Anxiety after a fall in elderly subjects and subsequent risk of developing post traumatic stress disorder at two months. A pilot study

Background

The psychological burden suffered by elderly subjects after a fall adds to rehabilitation difficulties. We hypothesised that Post Traumatic Stress Disorder (PTSD) may be at the root of these psychological post-fall problems. The immediate psychological state was examined after 2 months post-fall in order to determine the prevalence of anxiety and PTSD and their possible correlates.

Method

A single centre prospective survey including elderly subjects referred to an emergency department (ED) after a fall with a 2-month follow-up.

Results

30.5% of patients showed a significant level of anxiety after their fall and (26%) showed evidence supporting the presence of PTSD at 2-months. Immediate anxiety, ability to re-establish upright posture and a history of repeated falls were significant predictors of PTSD at 2-months.

Conclusion

persistent psychological problems post fall may be related to PTSD which is significantly correlated to immediate anxiety. This study can be seen as a first step in patient characterisation, and predicts who may benefit from which of the various approaches of rehabilitation.     

Hemodynamic effects of sublingual molsidomine in patients with or without cardiac failure

A haemodynamic study was performed in 12 men aged between 28 and 64 years, including 8 with clinical signs of congestive cardiac failure and an ejection fraction of less than 50 per cent. The pulmonary artery pressure, capillary pressure, left ventricular pressure, cardiac output and the arterial and venous oxygen tensions were measured before (T 0) and after sublingual administration of 4 mg of molsidomine (T 15, T 30, T 45, T 60 min) and 3 minutes after a dose of 0.6 mg sublingual trinitrine (given immediately after the measurements made at T 60). The haemodynamic modifications were very significant at the 30th minute and reached a plateau between the 45th and 60th minute. The left and right ventricular filling pressures fell by more than 25 per cent, the aortic pressure fell by 17 per cent. There was a mild decrease (8 per cent) in the cardiac index and the systolic index, without any significant change in the heart rate. The reduction in the cardiac index and the systolic index was not significant in patients with cardiac failure and an ejection fraction of less than 50 per cent. The peripheral vascular resistance fell by 9 per cent. Finally, there was a significant reduction in the cardiac work and power and especially in the pressure-time index per beat and per minute. The administration of 0.6 mg of sublingual trinitrine induced an additional reduction in the aortic pressure with acceleration of the heart rate and a slight increase in the cardiac output, but no additional venodilator effect was detected.(ABSTRACT TRUNCATED AT 250 WORDS)     

Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale

In a series of 24 consecutive patients referred to the echocardiography laboratory because of suspected patent foramen ovale, contrast two-dimensional and M-mode echocardiographic studies were performed during normal breathing and during two provocative tests: the Valsalva maneuver and cough. A right to left shunt was visualized in 8 patients during normal breathing, in 11 patients during the Valsalva maneuver and in 17 patients during the cough test. Cardiac catheterization performed in all 24 patients and postmortem examination available in 3 patients confirmed the patency of the foramen ovale in only 15 patients. In these 15 patients, echo contrast appeared in the left heart cavities in early systole and almost simultaneously with complete right heart opacification. In contrast, for the two false positive results during the cough test, ultrasound contrast appeared at any time of the cardiac cycle when the right heart cavities had been partially cleared of contrast material. Right and left atrial pressures were simultaneously measured in four patients, and the normal interatrial pressure gradient was reversed during the Valsalva maneuver and the cough test. Echocardiography during both provocative tests showed that the interatrial septum flattened or became convex toward the left atrium. The cough test appears to be more reliable and easier to perform in critically ill patients than the Valsalva maneuver for the detection of right to left shunting through a patent foramen ovale.     

Delayed gastric emptying in anorexia nervosa is improved by completion of a renutrition program

The effects of renutrition on gastric emptying and upper gastrointestinal symptoms were evaluated in 14 anorexia nervosa patients before and after weight gain. A double-isotope technique was used to measure gastric emptying of both the solid and the liquid phases of the meal. Upper gastrointestinal symptoms were frequent before renutrition, occurring in 78% of the patients. Among these symptoms, nausea, vomiting and gastric fullness were correlated well with slowing in gastric emptying of both solid and liquid phases of the meal, which was demonstrated, respectively, in 10 (71%) and nine (64%) of the 14 patients. For the 11 patients who subsequently gained body weight, we observed, without any pharmacological treatment, an improvement of gastric emptying of both solid and liquid phases of the meal in eight (73%) and seven (64%) patients, respectively. Gastric emptying was unchanged in the three other patients who gained very little weight during the time of the study. As gastric emptying improved, so did nausea, vomiting, and gastric fullness. In three patients who had initially gained weight, nausea and gastric fullness recurred, associated again in all cases with a delay in gastric emptying. In conclusion, in anorexia nervosa, delayed gastric emptying, which is a frequent feature and which is well correlated with some of the upper digestive complaints, can return to normal without any pharmacological treatment. In this improvement, psychological assistance may play a role, together with the correction of the malnutrition.     

Controlled trial comparing two types of enteral nutrition in treatment of active Crohn''s disease: elemental versus polymeric diet.

To determine whether an elemental diet or a polymeric defined formula diet would be more effective for treating active Crohn's disease, we conducted a prospective randomised clinical trial in 30 patients with active Crohn's disease unresponsive to steroids and/or complicated by malnutrition. They received a four to six week enteral nutrition course with either an elemental diet or a polymeric diet. Clinical remission occurred in 10 of the 15 patients on elemental diet compared with 11 of the 15 patients assigned to polymeric diet. Both groups showed similar improvements in nutritional status, biological inflammation, alpha 1 antitrypsin clearance, and colonoscopic lesions (diminished in 17 out of 24 patients). Most patients relapsed during the year after discharge. We conclude that enteral nutrition, whatever the diet, is an efficient primary therapy for active Crohn's disease but does not influence the long term outcome.     

Isolated stenosis of the anterior interventricular artery. Comparison of the effects of medical and surgical treatment (in a randomised series)

Forty-five patients presenting with unstable angina having 70 p. 100 stenosis of the left anterior descending artery judged acceptable for coronary bypass surgery were randomly allocated, using a table of random numbers, for medical (21 patients) or surgical treatment (24 patients). There were no significant differences between the two groups with regards to age (53 +/- 10 years for the medical group; 55 +/- 9 years for the surgical group), the length of follow-up (55 +/- 26 vs 61 +/- 28 months), left ventricular end diastolic volumes (87 +/- 27 vs 84 +/- 18 ml/m2) or ejection fraction (62 +/- 8 vs 59 +/- 11 p. 100). There were no deaths in the medical group; two patients developed uncomplicated myocardial infarction 19 days and 7 months after coronary angiography, respectively. 5 patients had recurrent angina and were referred for surgery. This operation of second intention did not pose any special problems. 6 of the 14 patients with stenosis of the LAD before the origin of the first septal artery had complications (infarction in 1 case, recurrent angina in 5 cases). In the surgical group, 1 patient died in the immediate postoperative period, of resistant cardiac arrhythmia; 2 patients developed uncomplicated peroperative myocardial infarction; 21 patients had no complications at all. The surgical patients were heparinised in the immediate postoperative period and anticoagulant therapy was continued with oral vitamin K antagonists for 6 months to 1 year, followed in some cases, by platelet antiaggregant therapy. 20 patients in this group underwent maximal exercise stress testing which was negative in 19 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Melatonin in elderly patients with insomnia.– A systematic review

Summary Background Melatonin is a hormone and antioxidant produced by the pineal gland of which four neurobiological roles have been claimed in the aged population: anti-ageing agent; free-radical scavenger; regulator of circadian rhythm; endogeneous sleep-inducer. The „melatonin replacement” hypothesis states that 1) the well-evidenced age-related decline contributes to insomnia and that 2) replacement with physiological doses of melatonin improves sleep. The aim of this review was to determine the evidence for the efficacy of melatonin in elderly insomniacs. Methods MEDLINE‘s database from 1990–2000 was searched with „melatonin”, „geriatrics” and „(frail)-elderly” as major subheadings. This resulted in 78 articles: only studies with empirical treatment data were reviewed (N=12). Results Six reports (abstract, research letter, retrospective case study, 3 open label studies) showed a trend towards efficacy of melatonin: sleep quality improved and in patients with Alzheimer‘s disease sundowning was reduced.?   In 6 double blind, randomised crossover trials, a total number of 95 patients (mean ages: 65–79yrs) were treated. Melatonin doses ranged from 0.5mg to 6mg; most took a single dose 30–120min before bedtime. In 3 studies a slow release form was used. Sleep quality was objectively measured by wrist actigraphy (n=4) and polysomnography (n=2), and additionally subjective sleep quality was assessed (n=2). Sleep latency decreased significantly in 4 studies. In 3 studies other measures of sleep quality (sleep efficiency, total sleep time and wake time during sleep) improved. Subjective sleep quality did not improve. No early-morning sleepiness occurred. Comparison of the studies suggests that melatonin is most effective in elderly insomniacs who chronically use benzodiazepines and/or with documented low melatonin levels during sleep. Conclusion There is sufficient evidence that low doses of melatonin improve initial sleep quality in selected elderly insomniacs. However, larger randomized controlled trials, with less strict inclusion criteria are necessary to yield evidence of effectiveness (i.e. clinical and subjective relevance) in geriatric patients who suffer from insomnia, before wide-spread use can be advocated. Received: 26 June 2001/Accepted: 10 July 2001     

FGF2 mediates DNA repair in epidermoid carcinoma cells exposed to ionizing radiation

Abstract Purpose: Fibroblast growth factor 2 (FGF2) is a well-known survival factor. However, its role in DNA repair is poorly documented. The present study was designed to investigate in epidermoid carcinoma cells the potential role of FGF2 in DNA repair. Materials and methods: The side population (SP) with cancer stem cell-like properties and the main population (MP) were isolated from human A431 squamous carcinoma cells. Radiation-induced DNA damage and repair were assessed using the alkaline comet assay. FGF2 expression was quantified by enzyme linked immunosorbent assay (ELISA). Results: SP cells exhibited rapid repair of radiation induced DNA damage and a high constitutive level of nuclear FGF2. Blocking FGF2 signaling abrogated the rapid DNA repair. In contrast, in MP cells, a slower repair of damage was associated with low basal expression of FGF2. Moreover, the addition of exogenous FGF2 accelerated DNA repair in MP cells. When irradiated, SP cells secreted FGF2, whereas MP cells did not. Conclusions: FGF2 was found to mediate DNA repair in epidermoid carcinoma cells. We postulate that carcinoma stem cells would be intrinsically primed to rapidly repair DNA damage by a high constitutive level of nuclear FGF2. In contrast, the main population with a low FGF2 content exhibits a lower repair rate which can be increased by exogenous FGF2.