Biomedical subjects

Abraham Adunsky

Publications and source records attributed to Abraham Adunsky.

35 records · Page 2Linked to original sources

PubMed2002

Heart rate variability parameters correlate with functional independence measures in ischemic stroke patients.

This study gives quantitative information regarding the effect of brain infarction on the regulation of the cardiovascular system. Electrocardiograms of 16 patients, ranging from 54 to 85 years old, admitted for rehabilitation after an ischemic supratentorial stroke, all without a history of cardiac disease or rhythm disturbances, were recorded during physiotherapy effort. All patients were evaluated for the functional independence measure (FIM) score 48 to 72 hours following admission and repeated at one week before discharge. The heart rate variability (HRV) parameters: standard deviation (SD) of the RR series, the power spectrum of the RR intervals for the low frequency range (LF: 0.04-0.15 Hz), and the high frequency range (HF: 0.15-0.4 Hz) were calculated. The results showed that all heart rate variability parameters had statistically significant relationship with the FIM on admission and discharge scores. In conclusion, the HRV parameters correlate with the clinical measures of function: the greater the HRV parameter the higher the FIM score. The presented technique may prove useful as a prognostic tool providing a simple way for determining functional performance of stroke patients.

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PubMed2002

A cross-sectional study of lipids and ApoC levels in Alzheimer's patients with and without cardiovascular disease.

BACKGROUND: There is increasing evidence supporting the role of atherogenic phenomena in Alzheimer's disease (AD). The possible significance of specific plasma lipid levels in the pathogenesis of AD remains controversial. While lipids such as cholesterol or chaperons such as apolipoprotein (Apo) E2 to ApoE4 have been assessed in AD, ApoC2 and ApoC3 have not been studied before. The present study investigated possible differences in levels of these lipids in AD patients, with or without cardiovascular diseases or risk factors. METHODS: This is a cross-sectional study. The medical charts of patients diagnosed with probable AD were screened for the presence of cardiovascular disease and cardiovascular risk factors. Included in the study were 105 AD patients: 53 with cardiovascular risk factors (AD(+CVD)) and 52 without risk factors (AD(-CVD)). Blood samples were analyzed for lipoproteins, ApoC2, and ApoC3. We used t tests, chi-square tests, and regression analyses to identify significant differences and to compare the relationships of variables among the groups. RESULTS: ApoC2 levels (3.5 +/- 0.3 and 3.4 +/- 0.4 mg/dl, respectively), ApoC3 (13.7 +/- 0.9 and 14.7 +/- 1.1 mg/dl, respectively), and high-density lipoprotein (HDL)/non-HDL ApoC3 ratios (1.6 +/- 0.2 and 1.3 +/- 0.2, respectively) were similar for the AD patients with and without cardiovascular risk factors. Levels of total cholesterol, triglycerides, low-density lipoproteins (LDL), very LDLs, and HDLs were similar in the two groups. A substantial proportion of both AD(+CVD) and AD(-CVD) patients showed high levels of total cholesterol and LDL, as well as low levels of HDL, ApoC2, and ApoC3, compared to normative values. Surprisingly, patients treated by cognitive enhancers showed significantly higher cholesterol ( p =.002) and triglyceride ( p =.015) levels, independent of age, gender, and cognitive level. CONCLUSIONS: There was no difference between AD patients, either with or without cardiovascular diseases or risk factors, with respect to plasma lipid profile, including ApoC2 and ApoC3. This could indicate that lipid metabolism may play a role in AD, whether with or without cardiovascular risk factors. The higher levels of some lipids, observed in a subset of patients treated by cognitive enhancers, deserves further investigation.

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PubMed2002

Dynamic cardiophysiologic variables correlate with lesion location and FIMTM in patients with ischemic stroke.

OBJECTIVE: To examine the correlation between a clinical measure of function in patients undergoing rehabilitation who had recently had an ischemic stroke and to examine cardiophysiologic measures registered during effort. DESIGN: A cohort study comprising a sample of consecutive patients, without a history of cardiac disease or rhythm disturbances, admitted for rehabilitation after an ischemic supratentorial stroke. All patients were examined for the FIM trade mark score and dynamic cardiophysiologic variables. Results were analyzed in relation to stroke location. Thirty-eight patients participated in the study. Ten patients had a superficial lesion, 20 had a deep brain lesion, and eight had no noticeable lesion by computed tomographic imaging. Function was measured with the FIM instrument 48-72 hr after admission and repeated at 1 wk before discharge. Electrocardiographic activity was recorded during physiotherapy treatment. The relationship between the RR and QT intervals in the electrocardiographic waveforms was found to estimate two cardiophysiologic variables, the constant (a) and the slope (b) values, reflecting the dynamic change of QT during physiotherapy effort. RESULTS: Only for the subgroup of patients who sustained a deep brain lesion did the motor items in the FIM instrument on admission and discharge scores have a statistically significant relationship with the slope variable (b) and an inverse statistically significant relationship with the constant variable (a). CONCLUSIONS: Deep brain infarction seems to result in a significant dysfunction of the autonomic nervous system, manifesting itself as distorted dynamic behavior of the QT interval and with impaired functional performance.

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PubMed2002

The "Sheba" model of comprehensive orthogeriatric care for elderly hip fracture patients: a preliminary report.

BACKGROUND: The progressive increase in the number of elderly patients with hip fractures and the particular multidisciplinary needs of this population call for the investigation of other models of orthogeriatric care. OBJECTIVES: To describe the nature and assess the feasibility of a comprehensive orthogeriatric unit attending to patients' surgical, medical and rehabilitation needs in a single setting. METHODS: This retrospective chart review describes consecutive older patients with hip fractures admitted directly from the emergency ward to an orthogeriatric ward. RESULTS: The mean age of the 116 patients evaluated was 82.4 years. Delay to surgery was 3.6 +/- 3.1 days and total length of stay 23.9 +/- 11.0 days. No patient was transferred to other acute medical wards of the hospital and 66.4% were able to return to their previous living place. Rates of major complications and mortality were extremely low. CONCLUSION: The present model of a comprehensive orthogeriatric ward is a practical, applicable and feasible service for elderly hip fracture patients and can cover the various needs of these patients. The deployment arrangements needed to establish and operate the ward were minimal and there were only a few management and organizational problems. The cost-effectiveness and other comparative benefits of this type of service have yet to be clarified.

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PubMed2002

[High rate of sacral fractures in elderly patients presenting pubic rami fractures].

BACKGROUND: Pubic rami fractures are common in the elderly, resulting from low energy traumatic falls. The recovery of some of these patients may be disproportionately slow. OBJECTIVE: To investigate the characteristics of older patients admitted with pubic rami fractures and possible associated pelvic fractures. PATIENTS AND METHODS: We have prospectively examined nineteen consecutive female patients admitted from the emergency ward with a diagnosis of pubic rami fractures, during a one-year period. Patients underwent bone scans and pelvis computerized tomography. RESULTS: Six of these patients had associated sacral fractures as demonstrated by pelvic CT scan. None of these sacral fractures was diagnosed on admission to the emergency ward. CONCLUSION: There is a considerable high rate of association of combined pubic and sacral fractures. Greater awareness of this clinical condition is required.

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PubMedDate not supplied

Plasma lipid levels in Alzheimer's disease patients treated by Donepezil hydrochloride: a cross-sectional study.

Donepezil hydrochloride is a central acetylcholine esterase inhibitor that is widely used in Alzheimer disease (AD). We have recently observed some differences in lipid profile between occasional cases of Donepezil hydrochloride users (DU) and non-users (DNU). This prompted us to study the levels of plasma lipids in these two groups, cross-sectionally. The medical charts of patients with probable AD were screened for current use of Donepezil hydrochloride and lipids profile, along with other clinical and demographic data. A total number of 105 patients were identified and included in the final analysis. Patients were divided into two groups (DU and DNU). Plasma levels of lipids were recorded. Mann-Whitney or t-test for continuous variables and Fisher exact test for categorical variables were used to test for significant differences between the groups. Regression analysis was applied to identify independently the factors associated with lipid levels. Thirty-three patients were DU and 72 DNU. The two groups differed in terms of age, lipid levels and cognitive level. DU had statistically significant higher levels of triglycerides compared with those not using the drug (P=0.036), higher total cholesterol (P<0.001), higher LDL (P=0.001), and higher VLDL (P=0.029) levels. DU showed statistically significant high odds ratios for having higher cholesterol and triglycerides levels. Multivariate regression analysis showed that there are marked differences between DU and DNU with respect to plasma lipid profile, also after correcting for age and sex. The higher plasma levels of cholesterol and triglycerides may reflect an adverse effect of Donepezil hydrochloride. Alternatively, this may indicate that the effect of the medication may involve lipid metabolism, rather than other proposed mechanisms.

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PubMedDate not supplied

Measuring the suffering of end-stage dementia: reliability and validity of the Mini-Suffering State Examination.

Assessment of suffering is extremely important in dying end-stage dementia patients (ESDP). We have developed and examined the reliability and validity of the Mini-Suffering State Examination (MSSE), in 103 consecutive bedridden ESDP. Main outcome measures included inter-observer reliability and concurrent validity. Reliability of the MSSE questionnaire was satisfactory, with Cronbach alpha values of 0.735 and 0.718 for the two physicians (Ph-1, Ph-2), respectively. The kappa agreement coefficient was 0.791. There was a high agreement for seven items (kappa 0.882-0.972) and a substantial agreement for the other three items (kappa 0.621-0.682) of the MSSE. MSSE was validated versus the comfort assessment in dying with dementia (CAD-EOLD) scale and resulted in a significant Pearson correlation (r=-0.796, P<0.001). We conclude that the MSSE scale is a reliable and valid clinical tool, recommended for evaluating the severity of the patient's condition and the level of suffering of ESDP. Use of MSSE may improve medical management and facilitate communication between patients and caregivers.

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PubMedDate not supplied

Folate status and folate related anemia: a comparative cross-sectional study of long-term care and post-acute care psychogeriatric patients.

Aging is associated with increased risk of anemia, poor nutrition, chronic illness, and impaired folate status. We aimed to investigate and compare folate status in long-term care psychogeriatric patients (LTCPP) and in post-acute care psychogeriatric patients (PACPP). This is a cross-sectional study conducted in a psychogeriatric medical center with long-term care and post-acute care wards. A total number of 553 LTCPP and 373 PACPP were studied. Low serum folic acid levels were found in 10% of LTCPP and in 13% of PACPP. Folic acid anemia (FAA) was found in 67% of LTCPP and 87% of PACPP (P = 0.046) with low serum folate levels. Mean levels of serum folate were similar but red blood cells folate (RBC-folate) was higher in PACPP (P = 0.025) and in males compared with women (P = 0.009). 56% of PACPP and 68% of LTCPP who had folic acid anemia presented with another type of anemia. Anemia of chronic disease was the most frequent coexisting anemia and was found in 65% of LTCPP and 52% of PACPP, followed by B12 deficiency anemia and iron deficiency anemia. We conclude that PACPP represent only a slightly different group, compared with LTCPP, with regard to the folate status. These high rates of folate and RBC-folate deficiencies, as well as of FAA and coexisting anemia, call for a routine evaluation of folate status in all psychogeriatric patients, whether LTCPP or PACPP.

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Plasma homocysteine levels and cognitive status in long-term stay geriatric patients: a cross-sectional study.

Many studies have established an association of total plasma homocysteine (Hcys) levels and the risk for dementia and Alzheimer disease. However, little is known on the relation between Hcys and cognitive status in long-term stay geriatric patients. This cross-sectional study was conducted in a long-stay geriatric center and included 186 eligible patients, staying for more than 6 months in the facility. We looked for patients' clinico-demographic data, as well as for laboratory data and cognitive status, evaluated by the mini-mental state examination (MMSE). Patients were divided into three groups according to Hcys levels and analyzed in order to explore potential association with cognitive levels, considering clinically important cofounders. Cognitive state of patients of the highest Hcys tertile was significantly impaired, compared with other groups (p < 0.0001) and characterized by a worse nutritional status. Pearson's correlation coefficient for Hcys and MMSE resulted -0.251 (p = 0.0005). The linear regression model for MMSE showed that homocysteine is significantly associated with MMSE: mean MMSE score of patients with homocysteine >13.7 was significantly lower than the mean MMSE of patients with homocysteine < or = 8.5, after controlling for all other parameters in the regression equation (beta = -2.7685, p = 0.007). We conclude that in our sample of patients, Hcys was associated with cognitive impairment. Hcys levels >13.7 micromol/l remained a significant independent parameter associated with the severity of cognitive impairment, after controlling for other confounders. A better understanding of the mechanisms underlying such interrelations may have research and interventional implications.

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PubMedDate not supplied

Exposure to opioid analgesia in cognitively impaired and delirious elderly hip fracture patients.

The objectives of this study were to characterize patterns of opioid analgesia in elderly hip fracture patients, to investigate the possible differences in the treatment of cognitively impaired, delirious, or cognitively intact patients, and to study the factors that may affect the doses received by such patients. This retrospective study comprised 184 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini-mental state examination, assessment of possible delirium by the confusion assessment method, type and doses of opioid received by these patients. We found that the amount of morphine equianalgesic dose differed significantly between demented and non-demented patients (7.5 +/- 1.8 vs. 14.1 +/- 4.9, P<0.001). Patients with cognitive decline or with delirium received only 53 and 34%, respectively, of the amount of opioid that was administered to cognitively intact patients. A significant association was observed between cognitive status, or delirium, and amount of opioid analgesia (P<0.001 and P=0.003, respectively). Other parameters such as age, length of stay and type of fracture, had no effect on the use of opioid analgesia. It is concluded that the management of pain in older persons with hip fracture surgery is suboptimal with regards to insufficient administration of opioid analgesia in demented and delirious patients. The adoption of a standardized protocol for pain control may help in reducing the extent of this problem.

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PubMedDate not supplied

Meperidine analgesia and delirium in aged hip fracture patients.

Delirium is quite frequent in elderly patients who sustain hip fractures. The use of Meperidine by physicians, unaware of the possible emergence of delirium in elderly patients, is very popular. We have retrospectively examined the incidence of delirium in 181 consecutive patients admitted to the orthogeriatric ward with hip fractures. We used the confusion assessment method to establish the presence of delirium in all patients. A database search was conducted to identify which patients were treated by Meperidine, or Morphine, prior to delirium onset. We identified 92 cases, 44 of whom were treated by Meperidine alone, and the other 48 treated by Morphine alone. Delirium was diagnosed in 13 (27.1%) Morphine treated patients as compared with 19 (43.2%) treated by Meperidine (P<0.001). Age, cognitive status and opiate use were associated with perioperative delirium. A subset regression analysis showed that exposure to Meperidine was significantly associated with delirium (odds ratio 2.5, P<0.01), in contrast with Morphine. Our results confirm the association between exposure to Meperidine and delirium, suggesting that this drug should be withdrawn in elderly hip fractured patients undergoing surgery, and substituted by low dose Morphine analgesia. Reducing the incidence of delirium, by adopting such an approach, may result in a significant potential of savings in direct costs, related to treatment of delirium in this population.

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PubMedDate not supplied

The unfavorable nature of preoperative delirium in elderly hip fractured patients.

The onset of delirium is frequent in elderly patients who sustain hip fractures. The purpose of this study was to characterize different patterns of preoperative and postoperative delirium, to study factors associated with preoperative delirium and to evaluate the possible different outcome of these patients. This retrospective study comprised 281 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini mental state examination (MMSE), assessment of possible delirium by the confusion assessment method (CAM) and functional outcome assessed by functional independence measure (FIM). A database search was conducted to identify whether delirium onset occurred prior to or following surgery. About 31% of the total sample developed delirium. Delirious patients tended to be more disabled (P = 0.03) and cognitively impaired (P = 0.018), compared with non-delirious patients. Most delirious cases (53%) had their onset in the preoperative period. Patients with preoperative delirium were older (P = 0.03), had a lower prefracture mobility (P < 0.01), impaired cognition (P = 0.04) and showed an adverse functional outcome in terms of FIM score. Regression analysis showed that prefracture dementia, prefracture mobility and low MMSE scores were strongly associated with higher probability of having preoperative delirium, with no additional effect of other variables. It is concluded that preoperative delirium should be viewed as a separate entity with unfavorable nature and adverse outcome. Careful preventive measures and better treating strategies should be employed to avoid this clinical condition.

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Blood transfusion requirements in elderly hip fracture patients.

The purpose of this study was to investigate blood transfusion patterns in elderly hip fractured patients and to determine the clinical predictive criteria for blood utilization. This retrospective study involved data analysis of 302 patients, undergoing surgical repair of pertrochanteric and subcapital fractures. Patients of the transfused group had significantly lower admission hemoglobin (P < 0.0001) and significantly more pertrochanteric fractures. About 80% of patients of the lowermost quartile of admission hemoglobin were transfused, compared with < 20% of the uppermost group (P < 0.0001). Admission hemoglobin levels < 12 g% and pertrochanteric fractures were independently associated with transfusions (odds ratio (O.R.) 0.475, C.I. 0.377-0.598, P < 0.0001 and O.R. 1.885, C.I. 1.05-3.215, P = 0.02, respectively). The results support the adoption of a policy considering primarily these two factors. Other factors we studied had no predictive power. Cross-matching may be reserved only for patients presenting with hemoglobin < 12 g% and pertrochanteric fractures. This practice seems safe and should help in reducing the extent of unnecessary blood ordering.

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Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients.

BACKGROUND AND PURPOSE: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period. METHOD: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine. RESULTS: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 +/- 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 +/- 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low. CONCLUSIONS: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.

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Multidimensional continuous pain assessment chart (MCPAC) for terminal cancer patients: a preliminary report.

Current use of pain measures is limited in clinical practice. The common pain measures neither target nor monitor the changes that occur with time with regard to the effect of other parameters associated with pain control. Changes in parameters, such as pain type, various pharmacological and nonpharmacological interventions, dosage of medications, and use of rescue doses, usually complicate pain control in terminal cancer patients. The authors propose use of a multidimensional, continuous pain chart that permits better assessment and control of pain. The chart integrates visual analogue pain assessment, special treatment techniques, regular medications and rescue doses, co-analgesics, pain categories, parameters relating to quality of life, sleep, and mobility. A total of 1,178 assessments were performed in 100 consecutive patients with full compliance. The chart permitted a continuous monitoring of patients 'most important needs concerned with pain control and was easily integrated into the hospice daily routines. We conclude that the chart represents an effective and friendly graphic tool to monitor pain and associated parameters that relate to the quality of the broad spectrum of pain control. The hope is that this tool may improve pain control by hospice professionals and facilitate communication between patients and the interdisciplinary team members.

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Dying dementia patients: too much suffering, too little palliation.

Patient suffering is a pathological syndrome traditionally viewed as encompassing psychological distress, spiritual concerns, and various aspects of physical pain. There is insufficient clinical evidence for suffering in dying dementia patients, which may lead to inappropriate evaluation and insufficient palliative treatment. Our objective was to evaluate the suffering of terminal dementia patients over time, from admission to a geriatric ward to the last day of life. The study included consecutive end-stage dementia patients in a general geriatric department of a tertiary hospital. Patients were evaluated weekly by the Mini Suffering State Examination scale (MSSE) which measures many domains related to suffering. Seventy-one patients were studied. Mean survival of patients was 38.0 +/- 5.1 days. MSSE increased during hospital stay from 5.62 +/- 2.31 to 6.89 +/- 1.95 (p < 0.001). According to MSSE scale, 63.4 percent and 29.6 percent of patients died with a high and intermediate level of suffering, respectively. Only 7 percent of the patients died with a low level of suffering. In particular, patients were restless (p < 0. 001), had pressure sores (p = 0.01), and were considered medically unstable (p < 0.001). We concluded that, despite traditional medical and nursing care, a large proportion of dying dementia patients experience an increasing amount of suffering as they approach death. New palliative treatment approaches should be developed for these patients.

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PubMedDate not supplied

Dying dementia patients: too much suffering, too little palliation.

Suffering is traditionally viewed as a state encompassing psychological distress, spiritual concerns, and various aspects of physical pain. There is insufficient clinical evidence for suffering in dying dementia patients, which may lead to inappropriate evaluation and insufficient palliative treatment. Our objective was to evaluate the suffering of terminal dementia patients over time, from admission to a geriatric ward to the last day of life. The study included consecutive end-stage dementia patients dying in a general geriatric department of a tertiary hospital. Patients were evaluated weekly by the Mini Suffering State Examination scale (MSSE). Seventy-one patients were studied. Mean survival of patients was 38.0 +/- 5.1 days. MSSE increased during hospital stays from 5.62 +/- 2.31 to 6.89 +/- 1.95 (p < 0. 001). According to the MSSE scale, 63.4 percent and 29.6 percent of patients died with a high and intermediate level of suffering, respectively. Only 7 percent of the patients died with a low level of suffering. In particular, patients were restless (p < 0. 001), had pressure sores (p = 0. 01), and were considered medically unstable (p < 0. 001). We concluded that, despite traditional medical and nursing care, a large proportion of dying dementia patients experienced an increasing amount of suffering as they approached death. New palliative treatment approaches should be developed for these patients.

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