ATTITUDES TOWARD SUICIDE AND SUICIDAL RISK AMONG YOUNGER AND OLDER PERSONS

Despite a burgeoning literature on some aspects of elder suicide, little is known about the specific attitudes that older people hold about suicide. The present study examined attitudes toward suicide and suicidal risk among 96 younger and 79 older adults. Participants completed the Suicide Opinion Questionnaire and the Suicide Risk Scale. Regarding suicidal risk, younger adults scored significantly higher than older adults. Regarding attitudes, older adults scored significantly higher than younger adults on 7 of 15 subscales, indicating that for older adults, suicide was more acceptable, more strongly related to a lack of religious conviction, more lethal, more normal, more irreversible or permanent, more strongly related to demographics, and more strongly related to individual aspects. An implication is that older adults hold both adaptive and maladaptive attitudes about suicide that may be useful in providing a social and cultural context to the study, prevention, and treatment of elder suicide.     

Effects of dexmedetomidine on propofol and remifentanil infusion rates during total intravenous anesthesia for spine surgery in adolescents

Introduction: Total intravenous anesthesia with propofol and a synthetic opioid is a frequently chosen anesthetic technique for posterior spinal fusion. Despite its utility, adverse effects may occur with high or prolonged propofol dosing regimens including delayed awakening. The current study investigated the propofol‐sparing effects of the concomitant administration of the α₂‐adrenergic agonist, dexmedetomidine, during spinal fusion surgery in adolescents. Methods: The surgical database of the department of orthopedic surgery was searched and patients (12–21 years of age) were identified who had undergone spinal fusion for either idiopathic or neuromuscular scoliosis during the past 24 months. Patients were assigned to two groups. Group 1 included patients anesthetized with propofol and remifentanil and group 2 included patients anesthetized with dexmedetomidine, propofol, and remifentanil. In the latter group, dexmedetomidine was administered as a continuous infusion of 0.5 μg·kg^?1·h^?1 started after the induction of anesthesia without a loading dose. Propofol was adjusted to maintain the bispectral index (BIS) number at 40–50 and remifentanil was adjusted to maintain the mean arterial pressure (MAP) at 50–65 mmHg. Labetolol or hydralazine was used if the MAP could not be maintained at 50–65 mmHg with remifentanil up to a maximum dose of 0.6 μg/kg/min. Statistical analysis included a nonpaired t‐test for parametric data (age, weight, remifentanil/propofol infusion requirements, and heart rate/blood pressure values). A nonparametric statistical analysis (Dunn) was used to compare BIS numbers. Parametric data are presented as the mean ± sd while nonparametric data are presented as the median and the 95th percentile confidence intervals. Results: Twelve patients received propofol–remifentanil–dexmedetomidine and 24 received propofol–remifentanil. There were no differences in the demographic data, BIS numbers or hemodynamic parameters between the two groups. There was a reduction in the propofol infusion requirements in patients who also received dexmedetomidine (71 ± 11 μg·kg^?1·min^?1) compared with those receiving only propofol–remifentanil (101 ± 33 μg·kg^?1·min^?1, P = 0.0045). No difference was noted in the remifentanil infusion requirements or the use of supplemental agents (hydralazine and labetolol) to maintain controlled hypotension. Conclusion: The concomitant use of dexmedetomidine in patients undergoing spinal fusion reduces propofol infusion requirements when compared with those patients receiving only propofol and remifentanil.     

Emergence delirium and postoperative pain in children undergoing adenotonsillectomy: a comparison of propofol vs sevoflurane anesthesia

Background: Emergence delirium (ED) is a frequent postoperative complication in young children undergoing ENT procedures and it may be exacerbated by sevoflurane anesthesia whereas propofol maintenance has been suggested to decrease the incidence of ED. The aim of this randomized, prospective, double‐blind study was to evaluate the effect of sevoflurane vs propofol anesthesia on the quality of recovery after adenotonsillectomy. Methods: Forty‐two patients were randomized to maintenance with either propofol or sevoflurane for adenotonsillectomy. At the conclusion of surgery, patients were extubated awake. ED and pain were assessed using the Pediatric Anesthesia Emergence Delirium (PAED) and the Children’s Hospital of Eastern Ontario Scale (CHEOPS), respectively. Higher PAED scores (0–20) indicate greater severity of ED. Nursing and parental satisfaction, hospital length of stay, postoperative nausea and vomiting (PONV), anesthetic complications, and subsequent emergency room admissions were also assessed. Results: Median PAED score was 14 in the propofol group and 17 in the sevoflurane group (NS). Propofol was associated with less pain medication required during recovery and a lower incidence of PONV (5.3% vs 36.8%, P < 0.05). Nursing and parental satisfaction as well as time spent in recovery room was similar for the two groups. Conclusion: Propofol anesthesia does not influence agitation after adenotonsillectomy, as measured by the PAED score. A PAED score of ≥10 was not useful in identifying patients with ED. However, propofol maintenance is associated with less need for pain medication in the recovery room and a lower incidence of PONV compared to sevoflurane anesthesia.     

A POSTOPERATIVE PROGNOSTIC NOMOGRAM FOR RENAL CELL CARCINOMA

PURPOSE: Few published studies have combined prognostic factors to predict the likelihood of recurrence after surgery for renal cell carcinoma. We developed a nomogram for this purpose. MATERIALS AND METHODS: With Cox proportional hazards regression analysis, we modeled pathological data and disease followup for 601 patients with renal cell carcinoma who were treated with nephrectomy. Predictor variables were patient symptoms, including incidental, local or systemic, histology, including chromophobe, papillary or conventional, tumor size, and pathological stage. Treatment failure was recorded when there was either clinical evidence of disease recurrence or death from disease. Validation was performed with a statistical (bootstrapping) technique. RESULTS: Disease recurrence was noted in 66 of the 601 patients, and those in whom treatment was successful had a median and maximum followup of 40 and 123 months, respectively. The 5-year probability of freedom from failure for the patient cohort was 86% (95% confidence interval 82 to 89). With statistical validation, predictions by the nomogram appeared accurate and discriminating with an area under the receiver operating characteristic curve, that is a comparison of the predicted probability with the actual outcome of 0.74. CONCLUSIONS: A nomogram has been developed that can be used to predict the 5-year probability of treatment failure among patients with newly diagnosed renal cell carcinoma. The nomogram may be useful for patient counseling, clinical trial design and patient followup planning.     

Hereditary Hemolytic Disease Secondary to Glucose-6-Phosphate Dehydrogenase Deficiency: Report of Three Cases with Special Emphasis on ATP Metabolism

1. Three cases of hereditary hemolytic disease secondary to G-6-PD deficiency are described. Two of the cases were first cousins of Scotch-Irish-English descent and the mode of inheritance was believed to be sex-linked.The third case was of Turkish origin; no family studies were availale.

2. The mothers, who were heterozygous for G-6-PD deficiency, showed onlyminimal expression of the defect, which was manifested by a slightly decreasedred cell survival in both mothers and an abnormal methemoglobin reductiontest in one of them.

3. All three cases showed a more pronounced fall in erythrocyte ATP afterincubation with phenylhydrazine than that observed in primaquine-sensitiveNegroes whose red cells were less deficient in G-6-PD.

4. It is suggested that the inability of the G-6-PD-deficient erythrocyte tomaintain adequate levels of ATP may be an important factor in the pathogenesis of the hemolytic process.

Submitted on August 26, 1963 Accepted on October 24, 1963     

DIFFERENTIAL RECALL BIAS AND SPURIOUS ASSOCIATIONS IN CASE/CONTROL STUDIES

Consider a case/control study designed to investigate a possible association between exposure to a putative risk factor and development of a particular disease. Let E denote the information required to specify a subject's exposure to the risk factor. We examine the effect that errors in the recorded values of E (which we denote by E^*) have on inferences of an association between disease and the risk factor. We concentrate on situations where the errors in recorded exposure are such that exposure is underestimated for controls and overestimated for cases. This phenomenon is referred to as differential recall bias and may lead to spurious inferences of an association between exposure and disease. We describe how the standard inferential techniques used in the analysis of data from case/control studies may be adjusted to take account of specified mechanisms whereby E is distorted to produce E^*. Such adjustments may be used to determine the sensitivity of an analysis to the phenomenon of differential recall bias and to quantify the extent of such bias that would be required to overturn the conclusions of the analysis. There remains the matter of judging whether a given distortion mechanism is reasonable in a particular context. This emphasizes the need for investigators to take account of differential recall bias in validation studies of exposure assessment techniques. The methodology developed here is applied to a recent major study investigating the possible association between lung cancer and exposure to environmental tobacco smoke. The log-odds ratio of 0⋅23 based on recorded exposure differs significantly from 0 (p<0⋅02). However, the association is rendered non-significant by a very modest degree of differential recall bias. For example, if 3⋅8 per cent of exposed controls report no exposure, 3⋅8 per cent of unexposed cases report exposure, and all other subjects report exposure accurately, the log-odds ratio drops to 0⋅07 and the corresponding p-value increases to 0⋅49.     

True Incidence of Pacemaker Syndrome

HELDMAN, D., ET AL.: True Incidence of Pacemaker Syndrome. Although the purported incidence of pacemaker syndrome according to the literature is only 5%–15%, this is based on a series of patients with VVI pacing. Increasing numbers of studies are being reported in which patients prefer the dual chamber mode despite little benefit being demonstrated on objective testing, suggesting that pacemaker syndrome may be more common than is generally reported. This study was designed to evaluate the reported symptoms in a series of patients programmed to both the VVI and one or more dual chamber modes. Forty unselected patients with dual chamber pacemakers were entered into a blind, randomized trial comparing the symptoms associated with VVI pacing to those associated with dual chamber pacing. Patients were randomized to either WI or dual chamber pacing. At the end of 1 week, questionnaires rating 16 different symptoms were completed. Blood pressure, LV function, presence of ventriculoatrial conduction, and ability to override the pacemaker were evaluated. The pacemaker was then programmed to the other mode. Overall, 12 of 16 symptoms were significantly worse in the VVI as compared to dual chamber mode. The most highly significant (p < 0.005) were shortness of breath, dizziness, fatigue, pulsations in the neck or abdomen, cough, and apprehension. Pacemaker syndrome was clinically recognized in 83% of patients paced in the WI mode with 65% of patients experiencing moderate to severe symptoms. There were no readily identified clinical, hemodynamic, or electrophysiological parameters that predicted which patients would develop pacemaker syndrome. Thus, when patients have an opportunity to experience both pacing modes in close proximity to one another, there is a high incidence of pacemaker syndrome in the VVI mode.