Detecting impaired language processing in patients with mild cognitive impairment using around-the-ear cEEgrid electrodes.

Mild cognitive impairment (MCI) is the term used to identify those individuals with subjective and objective cognitive decline but with preserved activities of daily living and an absence of dementia. Although MCI can impact functioning in different cognitive domains, most notably episodic memory, relatively little is known about the comprehension of language in MCI. In this study, we used around-the-ear electrodes (cEEGrids) to identify impairments during language comprehension in patients with MCI. In a group of 23 patients with MCI and 23 age-matched controls, language comprehension was tested in a two-word phrase paradigm. We examined the oscillatory changes following word onset as a function of lexico-semantic single-word retrieval (e.g., swrfeq vs. swift) and multiword binding processes (e.g., horse preceded by swift vs. preceded by swrfeq). Electrophysiological signatures (as measured by the cEEGrids) were significantly different between patients with MCI and controls. In controls, lexical retrieval was associated with a rebound in the alpha/beta range, and binding was associated with a post-word alpha/beta suppression. In contrast, both the single-word retrieval and multiword binding signatures were absent in the MCI group. The signatures observed using cEEGrids in controls were comparable with those signatures obtained with a full-cap EEG setup. Importantly, our findings suggest that patients with MCI have impaired electrophysiological signatures for comprehending single words and multiword phrases. Moreover, cEEGrid setups provide a noninvasive and sensitive clinical tool for detecting early impairments in language comprehension in MCI.

Candida prosthetic valve endocarditis: the complementary role of multidetector computed tomography and transoesophageal echocardiography in preoperative evaluation.

A 72-year-old man with previous mitral valve replacement and single coronary bypass surgery was diagnosed with recurrent candida endocarditis by transoesophageal echocardiography and positive blood cultures. Preoperative electrocardiogram-gated multidetector CT (MDCT) was ordered to evaluate the patency and course of the mammary graft. In addition to verifying graft patency, MDCT demonstrated a mobile vegetation on the mitral prosthesis as well as a vegetation on the posterior left atrial wall which was not visible by transoesophageal echocardiography. Multidetector CT also revealed signs of osteomyelitis in the thoracic spine. Repeated surgery confirmed these findings and mitral valve replacement with resection of the left atrial vegetation were performed. This case illustrates the complementary role of MDCT and echocardiography in the preoperative evaluation of fungal endocarditis.

Role of endoscopic retrograde cholangiopancreatography in the management of suspected choledocholithiasis.

BACKGROUND: Indications for endoscopic retrograde cholangiopancreatography (ERCP) are not precisely defined. With the increasing availability of magnetic resonance cholangiopancreatography (MRCP) and several prospective studies proving the accuracy of this modality, it is important to select appropriate criteria for invasive testing when common bile duct (CBD) pathology is suspected. METHODS: We reviewed 200 consecutive ERCPs performed for jaundice, pancreatitis, noninvasive visualization of CBD stones, radiologic evidence of CBD dilatation, elevated liver function tests, or biliary colic. Diagnostic and therapeutic yields are determined for each indication and various combinations thereof. RESULTS: Of the 180 ERCPs performed for suspected choledocholithiasis, 97 (53.8%) were performed for multiple indications, whereas 83 (46.2%) were performed for only one indication. One hundred two patients (56.6%) had CBD pathology, whereas 78 explorations (43.4%) were negative. If multiple indications for ERCP were present, the diagnostic yield was 85.6%. When there was only one indication, the diagnostic yield decreased to 25.3%. CONCLUSIONS: ERCP is an invasive procedure with significant morbidity that should be used selectively. MRCP may be a more appropriate initial evaluation of suspected CBD pathology in many patients.

Vancomycin sequestration during cardiopulmonary bypass surgery.

OBJECTIVE: The present study was designed to analyze vancomycin disposition in adult patients undergoing coronary bypass grafting during and following cardiopulmonary bypass (CPB). METHODS: Coronary bypass surgery was performed on 11 adults with a mean age (SD) of 62.9 (9.0) years old, who received a mean (SD) vancomycin prophylactic dose of 12.7 (1.0) mg/kg in a mean period of 41 (0.7) min. Using a two-compartment open model for pharmacokinetic analysis, the following parameters were obtained: alpha half-life, minutes (t(1/2alpha)); beta half-life, hours (t(1/2beta)); apparent volume of distribution, (V(d) l/kg); volume of the central compartment, (V(c) l/kg), constant between the "central to the peripheral" compartment, (k(12)); constant between the "peripheral to the central" compartment, (k(21)); total area under the concentration-time curve, (AUC mg/lxh) and a vancomycin clearance, (Cl(van) ml/min), respectively. RESULTS: The mean (SD) calculated pharmacokinetic parameters were: t(1/2alpha)17.6 (6) min, t(1/2beta) 8.4 (3.8) h, V(d) 0.803 (0.259) l/kg, V(c) 0.270 (0.162) l/kg, k(12) 0.03 (0.015), k(21) 0.012 (0.012), total AUC 10377.2 (3687.6) mg/lxh. The mean (SD) vancomycin clearance by the CPB machine was 9.51 (2.66) l/h, and the mean (SD) total vancomycin sequestrated by CPB was 331.7 (84) mg. A significant difference (6.3%; p = 0.001) was measured between the mean measured AUC during CPB (1088.1 +/- 253.9) and the same calculated parameter (1160.2 +/- 282). Five minutes after starting CPB, a decrease in vancomycin level was detected; this difference was found to be nearly 11% in absolute values. CONCLUSIONS: This confirmatory study demonstrated that the vancomycin blood concentrations obtained during the study allow recommending a safety prophylactic dose of 12mg/kg in adults who undergo open-heart surgery under CPB conditions. Sequestration of vancomycin by the oxygenator or/and tubing system of the CPB machine had occurred and had been measured in this study.

Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections.

OBJECTIVE: This study was undertaken to compare the efficacy of vancomycin prophylaxis with that of cefazolin in preventing surgical site infections in a tertiary medical center with a high prevalence of methicillin-resistant staphylococcal infections. METHODS: All adult patients (> or = 18 years) scheduled for cardiac surgery requiring sternotomy were randomly assigned to receive vancomycin (1 g every 12 hours) or cefazolin (1 g every 8 hours). Prophylaxis was started during the induction of anesthesia and continued for only 24 hours. Patients were followed up for at least 30 days (1 year for those receiving a cardiac implant). Surgical site infections were stratified according to the National Nosocomial Infections Surveillance System risk index. RESULTS: Of the 885 patients included in the study, 452 received vancomycin and 433 received cefazolin. The overall surgical site infection rates were similar in the two groups (43 cases in the vancomycin group, 9.5%, vs 39 cases in the cefazolin group, 9.0%, P =.8). Superficial and deep incisional surgical site infection rates were also similar in the two groups. There was a trend toward more frequent organ-space infections and infections with beta-lactam-resistant organisms among patients receiving cefazolin, but this trend did not reach statistical significance. In contrast, surgical site infections caused by methicillin-susceptible staphylococci were significantly more common in the vancomycin group (17 cases, 3.7%, vs 6 cases, 1.3%, P =.04). The durations of postoperative hospitalization and the mortalities were similar in the two groups. CONCLUSIONS: This trial suggests that vancomycin and cefazolin have similar efficacy in preventing surgical site infections in cardiac surgery.

Myocardial protection in operations requiring more than 2 h of aortic cross-clamping.

OBJECTIVE: Long periods of aortic cross-clamping time during cardiac surgery are associated with high rates of morbidity and mortality because of damage to the myocardium. Recently, we have used a method of myocardial protection based on the principles of hyperkalemic cardioplegic arrest. We use antegrade administration of warm, undiluted blood followed by continuous retrograde infusion of tepid, undiluted blood supplemented with potassium and magnesium. In this study, we have retrospectively reviewed our experience with this method of cardioprotection in operations requiring more than 2 h of cross-clamp time. METHODS: We retrospectively reviewed the medical records of 1280 patients who underwent myocardial revascularization, valve repair or replacement, or a combination of both operations between January 1, 1994 and December 31, 1997. Patients were divided into two groups: the short cross-clamp group (SXC) (n = 1144) had cross-clamp times < 120 min (mean, 78 +/- 20 min; range, 35-119 min) and the long cross-clamp group (LXC) (n = 136) had cross-clamp times > 120 min (mean, 154 +/- 31 min; range, 120-277 min). We compared preoperative, operative, and postoperative variables between the two groups. RESULTS: Significantly more patients in the long cross-clamp group (43.4%) underwent the combined operation than in the short cross-clamp group (2.3%), and the rate of reoperation was significantly higher in the long cross-clamp group (12%) than in the short cross-clamp group (5%). Despite these differences in operative complexity, we found no difference in hospital mortality rates between the two groups. The only significant postoperative differences were that the long cross-clamp group had a greater need for inotropic agents (43 vs. 29%), higher serum levels of creatine kinase (880 +/- 583 vs. 613 +/- 418) and CK-MB (10.9 +/- 6.4 vs. 5.9 +/- 5.2), and a longer hospital stay (9.6 vs. 6.1 days). CONCLUSION: Long, complex operations requiring more than 2 h of cross-clamping can be performed safely with our method of cardioprotection based on continuous retrograde infusion of tepid, hyperkalemic, undiluted blood.

Punch pulmonary valvectomy: another alternative to treat critical pulmonary stenosis.

For neonates with severe valvar stenosis, or valvar pulmonary atresia with an imperforate pulmonary valve, we present a simple but effective closed procedure using a specially designed valvectomy punch. Seven neonates, who were not suitable for any type of transcatheter procedure, were treated. There were two late deaths, neither directly related to the operation; 4 patients are developing well. This approach using the valvectomy punch is a fast, safe, and effective procedure.

Lesioned low density lipoprotein in atherosclerotic apolipoprotein E-deficient transgenic mice and in humans is oxidized and aggregated.

We analyzed lesioned LDL in both atherosclerotic humans and in the apo E deficient (E degree) mice and compared its characteristics to plasma LDL. Lesioned LDL, in comparison to plasma LDL, was minimally oxidized and aggregated. Upon incubation of E degree-aortic lesions with 125[I]-labeled LDL, a time-dependent oxidation of the lipoprotein occurred as evident by a rapid and substantial elevation in LDL-associated TBARS from 0.2 to 10.3 and 14.5 nmoles of MDA equivalents/mg LDL protein after 2 and 24 hours of incubation, respectively. Only minimal LDL aggregates could be detected after 2 hours of incubation. Extensive LDL aggregation (15%), however, occurred after 24 h of incubation. Similar results were obtained on using human lesioned aortas. We conclude that both oxidation and aggregation of lesioned LDL could be the result of aortic lesioned-induced modification of the lipoprotein, and both of these modified forms of LDL can further contribute to the acceleration of the atherosclerotic process.

Clinical characteristics of second primary tumors following breast cancer.

In the Multiple Primary Tumor Registry of the Northern Israel Cancer Center we found 247 patients with breast cancer who developed a second primary tumor. The major sites of the second tumor were mainly the other breast (42%), colon (14%), ovary (8%), and endometrium (7%). Only 24% of the second tumors were diagnosed in asymptomatic patients on a routine follow-up examination; 60% of these patients had contralateral breast cancer and 8% had colon cancer. More patients in this group had localized disease as compared to those diagnosed following appearance of symptoms. The time interval between the first symptoms suggesting malignancy and the diagnosis was longer than 6 weeks in 7%, as compared to 24% in patients diagnosed with a single cancer. In 69 patients (30%), delay was found between the first medical consultation and diagnosis. The agents responsible for the delay were the specialist (32%), the system and normal tests (54%), and the patients (8%). In the diagnosis of a single tumor, the physician and the patient shared a similar percentage of responsibility (29% and 33%). Educational efforts aimed mainly at physicians and patients regarding the early detection of second primary tumors are advocated. Methods that have been proven to detect cancer early, such as mammography, stool for occult blood, and sigmoidoscopy, should be utilized in asymptomatic patients with single tumors in the same way as in the healthy population.

Clinical characteristics of patients with a second primary tumor in the endometrium or ovary.

The clinical characteristics of patients with second primary tumors in the ovary and endometrium were compared to those with single primary tumors treated at our Center during the same period of time. Despite the fact that the patients were under medical surveillance for the first primary tumor, most second tumors were diagnosed following patient symptoms and complaints, and not at a routine follow-up appointment. Patients with a second primary endometrial cancer had a more advanced stage of disease at diagnosis as compared to those with single endometrial cancer. This was not found to be true for patients with second ovarian cancer. Patients with primary breast cancer and colon cancer, lymphoma or melanoma were found to be at higher risk for developing a second primary tumor in the endometrium or ovary as compared to those with a primary tumor at other sites. Although there are no proven means for the early detection of these gynecologic malignancies, it seems prudent to draw the attention of medical practitioners to the need for a better gynecologic evaluation for women with cancer at other sites during their follow-up visits. Studies on the efficacy of currently available diagnostic techniques should be carried out to evaluate their yield in this high risk group.

Clinical, demographic, and follow-up characteristics of patients with two primary metachronous tumors, one of them being in the colon.

The clinical characteristics of 152 patients diagnosed with two primary metachronous tumors--one or both of them in the colon--were studied. Nineteen patients had both primary tumors in the colon (Group I), 59 had the first primary tumor in the colon and the second tumor elsewhere (Group II), and 74 had the second primary tumor in the colon and the first primary tumor elsewhere (Group III). The group in which the second primary tumor was in the colon included significantly more female patients than did the other two groups, with a younger median age at diagnosis of first tumor. The median time interval between the two primary tumors was 44, 57, and 62 months in Groups I, II, and III, respectively. The number of clinic visits during the year before diagnosis of the second primary was similar in all groups, but only 60 percent of the patients kept their follow-up appointment. In most instances, the diagnosis was made after the patients' symptoms, although only a small percentage of the second primary tumors (15-30 percent) were diagnosed during routine follow-up. The second primary tumor occurred in the field of radiotherapy of the first primary tumor in 27 of 35 patients who received radiotherapy. To increase the number of patients diagnosed in an earlier stage of disease, they should be urged to keep their follow-up appointment, and physicians following patients with single tumors should be aware of the increased likelihood of a second tumor. To increase the cure rate of those tumors, efforts toward early diagnosis are warranted. This includes physical examination and mammography to detect breast cancer in women, annual occult blood tests and rectal examination, and sigmoidoscopy or colonoscopy at three-year intervals to detect colon cancer early.

Early sexual abuse and clinical depression in adult life.

Sexual abuse in childhood and adolescence was studied in 286 working-class mothers living in Islington, who were contacted on three occasions over a two-year period. The sample was collected primarily to study current vulnerability factors in the onset of depression, but childhood measures were also included to look at longer-term risk factors. Twenty-five women - 9% of the sample - reported sexual abuse involving physical contact before age 17 and, of these, 64% had case depression in a three-year period (which included the year before first interview). While such abuse was related to other earlier stressful experiences such as parental indifference, violence to the child and institutional stay, it was associated with an increased risk of depression over and above these factors. Sexual abuse before age 17 also related to having been divorced/separated or never having married/cohabited.

Life events, difficulties and recovery from chronic depression.

Reductions in an overall score of ongoing difficulties and the occurrence of a 'fresh start' event often preceded the recovery or improvement of women in a general-population survey suffering from chronic depression, i.e. with episodes lasting 12 months or more. In addition, overall levels of difficulties and presence of social support were independently related to recovery or improvement. Some of the life-changes preceding recovery were threatening, but all promised some hope of a better future. Evidence is presented that the results as a whole are unlikely to be due to incipient changes in clinical condition leading the women to make changes in their environment, but some bias of this kind cannot be entirely ruled out.

Social support, self-esteem and depression.

A prospective study of 400 largely working-class women with children living at home has used measures of self-esteem and 'social support' to predict the risk of depression in the following year once a stressor had occurred. Actual support received at the time of any crisis in the follow-up year was also measured. Self-esteem was correlated quite highly with some of the measures of support. A core tie was defined as a husband, lover or someone named as very close at first contact. Negative evaluation of self (i.e. low self-esteem), and various indices of lack of support from a core tie at the first interview, were associated with a greatly increased risk of subsequent depression once a stressor occurred. Lack of support from a core tie at the time of the crisis was particularly highly associated with an increased risk. There was also a high risk among those who were 'let down' - that is, for those who did not receive the support which they might have expected in terms of the first interview material. It is concluded that it is essential for prospective enquiries to take account of the actual mobilization of support in the follow-up period.