Major abdominal surgery in octogenarians: should high age affect surgical decision-making?

Background

Over the last decades longevity has increased significantly, with more octogenarians undergoing surgery. Here, we assess surgical outcomes after major abdominal surgery in octogenarians.

Methods

Observational cohort of 874 patients undergoing major abdominal elective surgery between January 2009 and March 2014. Seventy-six octogenarians were propensity matched to 76 younger patients, corrected for sex, body mass index, American Society of Anesthesiologists classification, comorbidity, indication, and type of surgery.

Results

Minor complications were more prevalent in octogenarians (P = .01) and consisted mainly of respiratory complications; progressing to respiratory insufficiency requiring intubation in 28.6%. Preoperative weight loss (odds ratio 3 [1.1 to 8.3]) and upper gastrointestinal surgery (odds ratio 11 [2 to 60]) were associated with minor complications.

Conclusions

Octogenarians are at increased risk of minor complications after major abdominal surgery. Major complication rates were similar, indicating the importance of preoperative assessment and standardized surgical techniques. Taking into account preoperative morbidities and type of surgery and techniques. Implementation of quality control algorithms may further improve outcomes in octogenarians.     

Primary mania versus HIV-related secondary mania in Uganda

OBJECTIVE: The authors hypothesized that in the majority of HIV-positive patients presenting with mania, the mania is secondary to HIV infection and that its presentation and correlates differ from those of HIV-negative patients with primary mania. METHOD: A comparative cross-sectional study was conducted with HIV-negative and HIV-positive patients admitted to psychiatric wards with acute mania. The authors compared the patients' psychiatric, physical, and immunological (CD4 cell counts) and other laboratory parameters. Pairwise comparisons were done for the two groups on a number of variables. RESULTS: Of 141 patients who presented with acute mania during a 6-month period and were eligible for the study, 61 met criteria for HIV-related secondary mania. Compared with HIV-negative patients with primary mania, they were older, more cognitively impaired less educated, and more likely to be female. Patients in this group had more manic symptoms: they were more irritable, more aggressive, more talkative, and had higher rates of paranoid delusions, visual hallucinations, and auditory hallucinations. More of the HIV-positive secondary mania group had CD4 counts below 350 cells/mm(3). CONCLUSIONS: Primary mania and HIV-related secondary mania are clinically and immunologically distinct. The relation between secondary mania and depressed CD4 counts suggests that in the setting of an HIV/AIDS epidemic in poor countries, secondary mania may be used as an indicator to initiate highly active antiretroviral therapy.     

An informant questionnaire for detecting Alzheimer's disease: are some items better than others?

A decline in everyday cognitive functioning is important for diagnosing dementia. Informant questionnaires, such as the informant questionnaire on cognitive decline in the elderly (IQCODE), are used to measure this. Previously, conflicting results on the IQCODEs ability to discriminate between Alzheimer's disease (AD), mild cognitive impairment (MCI), and cognitively healthy elderly were found. We aim to investigate whether specific groups of items are more useful than others in discriminating between these patient groups. Informants of 180 AD, 59 MCI, and 89 patients with subjective memory complaints (SMC) completed the IQCODE. To investigate the grouping of questionnaire items, we used a two-dimensional graded response model (GRM).The association between IQCODE, age, gender, education, and diagnosis was modeled using structural equation modeling. The GRM with two groups of items fitted better than the unidimensional model. However, the high correlation between the dimensions (r=.90) suggested unidimensionality. The structural model showed that the IQCODE was able to differentiate between all patient groups. The IQCODE can be considered as unidimensional and as a useful addition to diagnostic screening in a memory clinic setting, as it was able to distinguish between AD, MCI, and SMC and was not influenced by gender or education. (JINS, 2011, 17, 674-681).     

Subventricular zone neural progenitors from rapid brain autopsies of elderly subjects with and without neurodegenerative disease

In mice and in young adult humans, the subventricular zone (SVZ) contains multipotent, dividing astrocytes, some of which, when cultured, produce neurospheres that differentiate into neurons and glia. It is unknown whether the SVZ of very old humans has this capacity. Here, we report that neural stem/progenitor cells can also be cultured from rapid autopsy samples of SVZ from elderly human subjects, including patients with age‐related neurologic disorders. Histological sections of SVZ from these cases showed a glial fibrillary acidic protein (GFAP)‐positive ribbon of astrocytes similar to the astrocyte ribbon in human periventricular white matter biopsies that is reported to be a rich source of neural progenitors. Cultures of the SVZ contained 1) neurospheres with a core of Musashi‐1‐, nestin‐, and nucleostemin‐immunopositive cells as well as more differentiated GFAP‐positive astrocytes; 2) SMI‐311‐, MAP2a/b‐, and β‐tubulin(III)‐positive neurons; and 3) galactocerebroside‐positive oligodendrocytes. Neurospheres continued to generate differentiated progeny for months after primary culturing, in some cases nearly 2 years postinitial plating. Patch clamp studies of differentiated SVZ cells expressing neuron‐specific antigens revealed voltage‐dependent, tetrodotoxin‐sensitive, inward Na⁺ currents and voltage‐dependent, delayed, slowly inactivating K⁺ currents, electrophysiologic characteristics of neurons. A subpopulation of these cells also exhibited responses consistent with the kinetics and pharmacology of the h‐current. However, although these cells displayed some aspects of neuronal function, they remained immature, insofar as they did not fire action potentials. These studies suggest that human neural progenitor activity may remain viable throughout much of the life span, even in the face of severe neurodegenerative disease. J. Comp. Neurol. 515:269–294, 2009. © 2009 Wiley‐Liss, Inc.     

Inhibitory dendrite dynamics as a general feature of the adult cortical microcircuit

The mammalian neocortex is functionally subdivided into architectonically distinct regions that process various types of information based on their source of afferent input. Yet, the modularity of neocortical organization in terms of cell type and intrinsic circuitry allows afferent drive to continuously reassign cortical map space. New aspects of cortical map plasticity include dynamic turnover of dendritic spines on pyramidal neurons and remodeling of interneuron dendritic arbors. While spine remodeling occurs in multiple cortical regions, it is not yet known whether interneuron dendrite remodeling is common across primary sensory and higher-level cortices. It is also unknown whether, like pyramidal dendrites, inhibitory dendrites respect functional domain boundaries. Given the importance of the inhibitory circuitry to adult cortical plasticity and the reorganization of cortical maps, we sought to address these questions by using two-photon microscopy to monitor interneuron dendritic arbors of thy1-GFP-S transgenic mice expressing GFP in neurons sparsely distributed across the superficial layers of the neocortex. We find that interneuron dendritic branch tip remodeling is a general feature of the adult cortical microcircuit, and that remodeling rates are similar across primary sensory regions of different modalities, but may differ in magnitude between primary sensory versus higher cortical areas. We also show that branch tip remodeling occurs in bursts and respects functional domain boundaries.     

Low-dose versus high-dose oxytocin augmentation of labor — A randomized trial

OBJECTIVE: Our purpose was to compare the efficacy and safety of low-dose versus high-dose oxytocin regimens in the augmentation of labor.STUDY DESIGN: Three hundred ten term pregnancies requiring augmentation of labor underwent randomization to receive either a low-dose or high-dose oxytocin augmentation regimen. Maternal demographics, labor-delivery data, and neonatal outcome were compared.RESULTS: The hgih-dose oxytocin group had a significant lower cesarean section rate, regarless of parity (10.4% vs 25.7%. p < 0.001), with no differences in maternal complications and neonatal outcomes. The time needed to correct the labor abnormality as also significantly decreased (1.24 ± 1.4 hours vs 3.12 ± 1.6 hours, p < 0.001) in the high-dose group.CONCLUSIONS: The use of a high-dose oxytocin regimen benefits both nulliparous and multiparous women requiring labor augmentation by significantly lowering both the time necessary to correct the labor normality and the need for cesarean section.