Delirio postoperatorio en pacientes con historial de abuso de alcohol / Postoperative delirium in patients with history of alcohol abuse

Introducción. El delirio postoperatorio (DPO) es un estado confusional agudo caracterizado por cambios fluctuantes en el nivel de consciencia y la función cognitiva, que se desarrolla en un corto período de tiempo. El objetivo de este estudio fue evaluar la relación entre el abuso de alcohol y el desarrollo de DPO. Métodos. Estudio prospectivo incluyendo pacientes programados para cirugía electiva, admitidos en la unidad de cuidados post-anestésicos. Previamente a la cirugía, se preguntó a los pacientes sobre el consumo de alcohol, el cual se evaluó mediante el cuestionario Cutting Down, Annoyance, Guilt and Eye-opener (CAGE); la puntuación ≥2 se definió como abuso de alcohol. Las comparaciones se realizaron utilizando las pruebas exacta de Fischer o de χ2. Los factores de riesgo se analizaron mediante una regresión logística multivariante con razón de momios (RM) e intervalos de confianza del 95% (IC95%). Resultados. Doscientos veintiún pacientes fueron estudiados. El delirio se observó en el 11% de los pacientes. La incidencia del abuso de alcohol fue del 10%. Los pacientes con abuso de alcohol eran más frecuentemente varones (p<0,001) y tenían un mayor grado de riesgo perioperatorio de la ASA (ASAIII/IV) (p=0,021). La edad (RM: 5,9; IC95%: 2,2-15,9; p<0,001 para pacientes mayores de 65años), el estado físico ASAIII/IV (RM: 4,2; IC95%: 1,7-10,7; p=0,002) y el abuso de alcohol (RM: 4,2; IC 95%: 1,4-12,9; p=0,013) resultaron ser factores predictivos independientes del DPO. Conclusiones. Las características más frecuentes en los pacientes con DPO fueron la edad avanzada, una mayor puntuación para el estado físico según la clasificación ASA y el abuso de alcohol. El abuso de alcohol se considera un factor de riesgo independiente para el DPO (AU)

Introduction. Postoperative delirium (POD) is an acute confusional state characterized by changes in consciousness and cognition, which may be fluctuating, developing in a small period of time. The aim of this study was to evaluate the relationship between alcohol abuse and the development of POD. Methods. We prospectively evaluated consecutively all postoperative patients admitted in the Post-anesthesia Care Unit over a 1-month period for delirium, using the Portuguese versions of the the Nursing Delirium Screening Scale. Before surgery, alcohol consumption was inquired and alcohol abuse was assessed by the CAGE (Cutting Down, Annoyance, Guilt and Eye-opener) questionnaire; a score ≥2 defined alcohol abuse. Fischer exact test or chi-square was applied for comparisons. Risk factors were analyzed in a multivariate analysis using a logistic regression with odds ratios (OR) and 95% confidence intervals (95%CI). Results. Two hundred twenty-one patients were enrolled. Delirium was seen in 11% patients. The incidence of alcohol abuse was 10%. Patients with alcohol abuse were more frequently men (P<.001) and had a higher ASA physical status III/IV (P=.021). POD was more frequent in patients with alcohol abuse (30% vs. 9%; P=.002). Age (OR: 5.9; 95%CI: 2.2-15.9; P<.001 for patients ≥65years), ASA physical statusIII/IV (OR: 4.2; 95%CI: 1.7-10.7; P=.002) and alcohol abuse (OR: 4.2; 95%CI: 1.4-12.9; P=.013) were found to be independent predictors for POD. Conclusions. Older patients, higher ASA physical status and alcohol abuse were more frequent in patients with POD. Alcohol abuse was considered an independent risk factor for POD (AU)

Postoperative delirium in patients with history of alcohol abuse. / Delirio postoperatorio en pacientes con historial de abuso de alcohol.

INTRODUCTION: Postoperative delirium (POD) is an acute confusional state characterized by changes in consciousness and cognition, which may be fluctuating, developing in a small period of time. The aim of this study was to evaluate the relationship between alcohol abuse and the development of POD. METHODS: We prospectively evaluated consecutively all postoperative patients admitted in the Post-anesthesia Care Unit over a 1-month period for delirium, using the Portuguese versions of the the Nursing Delirium Screening Scale. Before surgery, alcohol consumption was inquired and alcohol abuse was assessed by the CAGE (Cutting Down, Annoyance, Guilt and Eye-opener) questionnaire; a score ≥2 defined alcohol abuse. Fischer exact test or chi-square was applied for comparisons. Risk factors were analyzed in a multivariate analysis using a logistic regression with odds ratios (OR) and 95% confidence intervals (95%CI). RESULTS: Two hundred twenty-one patients were enrolled. Delirium was seen in 11% patients. The incidence of alcohol abuse was 10%. Patients with alcohol abuse were more frequently men (P<.001) and had a higher ASA physical status III/IV (P=.021). POD was more frequent in patients with alcohol abuse (30% vs. 9%; P=.002). Age (OR: 5.9; 95%CI: 2.2-15.9; P<.001 for patients ≥65years), ASA physical statusIII/IV (OR: 4.2; 95%CI: 1.7-10.7; P=.002) and alcohol abuse (OR: 4.2; 95%CI: 1.4-12.9; P=.013) were found to be independent predictors for POD. CONCLUSIONS: Older patients, higher ASA physical status and alcohol abuse were more frequent in patients with POD. Alcohol abuse was considered an independent risk factor for POD.

Static stretching increases muscle fatigue during submaximal sustained isometric contractions.

AIM: The purpose of this study was to examine the acute effects of a static stretching protocol on neuromuscular fatigue of the flexor carpi radialis (FC) and flexor digitorum (FD). METHODS: Twenty-six healthy and right-handed men with a mean (SD) age of 27.1 (2.9) years volunteered for this study. The fatigue test was performed before (Pre) and after three sets of 50 s stretching (Post) applied to the right hand, and twice (T1 and T2) without stretching to the left hand as a control condition. Isometric handgrip fatigue exercise was maintained for 30s within the range 50-60% of the maximal voluntary contraction. From the electromyography (EMG), root mean squares (RMS) values and mean frequency (MF) were obtained for each 2s consecutive windows of test and normalized by the MVC obtained in 6s tests. From time series, coefficients of linear regression were determined used to compare Pre with Post and T1 with T2 by paired samples t-tests. RESULTS: Higher rate of increase in EMG on Post compared to Pre was found in both FC (P=0.015) and FD (P=0.006). A higher rate of decrease of MF for FC (P=0.004) and FD (P=0.005) was observed with Post compared to Pre. Conversely, the differences between T1 and T2 were not significant (P>0.05). CONCLUSION: These findings indicate that static stretching performed immediately before submaximal isometric muscle actions may increase neuromuscular fatigue assessed by EMG, suggesting that could reduce muscle's endurance capacity.

Bilateral whole lung lavage in pulmonary alveolar proteinosis--a retrospective study.

Whole lung lavage (WLL) is the gold standard technique for the treatment of Pulmonary Alveolar Proteinosis (PAP). In this paper we evaluated and discuss bilateral WLL, namely the procedure work-up and the therapeutic efficacy. Six bilateral WLL performed through a careful adherence to a modified Royal Brompton Hospital (London) technique were carried out without major complications and were associated with clinical and functional improvement of the PAP patients submitted to this procedure. As there are benefits in terms of time, patient comfort and cost effectiveness compared to unilateral WLL, associated with the efficacy and safety observed, bilateral WLL seems to be a suitable first choice for therapeutic lavage in PAP patients.

Fatty acids derived from a food frequency questionnaire and measured in the erythrocyte membrane in relation to adiponectin and leptin concentrations.

BACKGROUND/OBJECTIVES: Evidence on the association between fatty acids and adiponectin and leptin concentrations is scarce and inconsistent, which may in part be due to limitations of dietary reporting methods. We aimed to estimate the association of fatty acids, derived from a food frequency questionnaire (FFQ) and measured in the erythrocyte membrane, with adiponectin and leptin concentrations. SUBJECTS/METHODS: We studied 330 non-institutionalized inhabitants of Porto (52.4% women; age range: 26-64 years) evaluated in 2010-2011, as part of the EPIPorto cohort study. Fatty acids were derived from a validated semiquantitative FFQ and measured in the erythrocyte membrane by gas chromatography. Serum concentrations of adiponectin and leptin were determined through radioimmunoassay. Regression coefficients (ß) and 95% confidence intervals (95% CI) were obtained from linear regression models, after controlling for gender, age, education, leisure time physical activity and total body fat percentage (obtained from dual energy X-ray absorptiometry). RESULTS: Fatty acids measured by FFQ showed no significant associations with both adipokines. Lauric and linoleic acids, measured in the erythrocyte membrane, were significantly and positively associated with adiponectin (ß=0.292, 95% CI: 0.168-0.416; ß=0.150, 95% CI: 0.020-0.280) and leptin (ß=0.071, 95% CI: 0.003-0.138; ß=0.071, 95% CI: 0.002-0.140), whereas total n-3, eicosapentaenoic and docosahexaenoic acids were significantly but negatively associated with adiponectin (ß=-0.289, 95% CI: -0.420 to -0.159; ß=-0.174, 95% CI -0.307 to -0.040; ß=-0.253, 95% CI -0.383 to -0.124) and leptin (ß=-0.151, 95% CI: -0.220 to -0.083; ß=-0.080, 95% CI: -0.151 to -0.009; ß=-0.146, 95% CI: -0.214 to -0.078). Positive significant associations of palmitic and trans-fatty acids with adiponectin were also observed. CONCLUSIONS: A positive association of lauric and linoleic acids and a negative association of total n-3 fatty acids with both adipokines were observed only with fatty acids measured in the erythrocyte membrane.

Deregulation of adipokines related to target organ damage on resistant hypertension.

Resistant hypertension (RHTN) includes patients with controlled blood pressure (BP) (CRHTN) and uncontrolled BP (UCRHTN). In fact, RHTN patients are more likely to have target organ damage (TOD), and resistin, leptin and adiponectin may affect BP control in these subjects. We assessed the relationship between adipokines levels and arterial stiffness, left ventricular hypertrophy (LVH) and microalbuminuria (MA). This cross-sectional study included CRHTN (n=51) and UCRHTN (n=38) patients for evaluating body mass index, ambulatory blood pressure monitoring, plasma adiponectin, leptin and resistin concentrations, pulse wave velocity (PWV), MA and echocardiography. Leptin and resistin levels were higher in UCRHTN, whereas adiponectin levels were lower in this same subgroup. Similarly, arterial stiffness, LVH and MA were higher in UCRHTN subgroup. Adiponectin levels negatively correlated with PWV (r=-0.42, P<0.01), and MA (r=-0.48, P<0.01) only in UCRHTN. Leptin was positively correlated with PWV (r=0.37, P=0.02) in UCRHTN subgroup, whereas resistin was not correlated with TOD in both subgroups. Adiponectin is associated with arterial stiffness and renal injury in UCRHTN patients, whereas leptin is associated with arterial stiffness in the same subgroup. Taken together, our results showed that those adipokines may contribute to vascular and renal damage in UCRHTN patients.

Groundwater from infiltration galleries used for small public water supply systems: contamination with pesticides and endocrine disruptors.

Infiltration galleries are among the oldest known means used for small public water fountains. Owing to its ancestral origin they are usually associated with high quality water. Thirty-one compounds, including pesticides and estrogens from different chemical families, were analysed in waters from infiltration galleries collected in Alto Douro Demarcated Wine region (North of Portugal). A total of twelve compounds were detected in the water samples. Nine of these compounds are described as presenting evidence or potential evidence of interfering with the hormone system of humans and wildlife. Although concentrations of the target analytes were relatively low, many of them below their limit of quantification, four compounds were above quantification limit and two of them even above the legal limit of 0.1 µg/L: dimethoate (30.38 ng/L), folpet (64.35 ng/L), terbuthylazine-desethyl (22.28 to 292.36 ng/L) and terbuthylazine (22.49 to 369.33 ng/L).

Quantification of endocrine disruptors and pesticides in water by gas chromatography-tandem mass spectrometry. Method validation using weighted linear regression schemes.

A multi-residue methodology based on a solid phase extraction followed by gas chromatography-tandem mass spectrometry was developed for trace analysis of 32 compounds in water matrices, including estrogens and several pesticides from different chemical families, some of them with endocrine disrupting properties. Matrix standard calibration solutions were prepared by adding known amounts of the analytes to a residue-free sample to compensate matrix-induced chromatographic response enhancement observed for certain pesticides. Validation was done mainly according to the International Conference on Harmonisation recommendations, as well as some European and American validation guidelines with specifications for pesticides analysis and/or GC-MS methodology. As the assumption of homoscedasticity was not met for analytical data, weighted least squares linear regression procedure was applied as a simple and effective way to counteract the greater influence of the greater concentrations on the fitted regression line, improving accuracy at the lower end of the calibration curve. The method was considered validated for 31 compounds after consistent evaluation of the key analytical parameters: specificity, linearity, limit of detection and quantification, range, precision, accuracy, extraction efficiency, stability and robustness.

Contrasting patterns of population subdivision and historical demography in three western Mediterranean lizard species inferred from mitochondrial DNA variation.

Pleistocene climatic oscillations were a major force shaping genetic variability in many taxa. We analyse the relative effects of the ice ages across a latitudinal gradient in the Western Mediterranean region, testing two main predictions: (i) species with historical distributions in northern latitudes should have experienced greater loss of suitable habitat, resulting in higher extinction of historical lineages than species distributed in southern latitudes, where the effects of the ice ages were not as drastic. This would be reflected in the observation of lower diversity and number of differentiated lineages in northern areas. (ii) a signature of demographic expansion following the climate amelioration should be obvious in northern species, whereas in the south evidence of long-term effective population size stability should be observed. We used as models three species of wall lizards (Podarcis bocagei, Podarcis carbonelli and Podarcis vaucheri) that replace each other along the study area. We investigated the patterns of mitochondrial DNA diversity and subdivision and obtained demographic parameter estimates for each species. Our results suggest that P. bocagei, the northernmost species, bears low genetic diversity, a shallow coalescent history and marks of a demographic expansion. In contrast, P. vaucheri, the species with a southernmost distribution, shows deeper coalescence events, complex geographical substructure and no evidence for population growth. The species with an intermediate distribution, P. carbonelli, shows average levels of diversity, substructure and population growth. Taken together, these results conform to our main predictions and are explained by a differential influence of the ice ages on distinct latitudes.

Influence of the drying conditions of Sargassum sp. alga on the bioadsorption of hexavalent chromium.

Industrial wastes containing synthetic organic compounds and heavy metals are among the most dangerous residues, whose growth has followed the increase in industrial activity. Heavy metals are readily assimilated into the food chain and therefore easily accumulated in the ecosystem. To remove heavy metals from aqueous solutions, marine algae may be used as adsorbents either in their natural form or after treatments by a cross-linking process to improve their mechanical resistance. Drying of biosorbents, such as marine algae, is mentioned in many previous works as a step preceding the adsorption/dessorption cycle. Concerning algae, drying of its fresh biomass allows for proper storage and enhances performance in the sorption of heavy metals. In this work, physical and morphological analyses of fresh and dried Sargassum sp. marine algae, harvested offshore São Sebastião, São Paulo state, Brazil, were performed in order to assess the influence of drying conditions on the biosorption process. Chromium concentrations were also determined in different parts of the algal structure before and after the biosorption process. The drying promoted structural changes in the algae, like shrinkage and porosity reduction. It was also observed that the chromium retention was dependent on the structural arrangement of the alga parts, in which the leaf was the major biosorbent.

Overall characterization of cork dust explosion.

Explosibility and ignitability studies of air/cork dust mixtures were conducted in a near-spherical 22.7 L explosibility test chamber using pyrotechnic ignitors and in a furnace of 1.23 L. The suspension dust burned as air-dispersed dust clouds and the uniformity of the dispersion inside the chamber was evaluated through optical dust probes. The range of tested particle sizes went from a mass median diameter of 47.4 to 438.3 microm and the covered dust cloud concentration was up to 700-800 g/m(3). Measured explosion parameters included minimum explosible concentration, maximum explosion pressure, maximum rate of pressure rise and minimum autoignition temperature. The effect of dust particle size on flammability was evaluated and it was found that the minimum explosible concentration is around 40 g/m(3) and it is relatively independent of particle size below 180 microm. Maximum explosion pressure of 7.2 bar and maximum rate of pressure rise of 179 bar/s were detected for the smallest tested sizes. The limitations on the rates of devolatilization of the solid particles became rate controlling at high burning velocities, at high dust loadings and for large particle sizes. The effect of initial pressure on the characteristic parameters of the explosion was studied by varying the initial absolute pressure from 0.9 bar to 2.2 bar, and it was found that as initial pressure increases, there is a proportional increase of minimum explosion limit, maximum explosion pressure, and maximum rate of pressure rise. The influence of the intensity of the ignition energy on the development of the explosion was evaluated using ignition energies of 1000 J, 2500 J and 5000 J, and the experimental data showed that the value of 2500 J is the most convenient to use in the determination of minimum explosion concentration. The behavior of the cork dust explosion in hybrid methane air mixtures was studied for atmospheres with 2% and 3.5% (v/v) of methane. The effect of methane content on the characteristic parameters of the explosions was evaluated. The conclusion is that, the hazard and explosion danger rise with the increase of methane concentration, characterized by the reduction of the minimum dust explosion concentration. The minimum autoignition temperature obtained with the thermal ignition tests was 540 degrees C and the results have shown that this value is independent of particle size, for particles with mass median diameters below 80 microm.

Acute fluoxetine administration differentially affects brain C-Fos expression in fasted and refed rats.

In the present study we investigated the effect of acute fluoxetine administration on the expression of c-Fos in the rat brain under two different metabolic conditions: fed and fasting states. Wistar male rats, weighing 220+/-30g, received i.p. injections of saline solution or fluoxetine (10mg/kg), and were killed 2 h later. The brains were removed after transcardiac perfusion with phosphate-buffered saline followed by paraformaldehyde, and were then processed for immunohistochemistry. Fos-like immunoreactivity was quantified by a computerized system. Fasted animals faced an 18-h suppression of food intake, while fed groups were submitted to an initial 14-h period of fast followed by a 4-h period in which food was freely available. Both in fasting and fed states, fluoxetine-treated animals presented a significant increase in c-Fos expression in hypothalamic areas, limbic structures, circumventricular areas, and in mesencephalic and rhomboencephalic regions, as compared with saline-treated controls. The quantitative comparison of data obtained from fasted and fed animals showed that fasted rats treated with fluoxetine presented a higher c-Fos expression in the ventromedial hypothalamus and the paraventricular nuclei compared with the fed group, while in fluoxetine-treated fed rats c-Fos expression was higher in the arcuate nuclei, medial amygdala, locus coeruleus and dorsal raphe nuclei, as compared with fasted, fluoxetine-treated animals. These data indicate that the metabolic condition of the animals significantly modifies fluoxetine-induced brain c-Fos expression, suggesting that visceral and behavioral fluoxetine effects may be influenced by the metabolic state of the individual.

Wireless capsule endoscopy for evaluation of phenotypic expression of small-bowel polyps in patients with Peutz-Jeghers syndrome and in symptomatic first-degree relatives.

BACKGROUND AND STUDY AIMS: Peutz-Jeghers syndrome (PJS) is an inherited gastrointestinal hamartomatous polyposis disorder. Small-bowel intussusception and bleeding are the most common complications, and malignancy may also occur. Survey of the gastrointestinal tract, particularly of the small bowel, is difficult and current recommendations for management syndrome are ambiguous. We evaluated the feasibility of capsule endoscopy for identifying phenotypic expression of small-bowel polyps in patients with full-blown PJS and a previous diagnosis of gastrointestinal polyposis, and in symptomatic kindred of PJS patients with no previous diagnosis of gastrointestinal polyposis. PATIENTS AND METHODS: Two groups were studied: group A consisted of 14 patients with gastrointestinal polyposis, eight of whom had undergone previous small-intestine surgery; group B consisted of six symptomatic first-degree relatives of PJS patients; these patients had previous negative gastrointestinal endoscopic examinations. RESULTS: Numerous polyps were detected in all patients in group A. Most polyps were sessile, but the larger polyps tended to be pedunculated. Polyp density was highest in the jejunum (greater than in the ileum and duodenum). Seven patients had at least one large polyp (> 11 mm) and five of these patients subsequently underwent enteroscopy, which revealed that capsule endoscopy had correctly identified all the patients with large polyps, but had missed 20 % of the total number of large polyps in these patients. No polyps were detected by capsule endoscopy in group B patients, despite the excellent visualization of the small intestine. In all patients, the capsules were expelled within 24 hours, without complications, and the procedure was well tolerated. CONCLUSIONS: Capsule endoscopy is an effective and well-tolerated method for evaluating small-bowel pathology in patients with PJS.

Acute necrotizing esophagitis: a large retrospective case series.

BACKGROUND AND STUDY AIMS: Acute necrotizing esophagitis is a rarely described entity. Its incidence has not yet been established, and its multifactorial etiology remains unknown. The aim of the present study was to establish the incidence, clinical presentation, endoscopic course, accompanying factors, and pathogenesis of the condition. PATIENTS AND METHODS: A retrospective analysis of clinical, laboratory, endoscopic and histological data and the clinical course in 29 patients with acute necrotizing esophagitis was carried out over a 5-year period. RESULTS: Acute necrotizing esophagitis was observed in 29 of 10 295 upper gastrointestinal endoscopies (0.28 %) carried out during the 5-year period. The average age of the patients was 75.24 years (range 40 - 91), and they were predominantly male. Eighty-three percent of the patients had comorbid conditions. In all cases, acute necrotizing esophagitis became evident with upper gastrointestinal bleeding, without hemodynamic stabilization in the majority of cases (75.9 %). The lesions predominantly affected the lower two-thirds of the esophagus (59 %), and there were coexisting abnormal endoscopic findings in 83 % of cases. Empirical supportive therapy, including oral nutritional rest, omeprazole, sucralfate (15 cases) and broad-spectrum antibiotics (7 cases) was provided. The condition resolved in all patients. Ten patients in the group died of other causes (coexisting illnesses). CONCLUSIONS: Acute necrotizing esophagitis was more commonly recognized than has previously been reported. It is a serious clinical entity that should be considered in the differential diagnosis of upper gastrointestinal bleeding, particularly in elderly patients. The prognosis depends more on the patient's advanced age and on comorbid illnesses than on the course of the esophageal lesions, which resolved in all patients in this series.

Molecular and biochemical characterization of the Neurospora crassa glycogen synthase encoded by the gsn cDNA.

Glycogen synthases catalyze the transfer of a glucosyl moiety from a nucleotide phosphosugar to a nascent glycogen chain via an alpha1-->4 linkage. Although many genes coding for glycogen synthases have been described, the enzymes from rabbit and yeast are the best characterized. The fungus Neurospora crassa accumulates glycogen during exponential growth, and mobilizes it at the onset of stationary phase, or when placed at high temperature or starved for carbon. Through a PCR methodology, the gsn cDNA coding for the N. crassa glycogen synthase was isolated, and the amino acid sequence of the protein was deduced. The product of the cDNA seems to be the only glycogen synthase present in N. crassa. Characterization of the gsn cDNA revealed that it codes for a 706-amino acids protein, which is very similar to mammalian and yeast glycogen synthases. Gene expression increased during exponential growth, reaching its maximal level at the end of the exponential growth phase, which is consistent with the pattern of glycogen synthase activity and glycogen level. Expression of the gsn is highly regulated at the transcriptional level. Under culture conditions that induce heat shock, conidiation, and carbon starvation, expression of the gsn gene was decreased, and glycogen synthase activity and glycogen content behaved similarly.