Effect of fetal number on maternal serum uric acid concentration

The aim of this study was to examine whether maternal serum uric acid (UA) concentrations are influenced by the number of fetuses and whether this effect is confounded by maternal body mass index (BMI). Medical records of 207 consecutive twin and 69 triplet pregnancies admitted to our high-risk pregnancy unit between 1994 and 1998 were reviewed. Pregnancies complicated by acute or chronic renal diseases, vascular diseases, hypertension, hemolysis, diabetes mellitus, or proteinuria were excluded. The remaining 137 twin and 42 triplet pregnancies were matched with 118 consecutive singleton pregnancies who met the same exclusion criteria and were admitted in the first half of 1998. Each birth order study group was further stratified and compared within three maternal BMI subgroups. Serum UA concentrations were higher in twin and triplet pregnancies compared to singletons (4.6 +/- 1.3, 5.2 +/- 1.2, and 3.8 +/- 0.7 mg%, respectively; p <0.01). These differences in UA concentration persisted after grouping by BMI classes. Serum UA concentration in pregnancy are positively correlated with the number of fetuses. For clinical purpose, the UA cutoff concentration should be adjusted using mean + 2 SD as follows: 5.2, 7.2, and 7.6 for singleton, twin, and triplets, respectively.     

Law and geriatrics: an Israeli perspective on future challenges

This paper describes current problems in Israel in the fields of geriatric medicine and elder law. The background to the problems is discussed, with a commentary on the deficiencies in everyday practice. The author presents proposals for change both in the legislative system and in application of acceptable standards of medical care and practical use of improved legal provision.     

Anesthetic management of juvenile nasopharyngeal angiofibroma resection

OBJECTIVE: To evaluate the anesthetic implications of the surgical resection of juvenile nasopharyngeal angiofibroma (JNA). DESIGN: Retrospective study. SETTING: University-affiliated community hospital. PARTICIPANTS: Ten patients undergoing resection of JNA. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from the records of 10 patients undergoing resection of JNA were reviewed and analyzed with regard to demographics, history of the disease, characteristics of the tumor, surgical resection techniques, and anesthetic management. Patients were age 11 to 29 years. All had nasal obstruction as presenting symptom. There was no intracranial invasion. Eight tumors were resected via a lateral rhinotomy and 2 endoscopically (after embolization of the tumor's feeding vessels). Duration of surgery was 6 +/- 1 hours for rhinotomy and 6 and 6.5 hours for the 2 endoscopic resections. Anesthesia was induced in a rapid-sequence manner. Arterial and central venous catheters were placed in all patients. Mean arterial pressure was targeted to 55 to 65 mmHg by using increasing concentrations of isoflurane. The estimated blood loss was 4,800 +/- 1,600 mL and blood replacement was 3,200 +/- 1,400 mL in the first group. The 2 other patients lost 600 mL and 1,500 mL. Blood replacement in this group was 0 and 700 mL respectively. No mortality or major morbidity occurred. CONCLUSION: Resection of JNA should be considered a major procedure with many anesthetic challenges. Isoflurane may be employed to provide deliberate hypotension.     

Effect of late initiation of levodopa treatment in patients with long-standing Parkinson's disease

The time of initiation of levodopa therapy in patients with Parkinson's disease (PD) is still debatable, as is the hypothesis of levodopa toxicity Some researchers argue that late initiation of treatment will delay the appearance of response fluctuations. In the present study, 11 patients in whom treatment with low doses of levodopa was delayed for a mean of 7.9 +/- 3.1 years were followed for a mean of 15.7 +/- 3.3 years. Time of onset of response fluctuations and disease severity were compared with those in 17 patients with fluctuating PD who were treated with levodopa from disease onset. There was no significant change in time to onset of response fluctuations and dyskinesias once levodopa treatment was started, and late initiation of levodopa did not affect disease progression. The authors conclude that the decision of when to initiate levodopa treatment should be taken according to the patient's needs.     

Liposomal amphotericin B treatment for rhinocerebral mucormycosis: how much is enough?

Rhinocerebral Mucormycosis is a potentially life-threatening disease, which affects mainly immunocompromised patients. Treatment options include reversing immunosuppression, surgery and systemic and local administration of anti-fungal medication. Amphotericin B is the primary agent employed, but its use is often limited by frequent side effects. Complexing Amphotericin B with lipid structures avoids most of the negative side effects, most importantly the dose-limiting nephrotoxicity. No consensus has been reached regarding the appropriate duration, rate of administration or total dose of treatment. We present a case of a patient suffering from Rhinocerebral Mucormycosis treated by extensive surgery and Liposomal Amphotericin B. He was treated for 29 days at a rate of 3 mg/kg/d and a total dose of 5.6 gram. The dose of Liposomal Aphotericin B used in previously published articles ranged from 1.5 mg/kg/d to 5 mg/kg/d. The response to treatment may be evaluated by physical examination, microbiological cultures, radiological and pathological studies. Taking into account the considerable cost of liposomal Amphotericin B and other lipid complexed formulations, it is imperative to find out what is the appropriate treatment regime for Rhinocerebral and other mucormycosis infections.     

Intramuscular ziprasidone treatment of acute psychotic agitation in elderly patients with schizophrenia.

OBJECTIVE: Intramuscular (i.m.) ziprasidone treatment has been shown to be effective and well tolerated in reducing the symptoms of acute psychosis in adults. Few data are available as to safety in the elderly. The growing utilization of health services by elderly psychiatric patients warrants an evaluation in this population. METHOD: Consecutive elderly patients (60 years of and older) admitted to a psychogeriatric ward in a large, university-affiliated tertiary psychiatric center were treated by i.m. ziprasidone for acute psychotic agitation. Patients received three days of flexible-dose i.m. ziprasidone. After an initial dose of 10-20 mg, a subsequent dose of 10-20 mg could be given after 12 hours if needed (maximum daily dose: 40 mg). RESULTS: All treatment emergent side effects and adverse events along with the investigators' assessments of severity were systematically recorded as the primary outcome. The Brief Psychiatric Rating Scale (BPRS) and the Behavioral Activity Rating Scale (BARS) were the secondary outcomes. Twenty-one patients, six male and 15 female, mean age 71.4 +/- 1.3 years (range: 60-81 years) were enrolled. All had completed the three days i.m. ziprasidone treatment. There was one adverse event in a patient with untreated benign prostatic hypertrophy who developed urinary retention. Two side effects of mild severity that resolved spontaneously were observed: blurred vision and sedation. The BPRS decreased by 26.8 points after three days of treatment (p = 0.001). The BARS score, reflecting agitation, decreased significantly after each injection, reaching maximal decrease of 2.14 points at completion of study (p = 0.001). CONCLUSION: Intramuscular ziprasidone in this series of elderly patients suggests acceptable safety and efficacy in the management of acute psychotic agitation among elderly patients with schizophrenia.     

Viral prophylaxis in organ transplant patients

Viral pathogens have emerged as the most important microbial agents having deleterious effects on solid organ transplant (SOT) recipients. Antiviral chemoprophylaxis involves the administration of medications to abort transmission of, avoid reactivation of, or prevent progression to disease from, active viral infection. Cytomegalovirus (CMV) is the major microbial pathogen having a negative effect on SOT recipients. CMV causes infectious disease syndromes, augments iatrogenic immunosuppression and is commonly associated with opportunistic superinfection. CMV has also been implicated in the pathogenesis of rejection. Chemoprophylactic regimens for CMV have included oral aciclovir (acyclovir) at medium and high doses, intravenous and oral ganciclovir, and the prodrugs valaciclovir (valacyclovir) and valganciclovir. CMV prophylactic strategies should be stratified, with the highest-risk patients receiving the most 'potent' prophylactic regimens. Herpes simplex virus (HSV) reactivation in SOT recipients is more frequent, may become more invasive, takes longer to heal, and has greater potential for dissemination to visceral organs than it does in the immunocompetent host. Prophylactic regimens for CMV are also effective chemoprophylaxis against HSV; in the absence of CMV prophylaxis, aciclovir, valaciclovir or famciclovir should be used as HSV prophylaxis in seropositive recipients. Primary varicella-zoster virus (VZV) after SOT is rare and most commonly seen in the paediatric transplant population because of VZV epidemiology. Zoster occurs in 5-15% of patients, usually after the sixth post-transplant month. Prophylactic regimens for zoster are neither practical nor cost effective after SOT because of the late onset of disease and low proportion of affected individuals. All SOT recipients should receive VZV immune globulin after contact with either varicella or zoster. Epstein-Barr virus has its most significant effect in SOT as the precipitating factor in the development of post-transplant lymphoproliferative disorders. Antiviral agents that could be effective are the same as those used for CMV, but indications for and effectiveness of prophylaxis are poorly established. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are important pathogens in the SOT population as indications for transplantation. So-called 'prophylaxis' for recurrent HBV and HCV after liver transplantation is controversial, suppressive rather than preventive, and potentially lifelong. Influenza infection after SOT is acquired by person-to-person contact. During epidemic periods of influenza, transplant populations experience a relatively high frequency of infection, and influenza may affect immunosuppressed SOT recipients more adversely than immunocompetent individuals. Antiviral medications for prevention of influenza are administered as post-exposure prophylaxis to SOT recipients, in addition to yearly vaccine, in circumstances such as influenza epidemics and nosocomial outbreaks, and after exposure to a symptomatic individual during 'flu season'.