Prevalence and Predictors of Quality of Recovery at Home After Day Surgery

Traditionally, major complications and unanticipated admission/readmission rates were used to assess outcome after day surgery. However, in view of the relative absence of major complications the quality of recovery (QOR) should be considered one of the principal endpoints after day surgery. In our study, the level of QOR is defined by a combination of the Global Surgical Recovery (GSR) Index and the Quality of Life (QOL).The aim of this study was to analyze prevalence and predictors of QOR after day surgery on the fourth postoperative day.Elective patients scheduled for day surgery from November 2008 to April 2010 were enrolled in a prospective cohort study. Outcome parameters were measured by using questionnaire packages at 2 time points: 1 week preoperatively and 4 days postoperatively. Primary outcome parameter is the QOR and is defined as good if the GSR index >80% as well as the postoperative QOL is unchanged or improved as compared with baseline. QOR is defined as poor if both the GSR index ≤80% and if the postoperative QOL is decreased as compared with baseline. QOR is defined as intermediate in all other cases. Three logistic regression analyses were performed to determine predictors for poor QOR after day surgery.A total of 1118 patients were included. A good QOR was noted in 17.3% of patients, an intermediate QOR in 34.8%, and a poor QOR in 47.8% 4 days after day surgery. The best predictor for poor QOR after day surgery was type of surgery. Other predictors were younger age, work status, and longer duration of surgery. A history of previous surgery, expected pain (by the patient) and high long-term surgical fear were significant predictors of poor QOR in only 1 of 3 prediction models.The QOR at home 4 days after day surgery was poor in the majority of patients and showed a significant procedure-specific variation. Patients at risk for poor QOR can be identified during the preoperative period based on type of surgery, age, work status, and the duration of the surgery.     

Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program

Background  

Patient falls in hospitals are common and may lead to negative outcomes such as injuries, prolonged hospitalization and legal liability. Consequently, various hospital falls prevention programs have been implemented in the last decades. However, most of the programs had no sustained effects on falls reduction over extended periods of time.     

The effect of pressurized carbon dioxide as a temporary plasticizer and foaming agent on the hot stage extrusion process and extrudate properties of solid dispersions of itraconazole with PVP-VA 64.

The aim of the current research project was to explore the possibilities of combining pressurized carbon dioxide with hot stage extrusion during manufacturing of solid dispersions of itraconazole and polyvinylpyrrolidone-co-vinyl acetate 64 (PVP-VA 64) and to evaluate the ability of the pressurized gas to act as a temporary plasticizer as well as to produce a foamed extrudate. Pressurized carbon dioxide was injected into a Leistritz Micro 18 intermeshing co-rotating twin-screw melt extruder using an ISCO 260D syringe pump. The physicochemical characteristics of the extrudates with and without injection of carbon dioxide were evaluated with reference to the morphology of the solid dispersion and dissolution behaviour and particle properties. Carbon dioxide acted as plasticizer for itraconazole/PVP-VA 64, reducing the processing temperature during the hot stage extrusion process. Amorphous dispersions were obtained and the solid dispersion was not influenced by the carbon dioxide. Release of itraconazole from the solid dispersion could be controlled as a function of processing temperature and pressure. The macroscopic morphology changed to a foam-like structure due to expansion of the carbon dioxide at the extrusion die. This resulted in increased specific surface area, porosity, hygroscopicity and improved milling efficiency.     

Sensory axonopathy in hereditary distal spinal muscular atrophy

A girl of 14 year is presented with a distal spinal muscular atrophy (SMA) with autosomal recessive inheritance. The technical findings are in agreement with the diagnosis. Light microscopical examination of sural nerve biopsy, including teased fiber studies and morphometry, showed no abnormalities. Electron microscopical investigation however demonstrated axonal pathology. The question arises if distal SMA is a distal axonopathy mainly of motor nerves, but to some extent also of sensory nerves.     

Reversal of startle gating deficits in transgenic mice overexpressing corticotropin-releasing factor by antipsychotic drugs.

Chronically elevated levels of corticotropin-releasing factor (CRF) in transgenic mice overexpressing CRF in the brain (CRF-OE) appear to be associated with alterations commonly associated with major depressive disorder, as well as with sensorimotor gating deficits commonly associated with schizophrenia. In the present study, we tested the hypothesis that antipsychotics may be effective in normalizing prepulse inhibition (PPI) of acoustic startle in CRF-OE mice, which display impaired sensorimotor gating compared to wild-type (WT) mice. The typical antipsychotic haloperidol and atypical antipsychotic risperidone improved PPI in the CRF-OE mice, but were ineffective in WT mice. The atypical antipsychotic clozapine did not influence PPI in CRF-OE mice, but reduced gating in WT mice. This effect of clozapine in the CRF-OE mice may thus be regarded as a relative improvement, consistent with the observed effect of haloperidol and risperidone. As expected, the anxiolytic, nonantipsychotic chlordiazepoxide was devoid of any effect. All four compounds dose-dependently reduced the acoustic startle response irrespective of genotype. These results indicate that antipsychotic drugs are effective in improving startle gating deficits in the CRF-OE mice. Hence, the CRF-OE mouse model may represent an animal model for certain aspects of psychotic depression, and could be a valuable tool for research addressing the impact of chronically elevated levels of CRF on information processing.     

Penile flow- and blood pressure index and the effective dose of intracavernous papaverine

A simple test to predict the outcome of intracavernous papaverine treatment would be helpful in the management of erectile dysfunction. Doppler studies of the flaccid penis were compared with the results of intracavernous injection of papaverine. There was no correlation between these two. Therefore Doppler studies of the flaccid penis are not appropriate to predict the effect of intracavernous injection.     

Homocysteine-Lowering Therapy and Early Progression of Transplant Vasculopathy: A Prospective, Randomized, IVUS-Based Study

Although observational studies suggest that hyperhomocysteinemia may be a risk factor for coronary allograft vasculopathy (CAV), prospective data on homocysteine-lowering interventions and CAV development are lacking. We, therefore, randomized 44 de novo heart transplant (HT) recipients to 15 mg/day of 5-methyl-tetrahydrofolate (n=22), or standard therapy (control group, n=22) to investigate the effect of homocysteine lowering on the change in coronary intimal hyperplasia during the first 12 months after transplant, as detected by intra-vascular ultrasound (IVUS). Although 12 months after HT, homocysteinemia was lower in folate-treated patients (p<0.001), coronary intimal area increased similarly in the two groups (p>0.4). Conversely, hypercholesterolemia and cytomegalovirus infection were both associated with increased intimal hyperplasia (p<0.04), independently from folate intake. Sub-group analysis revealed that folate therapy reduced intimal hyperplasia in patients with hyperhomocysteinemia before randomization (n=19; p=0.02), but increased intimal hyperplasia in patients with normal homocysteine plasma concentrations (p=0.02). This bimodal effect of folate therapy persisted significantly after adjusting for cytomegalovirus infection and hypercholesterolemia. Despite effective in prevent hyperhomocysteinemia after heart transplantation, folate therapy does not seem to affect early CAV onset. However, sub-group analysis suggests that folate therapy may delay CAV development only in patients with baseline hyperhomocysteinemia, while may favor CAV progression in recipients with normal baseline homocysteinemia.     

Megaloblastic anaemia in an elderly patient treated with triamterene

The case is presented of an elderly woman in whom megaloblastic anaemia due to folate deficiency was diagnosed. It is speculated that this disorder was induced by treatment with triamterene.     

Small-dose oral iron absorption test in anaemic and non-anaemic elderly hospitalized patients

Abstract: The small-dose (20 mg) oral iron absorption test (OIAT) was performed in 76 hospitalized elderly patients and 30 healthy adults. Of the elderly patients, 34 were considered as iron deficient (serum ferritin level <20 μg/L) of whom 23 were anaemic and 11 not anaemic, 21 had the anaemia of chronic disorders (ACD) and another 21 were non-anaemic patients with a normal serum ferritin level. There was a significant inverse correlation between the serum ferritin level as a measure of iron store and the maximum increase in serum iron during a 3-h test (C_max), in the elderly as well as in the healthy adult group. A decision limit of 80 μg/dL for C_max is a good discriminant between absent (serum ferritin <20 μg/L) and adequate body iron stores. Sixty-eight per cent of the patients with a serum ferritin level <20 μg/L but virtually none of the ACD patients, non-anaemic elderly inpatients with normal serum ferritin levels and healthy adults had a C_max level >80 μg/L. Although further investigation is needed before the OIAT can be recommended as a valuable test for evaluating iron absorption, predicting mild iron deficiency and differentiating between different categories of anaemia, it seems worthwile that more effort should be done to validate this simple and safe test.     

Ultrastructure of the periaqueductal grey matter of the rat: an electron microscopical and horseradish peroxidase study.

The neurons of the mesencephalic periaqueductal grey substance (PAG) in the rat are small and medium sized. The cells are frequently located in small clusters, without interdigitating glial elements and may be connected by direct membrane appositions or by gap junctions. The inner zone of the PAG is cell poor. In many cases, the cytoplasm of the cells is filled with extensive rough endoplasmic reticulum, free ribosomes, Golgi apparatus, and large lysosome-like granules. The nuclei show large indentations. The cells have a high nucleus-cytoplasm ratio. The neuropil is very extensive and particularly rich in large numbers of small unmyelinated axons, dendrites, axonal varicosities, and synaptic connections. Myelinated fibres are relatively scarce. The orientation of the fibres was studied in transverse and horizontal sections, in combination with HRP track tracing experiments. It appeared that throughout the PAG most of the fibres were orientated longitudinally. Quantitation showed that most fibres were present in the inner zones of the PAG. Moreover, the diameter of the fibres adjacent to the aqueduct was smaller than that of the fibres in the peripheral parts of the PAG. The thin unmyelinated fibres made extensive synaptic connections within the PAG. Many synaptic varicosities were found in the neuropil of the PAG. There were four types of synaptic varicosities, characterized by different populations of clear and dense-core secretory granules and by the different morphology of the synaptic specializations. In general, the different types of varicosity were homogeneously distributed in the different parts of the PAG. Electron dense secretory granules, when present, were located at some distance from the synaptic junction. Serial sections revealed varicosities which contained only dense-core secretory granules, without synaptic specializations. The dendrites of PAG neurons generally lacked synaptic spines. Many dendrites, particularly those of neurons located in the peripheral parts of the PAG, were directed toward the aqueduct. The present study shows that the PAG is a very complex brain area. The crisscrossing of axons and dendrites with synaptic connections at considerable distances from the cell bodies render it very difficult to unravel the relationships between the possible sources and destinations of ongoing information. This structure complicates the search for relationships between the functional organization and the cytoarchitectural borders in the PAG area.