Does anticholinergics drug burden relate to global neuro-disability outcome measures and length of hospital stay?

PRIMARY OBJECTIVE: To assess the relationship between disability, length of stay (LOS) and anticholinergic burden (ACB) with people following acquired brain or spinal cord injury. RESEARCH DESIGN: A retrospective case note review assessed total rehabilitation unit admission. METHODS AND PROCEDURES: Assessment of 52 consecutive patients with acquired brain/spinal injury and neuropathy in an in-patient neuro-rehabilitation unit of a UK university hospital. Data analysed included: Northwick Park Dependency Score (NPDS), Rehabilitation complexity Scale (RCS), Functional Independence Measure and Functional Assessment Measure FIM-FAM (UK version 2.2), LOS and ACB. Outcome was different in RCS, NPDS and FIM-FAM between admission and discharge. MAIN OUTCOMES AND RESULTS: A positive change was reported in ACB results in a positive change in NPDS, with no significant effect on FIM-FAM, either Motor or Cognitive, or on the RCS. Change in ACB correlated to the length of hospital stay (regression correlation = -6.64; SE = 3.89). There was a significant harmful impact of increase in ACB score during hospital stay, from low to high ACB on NPDS (OR = 9.65; 95% CI = 1.36-68.64) and FIM-FAM Total scores (OR = 0.03; 95% CI = 0.002-0.35). CONCLUSIONS: There was a statistically significant correlation of ACB and neuro-disability measures and LOS amongst this patient cohort.

Clinical symptomatology of coronary artery disease and results of exercise thallium scintigraphy: gender-related differences.

Exercise thallium stress test is the mainstay of the noninvasive assessment of patients with symptomatology suggestive of coronary artery disease. The diagnostic accuracy of thallium scintigraphy as a screening test for coronary artery disease in women as compared to men, however, remains controversial. In order to determine whether gender-related differences in the detection of coronary artery disease using exercise thallium scintigraphy are demonstrable in all age groups, we analyzed the exercise thallium results in 335 outpatients (189 male, 146 female), who were referred by their primary physicians to our institution for evaluation of clinically suspected coronary artery disease. Overall, 50.3 percent of men had a positive for ischemia thallium stress test vs 29.5 percent of women (p < 0.0002). In the subgroup of patients 65 years of age or above, 67.4 percent of men had a positive for ischemia thallium stress test vs 27.6 percent of women (p < 0.003). In the subgroup of patients upto 40 years of age, 37.9 percent of men had a positive for ischemia thallium stress test vs 25.0 percent of women (p = NS). We conclude that symptoms suggestive of coronary artery disease are less predictive of positive exercise thallium stress tests in women as compared to men even above age 65 when the prevalence of coronary artery disease is known to be similar. This suggests that women may have lower threshold for perception of symptoms or that physicians have lower threshold for referring women for screening of coronary artery disease.

Gender differences in modulation of peripheral vascular adrenoceptors.

We have previously demonstrated that women have smaller digital vasoconstrictive responses to intra-arterial phenylephrine and clonidine than men. Subsequent research suggested that women have higher levels of peripheral vascular sympathetic tone than men. We therefore sought to determine if reducing sympathetic tone by reflex heating would affect the sex difference in peripheral vascular α-adrenergic responsiveness. Twenty-two normal male and 21 normal female volunteers were studied during either heated or unhealed conditions while phenylephrine HCL and clonidine HCL were infused through a brachial artery catheter. Phenylephrine caused greater vasoconstriction in men than in women which was unaffected by heating. Clonidine also caused significantly greater vasoconstriction in men than in women. However, heating significantly increased clonidine-induced vasoconstriction in women but not in men. These data suggest that reduction of sympathetic tone elevates peripheral vascular α2-adrenergic sensitivity in women; this effect does not occur in men.

Cold-induced potentiation of alpha 2-adrenergic vasoconstriction in primary Raynaud's disease.

OBJECTIVE: To determine the effects of local cooling on alpha-adrenergic responses in the fingers of patients with idiopathic Raynaud's disease. METHODS: Clonidine HCl and phenylephrine HCl were administered through a brachial artery catheter while blood flow was measured by plethysmography in cooled and uncooled fingers. RESULTS: Cooling potentiated alpha 2-adrenergic vasoconstriction in the patients but depressed this response in the controls. Vasoconstrictive responses to phenylephrine were not significantly affected by cooling but were significantly greater in the patients than in the controls. CONCLUSION: Cold-induced sensitization of peripheral vascular alpha 2-adrenoceptors may be involved in the mechanism by which cooling triggers the vasospastic attacks of Raynaud's disease.

Local temperature modulates alpha 1- and alpha 2-adrenergic vasoconstriction in men.

Previous work in the canine saphenous vein has shown that cooling augments alpha 2- but not alpha 1-mediated contractile responses and that warming produces the opposite effects. Here we sought to determine whether these results occur in the human finger, a cutaneous vascular bed. Healthy men received brachial artery infusions of phenylephrine and clonidine with and without yohimbine while sympathetic tone was reduced by hearing the legs. Finger blood flow was recorded by venous occlusion plethysmography from two fingers, one cooled and one uncooled, on each hand. Cooling augmented alpha 2-adrenergic vasoconstriction produced by clonidine; this effect was reduced by yohimbine, an alpha 2-adrenergic antagonist. In contrast, cooling abolished alpha 1-adrenergic vasoconstriction produced by phenylephrine, which was not affected by yohimbine. Further studies were conducted in which fingers were warmed rather than cooled. Warming augmented alpha 1- but reduced alpha 2-adrenergic vasoconstriction. Thus, in human fingers, cooling augments alpha 2- and suppresses alpha 1-adrenergic vasoconstriction, whereas warming produces the opposite effects.

Clinical and hemodynamic performance of the Ionescu-Shiley valve in the small aortic root. Results in 117 patients with 17 and 19 mm valves.

The Ionescu-Shiley pericardial valve was our bioprosthetic valve of choice between 1981 and 1985 for patients in whom the aortic anulus could not accept a valve larger than 19 mm in outer diameter or in whom the avoidance of warfarin sodium (Coumadin) was important. A series of 117 consecutive patients who received 17 or 19 mm valves for isolated aortic valve replacement or aortic valve replacement combined with coronary artery bypass grafting or other valvular procedures was analyzed. Overall, 74% of the patients were female, with a mean age of 70.9 years and a body surface area of 1.67 +/- 0.19 m2; 92.3% were in New York Heart Association class III-IV, and the operation was urgent or emergent in 46%. The operative mortality rate was 7.7%, with no deaths in patients undergoing isolated elective first-time aortic valve replacement. Mean follow-up for survivors was 2.5 years (10 to 62 months). There were 20 late deaths, of which three were valve related, three were due to sudden death or arrhythmias, and two were due to persistent heart failure. The actuarial survival rate at 5 years was 68%. Clinical follow-up revealed a low incidence of valve-related complications, and 96.4% of survivors were in class I-II. Postoperative echocardiography before hospital discharge revealed a maximum instantaneous gradient of 18.4 +/- 3.0 mm Hg in five patients having a 17 mm valve and 31.3 +/- 12.7 mm Hg in 20 patients having a 19 mm valve. Doppler echocardiography was performed in 22 patients at a mean follow-up of 39.3 +/- 11.7 months. The maximum instantaneous gradient was 25 +/- 17.2 mm Hg for 17 mm and 17.41 +/- 5.4 mm Hg for 19 mm valves at late follow-up. The effective orifice area was 0.85 +/- 0.1 cm2 for 17 mm and 1.21 +/- 0.21 cm2 for 19 mm valves. This study defines the normal range of Doppler echocardiographic transprosthetic gradients for the Ionescu-Shiley valve and confirms that low operative mortality and excellent clinical improvement can result from the use of small Ionescu-Shiley valves in elderly patients despite moderate postoperative transvalvular gradients.