 27. The probability of developing AIDS was calculated at 13.9% at 5 years, 27.7% at 7 years and 33.7% at 10 years. The probability of a CD4 count below 200/mm3 was 32.7, 55.6 and 67% at 5, 7 and 10 years respectively. For patients with a CD4 count below 200, the probability of developing AIDS was 18% at 1 year, 39% at 2 years and 51% at 3 years. CONCLUSIONS: SEROCO has been a most useful prospective epidemiological tool due to the diversity of the subjects included. The observed natural history of HIV infection will lead to specific research projects aimed at better understanding the disease process.

[Incomplete penile amputation: diagnostic and therapeutic challenge].

Traumatic penile amputation is a severe injury associated with a potential for multidisciplinary dysfunction. Since such injuries are rare, diagnostic and therapeutic experience is minimal. While complete penile amputation is a straight-forward diagnosis, incomplete amputations are not as evident and diagnosis may be delayed. The therapeutic endpoint includes restoration of an acceptable appearance of the phallus and a urethral meatus that allows normal voiding. Other objectives include re-establishment of sexual potency and fertility. As in other amputations, the treatment of choice is meticulous microsurgical replantation, including re-anastomosis of dorsal and cavernosal arteries, the deep dorsal vein, the urethra and nerves, as well as suturing the tunica albuginea. While appropriate cosmetic results and normal voiding can be achieved in most cases, potency is less frequently achieved due to neurological deficit leading to impaired erection and loss of sensation. Penile amputation is thus a complex therapeutic challenge, as meticulous anatomic reconstruction of blood vessels and nerves is essential for restoration of function. Since incomplete penile amputation may be overlooked when other more obvious injuries draw attention, this injury should be suspected in all cases of penetrating injury of the male genitalia. We present a 17-year-old man who sustained an incomplete penile amputation in a traffic accident.

[Acute, painful, swollen testis in polyarteritis nodosa: a diagnostic problem].

An acutely painful and swollen testis mandates urgent diagnostic and therapeutic measures since this symptom complex may indicate torsion of the testis. Prompt scrotal exploration is necessary if the testis is to be saved from ischemic necrosis. Polyarteritis nodosa (PAN) is a vasculitis involving mainly medium and small sized arteries and may damage any organ. In PAN, the presentation of an acutely painful and swollen testis raises a perplexing diagnostic problem since the symptoms may be related to vasculitis involving the testis on the one hand, or represent primary testicular pathology unrelated to the underlying PAN. A 31-year-old man with PAN who presented with acute pain and swelling in a solitary testis is reported.

[Coniotomy: surgical airway management in trauma before hospitalization].

To assess the efficacy of prehospital coniotomy (cricothyrotomy), information regarding all coniotomies performed by military physicians during the last 3.5 years was analyzed. 26 were performed between October 1991 and May 1995, of which 23 were successful (88.4%). Failures were due to poor anatomic identification of the cricothyroid membrane. Most patients suffered head or neck injuries (in 61.5% and 19%, respectively). The main indications were anatomical distortion of the pharynx and larynx and failure to intubate. Intubation was attempted in 22 patients prior to coniotomy (multiple attempts in 17). Since coniotomy is a life-saving procedure, it should be part of the armamentarium of any physicians. Coniotomy in the field is associated with a high success rate. The procedure is recommended in trauma victims who need airway establishment and cannot be intubated or in whom intubation has failed.