Admitting elderly patients to the ICU: dilemmas and solutions

Since intensive care is expensive and has limited efficacy, its use should be reserved primarily for patients with acute, reversible illnesses. Although age is related to ICU mortality, more important predictors of ICU outcome are severity of the acute illness, the admitting diagnosis, and previous health status. Thus, age should not be the sole factor considered prior to ICU transfer or the initiation or denial of resuscitative efforts. Geriatric physicians should prospectively develop individualized plans for each of their patients based upon the patients' wishes after a discussion of diagnosis, prognosis, and the likely efficacy and side effects of the available treatments.     

A new version of the ischemic tourniquet pain test.

A new method of producing ischemic tourniquet pain is presented. The present test model showed a sex difference in the pain recordings. Sum pain intensity (SPI) for a 5 min trial period of ischemic pain was lower for males than for females (p less than 0.0001). The observed variability between male test subjects was greater than between female subjects, while the variation in pain scores within subjects was lower for males compared to females. The differences between sexes as a group with respect to variability of pain recordings were not statistically significant. Due to the observed sex differences in pain recording it is recommended to use test subjects of the same sex when restricting the test procedure to a limited number of subjects. The present version of the tourniquet pain test, used according to the recommended criteria, allows discriminating between i.v. administered placebo, opioid analgesics (pethidine) and ketamine.     

Prolonged analgesic effect of ketamine, an N-methyl-D-aspartate receptor inhibitor, in patients with chronic pain

We examined the role of N-methyl-D-aspartate (NMDA) receptors in chronic (pathological) pain in humans by using the NMDA receptor antagonist ketamine as a probe. Thirty patients with neuropathic pain in the trigeminal area were given an i.m. injection of ketamine 0.4 mg/kg combined with midazolam 0.05 mg/kg. Pethidine 1.0 mg/kg served as a control. Three different response patterns were observed. Ketamine caused a long-term (6-24 h) analgesic effect partly dissociated from the mental side effects in 8 of the 26 patients who completed the study; these patients also had a slight analgesic effect of pethidine. In nine patients, ketamine caused a short-lasting (<2 h) analgesic effect closely associated with the mental side effects, whereas pethidine caused little or no analgesia. The remaining nine patients did not experience any reduction of pain after either drug in spite of characteristic side effects. One week after the i.m. challenge the patients received either 4.0 mg/kg ketamine hydrochloride or placebo capsules to be taken orally as a nightly dose for three consecutive nights. Five of the eight patients who had a long-term analgesic effect of the i.m. challenge reported decreased pain on days after ketamine. None of the others reported an analgesic effect. The phenomenon of long-term depression of pain in a subgroup of patients was thus confirmed when ketamine was given p.o. These findings indicate that NMDA receptors are involved in the perception and maintenance of pathological pain in some patients. In others, pain appears to be mediated by NMDA receptor-independent mechanisms. We suggest that NMDA receptor-independent transmission in central pain pathways may contribute to the reduced efficiency of analgesic drugs often seen in chronic pain states.     

Mental disorders among persons with heart disease - results from World Mental Health surveys

OBJECTIVES: While depression and heart disease often co-occur in Western countries, less is known about the association of anxiety and alcohol use disorders with heart disease and about the cross-cultural consistency of this association. Consistency across emotional disorders and cultures would suggest that relatively universal mechanisms underlie the association. METHODS: Surveys with 18 random population samples of household-residing adults in 17 countries in Europe, the Americas, the Middle East, Africa, Asia and the South Pacific were carried out. Medically recognized heart disease was ascertained by self-report. Mental disorders were assessed with the World Mental Health Composite International Diagnostic Interview, a fully structured diagnostic interview. RESULTS: Specific mood and anxiety disorders occurred among persons with heart disease at rates higher than those among persons without heart disease. Adjusted for sex and age, the pooled odds ratios (95% confidence interval) were 2.1 (1.9-2.5) for mood disorders, 2.2 (1.9-2.5) for anxiety disorders and 1.4 (1.0-1.9) for alcohol abuse/dependence among persons with versus those without heart disease. These patterns were similar across countries. CONCLUSIONS: An excess of anxiety disorders and that of mood disorders are found among persons with heart disease. These associations hold true across countries despite substantial between-country differences in culture and mental disorder prevalence rates. These results suggest that similar mechanisms underlie the association and that a broad spectrum of mood-anxiety disorders should be considered in research on the comorbidity of mental disorders and heart disease.     

Insomnia and role impairment in the community

BACKGROUND: Estimates of the occurrence of insomnia are not available in sub-Sahara Africa where demographic profile is different from that in developed countries. However, such estimates need to be considered along with associated functional role impairment in assessing the extent of public health burden due to insomnia. METHODS: Face-to-face interviews with a representative sample of persons aged 18 years and over (n = 6,752) in 21 of Nigeria's 36 states (representing about 57% of the national population) was conducted using the Composite International Diagnostic Interview, version 3. Role impairment, defined as proportion of lost work over the prior month, was assessed using the World Health Organization's Disability Assessment Schedule. RESULTS: Insomnia, defined as any sleep complaint lasting at least two weeks in the previous 12-months, was reported by 11.8%, with rates varying between 5.4% for early morning awakening, 7.7% for difficulty initiating sleep, and 8.5% for difficulty maintaining sleep. Increasing age was associated with higher rates of every type of insomnia but females were only more likely than males to report difficulty initiating sleep. Independently, chronic pain conditions, chronic medical conditions, as well as the presence of a DSM-IV mental disorder significantly increased the risk of having insomnia. Multivariate analysis suggests that, even though demographic factors and comorbid physical and mental conditions partly accounted for the association of insomnia with role impairment, a decrement of about 6% of estimated lost work in the prior month was probably attributable to insomnia. CONCLUSIONS: Findings indicate that insomnia is common even in this relatively young population. Its negative effect on role functioning is considerable, is not entirely accounted for by comorbid medical and mental conditions, and may be of public health significance.     

Making sense of evidence

There is a constant stream of information emanating from psychiatric research. The challenge for the clinician to keep abreast of the latest research findings is huge. However, even more daunting is the task of making sense of the sometimes conflicting data. In this paper, we provide some examples of evidence that seemed to have been accepted with relatively little critical examination. We discuss how evidence may look plausible on the surface either because contextual factors have not been considered or because they fit into a pre-determined world view. We argue that, in the end, the process of making sense of evidence is not straightforward and that professional biases and social prejudices often influence decisions.     

Competitive blockade of alpha-adrenergic receptors in rat heart by prazosin

Phenylephrine (PE) in presence of propranolol evokes an alpha-adrenergic inotropic response in rat heart. The time course of this response is characterized by a transient decrease in maximal developed tension (Tmax) to subcontrol levels (negative phase of the inotropic response) followed by an increase which reaches maximum after 4-5 min. (positive phase of the inotropic response). Prazosin (PRZ), a selective alpha 1-receptor blocker, inhibited preferentially the positive phase of the inotropic response and displaced the dose-response curve of PE to the right in nanomolar concentrations, indicating a competitive mechanism of inhibition. Phentolamine, a non-selective alpha-blocker, blocked both the negative and the positive phase of the inotropic response to about the same degree. PRZ appears to be a competitive alpha-adrenergic antagonist with high affinity in rat heart. Two populations of alpha-adrenergic receptors may be present: one stimulatory (alpha 1) and one inhibitory.