¿Es segura la coleciestectomía laparoscópica ambulatoria en turno de tarde? / Is ambulatory laparoscopic cholecystectomy safe to perform on the afternoon shift?

INTRODUCCIÓN: La colecistectomía laparoscópica (CL) se considera el tratamiento quirúrgico recomendable para los pacientes portadores de esta entidad clínica. Uno de los beneficios es la pronta recuperación. Objetivos: El objetivo general de este estudio fue el de determinar la utilidad del régimen ambulatorio en pacientes sometidos a CL, bajo control perioperatorio. MATERIAL Y MÉTODOS: Se realizó un estudio de serie de casos en 150 pacientes programados para CL. Se analizaron las variables hemodinámicas en dos fases: Chi cuadrado, con p < 0,05. También se abordó el análisis del tiempo de duración de la intervención quirúrgica, el tiempo de recuperación posoperatoria y la valoración de Aldrete para cirugía ambulatoria. RESULTADOS: Fueron evaluados como: ASA I = 87 (58 %), ASA II = 63 (42 %). Las variables antropométricas: edad: X = 37,7 ± 15 DE. Peso: X = 70,88 ± 26. La duración de la cirugía fue: X = 66,5 ± 22 minutos. El tiempo de estancia posoperatoria fue: X = 5,55 ± 1,2 horas. Las variables hemodinámicas analizadas con T Pareada no muestran diferencias estadísticamente significativas. La valoración de Aldrete para pacientes ambulatorios fue de X = 19 puntos. CONCLUSIONES: El 100 % de los pacientes controló el dolor y fueron ambulatorios. De acuerdo con nuestros hallazgos, nos permitimos proponer a la colecistectomía laparoscópica para su adecuación en el régimen ambulatorio bajo manejo perioperatorio

INTRODUCTION: Laparoscopic Cholecystectomy (LC) is considered the recommended surgical treatment for patients with this clinical entity. One of the benefits is the speedy recovery.Objectivs: The general objective of this study was to determine the utility of the ambulatory regimen in patients undergoing CL, under perioperative control. MATERIAL AND METHOD: A case series study was carried out on 150 patients scheduled for LC. The hemodynamic variables were analyzed in two phases; when entering the unit and being discharged (through Paired T, with p < 0,05), the presence of pain (analysed visual scale) was also analyzed using Chi Square (X2), with p < 0,05. The analysis of the duration of the surgical intervention, the postoperative recovery time and the evaluation of Aldrete for Ambulatory Surgery were also addressed. RESULTS: They were evaluated as: ASA I = 87 (58 %), ASA II = 63 (42 %). The anthropometric variables: age: X = 37.7 years ± SD 15. Weight: X = 70,88 kg ± SD 26. The duration of the surgery was: X = 66.5 ± 22 minutes. The postoperative stay time was: X = 5.55 ± SD 1.2 hours. The hemodynamic variables analyzed with Paired T, do not show statistically significant differences. The Aldrete assessment for outpatients was X = 19 points. CONCLUSIONS: 100 % of the patients had pain control and were ambulatory. According to our findings, we allow us to propose laparoscopic cholecystectomy for its adaptation in the ambulatory regimen under perioperative managemen

Association between lifetime headache and history of suicide attempts in the elderly.

BACKGROUND: Pain-related conditions have been reported to play a key role among risk factors for suicide. Headache in particular has been repeatedly associated with suicidal thoughts and behaviors. The aims of this study were: 1) to assess the association between lifetime headache (both non-migrainous headache and migraine) and lifetime suicide attempts (SA); 2) to differentiate, within subjects with lifetime SA, patients with and without lifetime headache in terms of socio-demographic and clinical features. METHODS: We studied 1965 subjects from a cohort of community-dwelling persons aged 65 years and over without dementia (the ESPRIT study), divided in two groups: those with (n=75), and those without a lifetime SA (n=1890). Logistic regression analyses were used to compare these groups according to lifetime headache status. RESULTS: After adjusting for gender, living alone, tobacco and alcohol consumption, and depressive, manic/hypomanic and anxiety disorders, lifetime headache frequency was significantly higher in subjects with a lifetime SA compared with controls (OR=1.92 [1.17-3.15]). Additionally, different factors were identified as being associated with lifetime SA in participants with lifetime headache (female gender, a lower level of high-density lipoprotein cholesterol, insomnia, lifetime major depression) versus participants without headache (glycemia and lifetime major depression). CONCLUSIONS: Lifetime headache was associated with lifetime SA. Subjects who are women and report the co-occurrence of headache and insomnia as well as lifetime major depression require higher attention and a careful screening for suicidal thoughts and behaviors.

Designing prevention programmes to reduce incidence of dementia: prospective cohort study of modifiable risk factors.

OBJECTIVE: To estimate the percentage reduction in incidence of dementia that would be obtained if specific risk factors were eliminated. DESIGN: Prospective seven year cohort study. SETTING: General population, Montpellier, France. PARTICIPANTS: 1433 people aged over 65 with a mean baseline age of 72.5 (SD 5.1) years. MAIN OUTCOME MEASURES: Diagnosis of mild cognitive impairment or dementia established by a standardised neurological examination. RESULTS: Cox models were constructed to derive hazard ratios and determine confounding and interaction effects for potentially modifiable risk factors for dementia. Mean percentage population attributable fractions were calculated with 95% confidence intervals derived from bootstrapping for seven year incidence of mild cognitive impairment or dementia. The final model retained crystallised intelligence (population attributable fraction 18.11%, 95% confidence interval 10.91% to 25.42%), depression (10.31%, 3.66% to 17.17%), fruit and vegetable consumption (6.46%, 0.15% to 13.06%), diabetes (4.88%, 1.87% to 7.98%), and apolipoprotein E epsilon4 allele (7.11%, 2.44% to 11.98%). CONCLUSIONS: Increasing crystallised intelligence and fruit and vegetable consumption and eliminating depression and diabetes are likely to have the biggest impact on reducing the incidence of dementia, outweighing even the effect of removing the principal known genetic risk factor. Although causal relations cannot be concluded with certainty, the study suggests priorities that may inform public health programmes.

Leisure activities and the risk of dementia in the elderly: results from the Three-City Study.

OBJECTIVE: There is accumulating evidence that involvement in leisure activities may be related to risk of dementia; however, there is no consensus concerning the underlying mechanism of this association. Hypothesizing that leisure activities may contribute to cognitive reserve (CR), we examined the association between leisure activities and risk of incident dementia and its subtypes within a general population sample, categorizing leisure activity as stimulating, passive, physical, and social. The possibility that these associations may be driven by other proxies of CR was also examined. METHODS: Analyses were carried out on 5,698 dementia-free participants aged 65 and over included in the Three-City cohort study in Dijon and Montpellier (France) in 1999-2001. Hazard ratios (HR) were calculated for incident dementia and its subtypes (mixed/vascular dementia and Alzheimer disease) in relation to category of leisure activity. RESULTS: Stimulating leisure activities were found to be significantly associated with a reduced risk of dementia (n = 161, HR = 0.49, 95% confidence interval [CI]: 0.31; 0.79) and Alzheimer disease (n = 105, HR = 0.39, 95% CI: 0.21; 0.71) over the 4-year follow-up 1) independently of other proxies of CR, 2) after adjusting for vascular risk factors, depressive symptoms, and physical functioning, and 3) independently of other leisure activities. Furthermore, no significant association was found with other leisure activities and dementia after controlling for the potential confounders. CONCLUSION: Our findings support the hypothesis that cognitively stimulating leisure activities may delay the onset of dementia in community-dwelling elders.

Risk profiles for mild cognitive impairment and progression to dementia are gender specific.

OBJECTIVE: To examine risk factors for mild cognitive impairment (MCI) and progression to dementia in a prospective community-based study of subjects aged 65 years and over. METHODS: 6892 participants who were over 65 and without dementia were recruited from a population-based cohort in three French cities. Cognitive performance, clinical diagnosis of dementia, and clinical and environmental risk factors were evaluated at baseline and 2-year and 4-year follow-ups. RESULTS: 42% of the population were classified as having MCI at baseline. After adjustment for confounding with logistic regression models, men and women classified as having MCI were more likely to have depressive symptomatology and to be taking anticholinergic drugs. Men were also more likely to have a higher body mass index, diabetes and stroke, whereas women were more likely to have poor subjective health, to be disabled, to be socially isolated, and to suffer from insomnia. The principal adjusted risk factors for men for progression from MCI to dementia in descending order were ApoE4 allele (OR = 3.2, 95% CI 1.7 to 5.7), stroke (OR = 2.8, 95% CI 1.2 to 6.9), low level of education (OR = 2.3, 95% CI 1.3 to 4.1), loss of Instrumental Activities of Daily Living (IADL) (OR = 2.2, 95% CI 1.1 to 4.5) and age (OR = 1.2, 95% CI 1.1 to 1.2). In women, progression is best predicted by IADL loss (OR = 3.5, 95% CI 2.1 to 5.9), ApoE4 allele (OR = 2.3, 95% CI 1.4 to 4.0), low level of education (OR = 2.2, 95% CI 1.3 to 3.6), subclinical depression (OR = 2.0, 95% CI 1.1 to 3.6), use of anticholinergic drugs (OR = 1.8, 95% CI 1.0 to 3.0) and age (OR = 1.1, 95% CI 1.1 to 1.2). CONCLUSIONS: Men and women have different risk profiles for both MCI and progression to dementia. Intervention programmes should focus principally on risk of stroke in men and depressive symptomatology and use of anticholinergic medication in women.

Life-time history of suicide attempts and coronary artery disease in a community-dwelling elderly population.

BACKGROUND: Numerous studies have observed a strong relationship between coronary artery disease (CAD) and psychiatric disorder; notably depression, anxiety and panic attacks. No study has, however, explored the question of whether persons suffering from CAD might also be at high risk of suicide attempts. OBJECTIVE: The aim of the present study is to examine the relationship between CAD within a general population cohort and life-time history of psychiatric disorder and suicidal behaviour. METHOD: A representative sample of 1,843 non-institutionalized persons over 65, drawn at random from the electoral roll, was given a standardized neurological and psychiatric examination based on DSM-IV criteria. The clinical examination also included an electrocardiogram (ECG) and a questionnaire relating to life-time medical history. Cardiac events were validated by the general practitioner. RESULTS: Within this general population sample the prevalence of suicide attempts was 3.9%. A significant positive association was observed between life-time prevalence of CAD and suicide attempts (p<0.04). Suicide attempts were associated with major depression (p<0.001) co-morbid anxiety and depression (p<0.001) but not anxiety alone (p=0.16). A logistic regression analysis showed that the relationship between suicide attempts and CAD persists after adjustment for depression and anxiety. CONCLUSION: CAD is associated with suicidal behaviour independently of depression, however, longitudinal studies are required to clarify the direction of causality and to integrate genetic, biological, environmental and psychological factors into an aetiological model.

[Subhepatic abscess as a late complication of missed intraperitoneal gallstone after laparoscopic cholecystectomy]. / Absceso subhepático como complicación tardía de un cálculo intraperitoneal abandonado tras una colecistectomía laparoscópica.

Laparoscopic cholecystectomy is the treatment of choice in symptomatic cholelithiasis. Despite its many advantages over the conventional laparotomic approach, accidental perforation of the gallbladder with spilled stones and bile leakage is frequent during this procedure. Complications from missed gallstones are uncommon, although they can sometimes lead to severe consequences. Great effort must be made to achieve laparoscopic retrieval of all the gallstones missed into the peritoneal cavity and conversion to an open procedure should be used only in selected cases. We report a case of subhepatic abscess as a late complication of a missed gallstone during a previous laparoscopic cholecystectomy.

[Primary hepatic actinomycosis]. / Actinomicosis hepática primaria.

Primary hepatic actinomycosis is a rare infection that can clinically be confused with hepatic pyogenous abscesses or neoproliferative processes. We present the case of a 71-year-old man who had previously undergone total gastrectomy for gastric adenocarcinoma. After 4 years of favorable clinical course he presented a space-occupying lesion in the right hepatic lobe. Diagnostic tests were nonspecific and the diagnosis was confirmed by histological study of a biopsy of the lesion obtained through laparotomy. Prolonged antibiotic treatment produced a complete response. The etiopathogenesis and diagnostic-therapeutic options of hepatic actinomycosis are reviewed.

Neuroanatomical localisation and clinical correlates of white matter lesions in the elderly.

BACKGROUND: White matter lesions (WML) in elderly people co-occur with hypertension, depression, and cognitive impairment. Little is known about the density and distribution of WML in normal elderly people, whether they occur randomly in the aging brain or tend to cluster in certain areas, or whether patterns of WML aggregation are linked to clinical symptoms. OBJECTIVES: To describe patterns of WML distribution in a large representative population of elderly people using non-inferential cluster analysis; and to determine the extent to which such patterns are associated with clinical symptomatology. METHOD: A population sample of 1077 elderly people was recruited. Multiple analysis of correspondence followed by automatic classification methods was used to explore overall patterns of WML distribution. Correspondence was then sought between these patterns and a range of cerebrovascular, psychiatric, and neurological symptoms. RESULTS: Three distinct patterns of spatial localisation within the brain were observed, corresponding to distinct clusters of clinical symptoms. In particular WML aggregation in temporal and occipital areas was associated with greater age, hypertension, late onset depressive disorder, poor global cognitive function, and overall WML frequency. CONCLUSIONS: WML localisation is not random in the aging brain, and their distribution is associated with age and the presence of clinical symptoms. Age differences suggest there may be patterns of progression across time; however, this requires confirmation from longitudinal imaging studies.

Prevalence of DSM-IV psychiatric disorder in the French elderly population.

BACKGROUND: France has high rates of psychotropic drug consumption and suicide in the elderly population, but it has not yet been possible to determine whether this is due to exceptionally high morbidity rates. AIMS: To describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder. METHOD: A study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM-IV criteria were re-examined by a clinical panel. RESULTS: Forty-six per cent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis. CONCLUSIONS: Results show very high rates of lifetime but not current major depression. Rates of current phobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.

The detection of mild cognitive impairment in the general practice setting.

Results from a general practice study of cognitive impairment are used to construct guidelines for the detection of mild cognitive impairment (MCI) in general practice. The role of the general practitioner in the diagnosis of MCI is discussed and the potential feasibility of general practice screening is evaluated with data from a two-year prospective study conducted in the Montpellier region of France. Neuropsychological tests with the highest predictive value for dementia conversion and suitable for use in general practice, were determined by logistic regression modelling. An examination comprising three tests (delayed auditory verbal recall, verbal fluency and visuospatial construction), were found to give a specificity of 99% and sensitivity of 73%. Reports from other research centres suggest that MCI detection should not be limited to cognitive performance alone. It is suggested that proxy observations of behavioural change and information relating to loss of ability to perform activities of daily living should also be used to improve sensitivity and also to provide information needed in patient management. It may be potentially feasible for the family practitioner to verify cognitive complaints and to screen for MCI with a high degree of accuracy using a brief test battery derived from empirical observations in population studies.

Prediction of transition from cognitive impairment to senile dementia: a prospective, longitudinal study.

OBJECTIVE: The purpose of this investigation was to replicate the statistical approach used in a previous investigation (Toronto study) within a French population to determine the best predictive model for Alzheimer's disease (AD). METHOD: Data from neuropsychological tests from two prospective studies were entered into a regression model. RESULTS: Replication of the statistical approach in the Montpellier sample produced a three-test model with a specificity of 99% and sensitivity of 73%. This model consisted of a delayed auditory verbal recall test, a construction test, a category fluency test and provides probability estimates for the transition to dementia in individual cases. CONCLUSION: The models derived from these two longitudinal studies provide an empirical basis for the selection of tests for the definition of mild cognitive impairment of the Alzheimer type (MCI-A). The small set of tests derived are suitable for use in general practice.

[Mild cognitive decline in the elderly: nosology and clinical status]. / Le déclin cognitif léger chez les personnes âgées: nosologie et statut clinique.

Cognitive impairment without dementia is common in elderly persons and causes significant impairment in capacity to perform everyday activities. A number of nosological entities have been proposed for the classification of sub-clinical cognitive dysfunction. The more recent concepts assume an underlying organic condition, in particular the presence of early stage dementia. While prospective studies suggest that persons with mild cognitive disorder have a high risk of developing dementia, long-term follow-up of subjects with mild cognitive impairment suggests that dementia alone does not explain all cases. Cognitive disorder in the elderly must be construed as a common outcome for a number of interacting pathologies whose expression is also mediated by genetic, environmental and social factors.

Disability and mild cognitive impairment: a longitudinal population-based study.

OBJECTIVE: To determine whether mild cognitive deficit is associated with parallel changes in ability to perform activities of daily living. BACKGROUND: While considerable research has been conducted on the effect of senile dementia and other neurodegenerative disorders on ability to perform everyday activities, little is known about the much larger group of elderly persons suffering from mild cognitive deficits. METHODS: Disability prevalence was estimated in 368 persons over the age of 65 years recruited from the general population via a general practitioner network. Subjects were followed over a 3-year period using computerized cognitive assessment and observations of everyday functioning. Standardized neurological assessment in the third year permitted the identification of subjects who have evolved towards dementia. RESULTS: An overall disability prevalence was found in the general population of 26.3%, with 30.8% in subjects with sub-clinical cognitive impairment. Longitudinal follow-up showed cognitive decline over time without dementia to be paralleled by changes in activity performance, with visuospatial deficits having the most marked effect on overall functioning. High intelligence quotient (IQ) and education are seen to reduce the degree of activity loss, but only when senile dementia is not present. CONCLUSIONS: Difficulties in the performance of everyday activities were found more frequently in non-demented subjects with mild cognitive deficits than in the general population. High pre-morbid levels of ability are seen to have a protective effect. A diagnosis of dementia should not therefore be required by persons with cognitive impairment applying for home help.

Classification criteria for mild cognitive impairment: a population-based validation study.

OBJECTIVE: To evaluate the predictive validity and temporal stability of diagnostic criteria for mild cognitive impairment (MCI). BACKGROUND: MCI has been proposed as a nosologic entity referring to elderly persons with subclinical cognitive deficits due to incipient dementia. Classification criteria, which have been derived from small, selected clinical groups, are currently disputed, and have not yet been assessed within the general population. METHODS: Subjects meeting current criteria for MCI and also age-associated cognitive decline (AACD-a similar concept that is assumed to be related to normal cognitive aging processes rather than incipient dementia) were identified within each of three waves of a longitudinal population study, which included a standardized neurologic examination. RESULTS: In the general population, the prevalence of MCI was estimated to be 3.2% and AACD 19.3%. MCI was a poor predictor of dementia within a 3-year period, with an 11.1% conversion rate. Subjects with MCI also constituted an unstable group, with almost all subjects changing category each year. Discriminant function analysis failed to isolate a homogeneous clinical group. Subjects classified as AACD, contrary to the theoretical assumptions underlying the disorder, represented a more stable group, with a 28.6% conversion rate to dementia over 3 years (relative risk = 21.2). CONCLUSION: MCI criteria perform poorly when applied to a representative population sample. The authors propose modifications to current diagnostic criteria to increase their capacity to detect incipient dementia.

The telostei immunoglobulin light IGL1 and IGL2 V, J and C genes.

'Teleostei Immunoglobulin Light IGL1 and IGL2 V, J and C Genes', the 12th report of the 'IMGT Locus in Focus' section, comprises 8 tables: (1) 'Teleostei IGL1V genes'; (2) 'Teleostei germline IGL1J genes'; (3) 'Teleostei IGL1C genes and alleles'; (4) 'Teleostei IGL2V genes'; (5) 'Teleostei germline IGL2J genes'; (6) 'Teleostei IGL2C genes and alleles'; (7) 'FR-IMGT and CDR-IMGT length of the Teleostei IGL1V genes', and (8) 'FR-IMGT and CDR-IMGT length of the Teleostei IGL2V genes'. These tables are available on the IMGT Marie-Paule page from IMGT, the international ImMunoGeneTics database (http://imgt.cines.fr: 8104) created in 1989 by Marie-Paule Lefranc, Université Montpellier II, CNRS, France.

The Teleostei immunoglobulin heavy IGH genes.

'Teleostei Immunoglobulin Heavy IGH Genes', the eleventh report of the 'IMGT Locus in Focus' section, comprises four tables: (1) 'Teleostei IGHV genes'; (2) 'Teleostei germline IGHJ genes'; (3) 'Teleostei IGHC genes and alleles'; (4) 'FR-IMGT and CDR-IMGT length of the Teleostei IGHV genes'. These tables are available at the IMGT Marie-Paule page from IMGT, the international ImMunoGeneTics database (http://imgt.cines.fr: 8104) created in 1989 by Marie-Paule Lefranc, Université Montpellier II, CNRS, France.