Limitation of therapeutic activity in elderly critically ill patients. Project for the Epidemiological Analysis of Critical Care Patients

OBJECTIVE: To establish whether the age of patients admitted into the intensive care unit (ICU) influences the amount of therapy received. DESIGN: Observational, prospective, multicenter study. SETTING: Eighty-six multidisciplinary ICUs in Spain, including coronary patients. PATIENTS: The patients (n = 8,838) were studied during a 6-month period between 1992 and 1993. Patients < 16 yrs of age and patients dying within the first 6 hrs were excluded from the study. MEASUREMENTS AND MAIN RESULTS: We collected data on age, gender, type of diagnosis at the time of admission, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) II and III, quality of life survey score, therapeutic activity during the first 24 hrs by Therapeutic Intervention Scoring System, and ICU and hospital mortality rates. In the sample of patients, 12.5% were > 75 yrs of age. Compared with younger patients, these patients had higher APACHE II (18.41 +/- 0.23 vs. 15.14 +/- 0.09 points, p < .001) and APACHE III (65.8 +/- 0.81 vs. 53.32 +/- 0.33 points, p < .001) scores, a higher quality of life survey score (i.e., worse quality of life, 7.19 +/- 0.19 vs. 3.86 +/- 0.05 points, p < .001), and a greater ICU mortality rate (21.9% vs. 15.3%, p < .00001) and hospital mortality rate (30.8% vs. 19.3%, p < .00001). However, patients > 75 yrs had a lower Therapeutic Intervention Scoring System score (19.83 +/- 0.28 vs. 21.17 +/- 0.12 points, p < .001). Multivariate analysis showed that once severity, need for mechanical ventilation, diagnostic group, and mortality rate were taken into account, there was less therapeutic activity in patients > 75 yrs of age. CONCLUSIONS: Patients > 75 yrs of age represent a large proportion of patients in Spanish ICUs. Although their mortality rate and severity scores were higher than those values in younger patients, patients > 75 yrs of age received less therapy.     

Continuous i.v. administration of the angiotensin-converting enzyme inhibitor enalaprilat in the critically ill: effects on regulators of circulatory homeostasis

Several components are responsible for circulatory control at the central, regional, and microcirculatory level. Angiotensin-converting enzyme (ACE) inhibitors are known to act beneficially on circulation by various mechanisms. The influence of continuous i.v. administration of the ACE inhibitor enalaprilat on regulators of circulation was studied in 45 critically ill patients. According to a prospective randomized sequence, either 0.25 mg/h (group 1, n = 15) or 0.5 mg/h (group 2, n = 15) of enalaprilat or saline solution as placebo (control group, n = 15) were continuously given. Infusion was started on the day of admission to the intensive care unit (ICU) and continued for the next 5 days. From arterial blood samples, plasma levels of endothelin-1 (ET), atrial natriuretic peptide (ANP), renin, vasopressin, angiotensin-II, and catecholamines (epinephrine, norepinephrine) were measured. All measurements were carried out before infusion (= baseline values) and during the next 5 days. In both enalaprilat groups, mean arterial blood pressure (MAP) decreased similarly; heart rate (HR) and central venous pressure (CVP) did not change, and were without differences in comparison to the untreated control. Except for ET, plasma levels of all vasoactive substances exceeded normal range at baseline. Angiotensin-II plasma concentrations significantly decreased during enalaprilat infusion (0.25 mg/h: from 53.1 +/- 11.3 to 22.1 +/- 9.3 pg/ml; 0.50 mg/h: 62.1 +/- 14.4 to 17.9 +/- 7.9 pg/ml), but they remained significantly elevated in the untreated control patients. Vasopressin plasma level increased only in the control group (p < 0.01) and decreased in the patients in whom 0.50 mg/h of enalaprilat was infused.(ABSTRACT TRUNCATED AT 250 WORDS)     

Separation of zirconium from hafnium in nitric acid solutions by solvent extraction using dibutyl butylphosphonate: Part 1. Chemistry of the separation

The solvent extraction of zirconium and hafnium from nitric acid solutions into dibutyl butylphosphonate (DBBP)/Solvesso 150 has been studied, as a function of acidity, DBBP and metal concentration. Extraction of complexes containing two DBBP molecules per atom of zirconium or hafnium have been demonstrated. Separation factors for zirconium from hafnium have been obtained at different acidities and metal concentrations.     

Effects of venlafaxine on blood pressure: a meta-analysis of original data from 3744 depressed patients

BACKGROUND: Venlafaxine hydrochloride, a structurally novel antidepressant, is also the first nontricyclic serotonin/norepinephrine reuptake inhibitor. Although venlafaxine has an overall side effect and safety profile that is comparable to other newer antidepressants, it can cause both transient and sustained elevations of supine diastolic blood pressure (SDBP), probably the result of noradrenergic potentiation. METHOD: Presented here is a meta-analysis of original data on blood pressure, using both random effects and a multivariate survival analyses. The sample consisted of 3744 patients with major depression who were studied in controlled clinical trials comparing venlafaxine with imipramine and/or placebo. Patients were treated for 6 weeks of acute phase therapy; some responders received up to 1 year of continuation phase therapy. RESULTS: Venlafaxine and imipramine were associated with small, but statistically significant, increases in SDBP during acute phase therapy. When compared with imipramine and placebo, venlafaxine was also associated with a greater proportion of persistent elevations of SDBP during continuation therapy. The effect of venlafaxine was highly dose dependent, and the incidence of elevated SDBP was statistically and clinically significant only at dosages above 300 mg/day. Venlafaxine did not adversely affect the control of blood pressure for patients with preexisting high blood pressure or elevated baseline values. CONCLUSION: Venlafaxine has a dose-dependent effect on SDBP that is clinically significant at high dosages. Concern about blood pressure effects should not deter first-line use of this effective antidepressant, although more extensive studies of patients with cardiovascular diseases are still necessary.     

Practice guidelines for evaluating new fever in critically ill adult patients. Task Force of the Society of Critical Care Medicine and the Infectious Diseases Society of America

OBJECTIVE: The development of practice guidelines for evaluating adult patients who develop new fever in the intensive care unit (ICU) for the purpose of guiding clinical practice. PARTICIPANTS: A task force of 13 experts in disciplines related to critical care medicine, infectious diseases, and surgery was convened from the membership of the Society of Critical Care Medicine and the Infectious Disease Society of America. EVIDENCE: The task force members provided personal experience and determined the published literature (articles retrieved with use of MEDLINE or textbooks) from which consensus would be sought. The published literature was reviewed and classified into one of four categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times in person and twice monthly by teleconference over a 1-year period to identify the pertinent literature and arrive at consensus recommendations. Consideration was given to the relationship between the weight of scientific evidence and the experts' opinions. Draft documents were composed and debated by the task force until consensus was reached by nominal group process. CONCLUSIONS: The panel concluded that because fever can have many infectious and noninfectious etiologies, a new fever in an adult patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiological tests. A cost-conscious approach to obtaining diagnostic studies should be undertaken if they are indicated after a clinical evaluation. The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic options can be identified.     

Effects of Motivational Cues on Perceptual Asymmetry: Implications for Creativity and Analytical Problem Solving.

In 4 experiments, participants were led to focus on either the prospect of positive outcomes (approach anticipation) or the prospect of negative outcomes (avoidance anticipation) and were subsequently administered behavioral measures of relative hemispheric activation. It was found that approach, relative to avoidance-related anticipatory states, produced greater relative right (diminished relative left) hemispheric activation. Experiment 3 additionally demonstrated that this pattern of activation was reversed when approach and avoidance states were not merely anticipatory but were also emotionally arousing. Finally, Experiment 4 replicated earlier findings demonstrating an influence of approach and avoidance anticipatory states on creativity and analytical problem solving (R. S. Friedman & J. F?rster, 2001, 2003) and provided evidence that such effects are mediated by differences in relative hemispheric activation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Effects of Frequency and Predictability on Eye Fixations in Reading: Implications for the E-Z Reader Model.

Readers read sentences containing target words varying in frequency and predictability. The observed pattern of data for fixation durations only mildly departed from additivity, with predictability effects that were slightly larger for low-frequency than for high-frequency words. The pattern of data for skipping was different as predictability affected only the probability of skipping for high-frequency target words. Simulations of these data using the E-Z Reader model indicated that a single-process model was unlikely to provide a good fit for both measures. A version of the model that assumes that (a) word-encoding time is additively affected by frequency and predictability and (b) difficulty with postlexical processing of the target word causes a double take accounted for the data while indicating that the relationship between the duration of hypothesized word-encoding stages and observed fixation durations is not likely to be transparent. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of job enrichment and task goals on satisfaction and productivity: Implications for job design.

A 2-phase research project investigated the effects of job enrichment and goal setting on employee productivity and satisfaction in a well-controlled, simulated job environment. In the 1st phase, 2 conditions of goal setting (assigned goals vs no goals) and 2 conditions of job enrichment (enriched vs unenriched) were established, producing 4 experimental conditions in which 42 part-time workers took part. Job enrichment had a substantial impact on job satisfaction but little effect on productivity. Goal setting, on the other hand, had a major impact on productivity and a less substantial impact on satisfaction. In the 2nd phase (after 2 days' work), Ss with unenriched jobs worked under the enrichment conditions and Ss originally without goals were assigned goals. Again, job enrichment had a positive effect on job satisfaction, while goal setting had a positive effect on performance. Results are discussed in terms of the current theoretical approaches for understanding employee motivation on the job. (32 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of a drinking event on behavioral skills and condom attitudes in men: Implications for HIV risk from a controlled experiment.

This study experimentally tested the effects of a drinking event on HIV-related behavioral skills and condom attitudes. Sixty unmarried, heterosexual men were assigned to 1 of 3 conditions (sober, placebo, or alcohol). Participants who consumed alcohol demonstrated lower skill to negotiate for condom use relative to sober controls. More negative condom attitudes were expressed by participants with stronger sex-related alcohol expectancies, especially when these expectancies were triggered by subjective intoxication. Hierarchical regression analyses revealed that the experimental factors accounted for variance in behavioral skills and condom attitudes beyond that explained by known predictors of sexual risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

New directions for basic psychoanalytic research: Implications from the work of Benjamin Rubinstein.

Basic, theoretically relevant research on psychoanalysis needs the theory to be restated in nonmetapsychological terms. B. B. Rubinstein's (1975, 1976) hierarchical restructuring of the clinical theory provides such a framework of testable propositions. Because the propositions are intrinsically probabilistic, research therefore cannot follow a standard experimental paradigm, but must seek empirical generalizations. Paradoxically, this means a new emphasis on the individual. Moreover, Rubinstein showed, psychoanalytic theory deals not with single acts or thoughts but with classes of them. Numerous implications of this position for research done by teams and by solo practitioners are developed with examples. If basic research is to flourish, a number of changes in psychoanalytic institutes and organizations are needed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of the ribavirin-interferon alpha combination on cultured peripheral blood mononuclear cells from chronic hepatitis C patients

The mechanisms associated with dysfunction of the cerebral vasculature following head trauma have not yet been fully elucidated. In an attempt to shed more light on the matter, we investigated the endothelial-mediated dilations in the rat middle cerebral artery (MCA) following severe traumatic brain injury (TBI). Rats were subjected to severe controlled cortical impact injury (CCI; 5 m/s, 130 ms duration, 3 mm deformation) over the right parietal cortex. At 24 h postinjury, ipsilateral segments of MCA and corresponding contralateral segments were isolated, mounted in a vessel chamber, and pressurized. The responses to 2 methylthio-ATP (2MeSATP), a selective agonist for the P2Y1 purinoceptors, N(omega)-nitro-L-arginine (L-NAME), an NO synthase inhibitor, and S-nitroso-N-acetylpenicillamine (SNAP), an exogenous NO donor, were determined. 2MeSATP elicited concentration dependent dilations in all MCAs studied. Ipsilateral MCAs harvested following TBI or sham-TBI, showed similar maximum dilations to 2MeSATP [70 +/- 4% (n = 17) and 72 +/- 6% (n = 13), respectively]. However, TBI reduced the concentration of 2MeSATP necessary to elicit one-half of the maximum dilation (EC50) from 15 to 9 nM (p < 0.05). Inhibition of NO synthase with 10(-5) M L-NAME abolished the dilation to 2MeSATP in both TBI and sham-TBI MCAs. The constriction to L-NAME was significantly reduced in TBI MCAs compared to sham vessels. Dilations to SNAP, an NO donor, were not altered by TBI indicating that the mechanisms of dilation involving NO in the vascular smooth muscle were not affected. Unlike other pathological conditions which often diminish endothelial-mediated responses, severe TBI enhanced the sensitivity to 2MeSATP without altering the maximum response.     

Effects of foveal processing difficulty on the perceptual span in reading: Implications for attention and eye movement control.

Two experiments were conducted to examine the effects of foveal processing difficulty on the perceptual span in reading. Subjects read sentences while their eye movements were recorded. By changing the text contingent on the reader's current point of fixation, foveal processing difficulty and the availability of parafoveal word information were independently manipulated. In Experiment 1, foveal processing difficulty was manipulated by lexical frequency, and in Experiment 2 foveal difficulty was manipulated by syntactic complexity. In both experiments, less parafoveal information was acquired when processing in the fovea was difficult. We conclude that the perceptual span is variable and attentionally constrained. We also discuss the implications of the results for current models of the relation between covert visual–spatial attention and eye movement control in reading. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Superior sensitivity for tactile stimuli oriented proximally-distally on the finger: Implications for mixed class 1 and class 2 anisotropies.

Inferior performance for obliquely oriented stimuli is often observed on higher level visual and somatosensory tasks and also on tests of low-level visual sensory ability. This study demonstrated an anisotropy of low-level somatosensory performance. Sensitivity to gratings on the finger pad was highest for gratings oriented proximally-distally, intermediate for oblique gratings, and lowest for medial-lateral gratings. This pattern supports a model proposing that detection threshold is determined by the number of neurons tuned to a stimulus (A. Anzai, A. Bearse, Jr., R. D. Freeman, & D. Cai, 1995). A classification of somatosensory and visual anisotropies is proposed in which orientation biases are classified as being attributable to either anisotropic sensory filtering (Class 1) or anisotropic higher level processing (Class 2). It was concluded that a given instance of anisotropic visual or somatosensory performance may stem from low-level sensory factors, high-level factors, or a mixture of the two, depending on the task demands. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain

To make health care more responsive to patient needs, insight into patient priorities is needed. A systematic literature review, using electronic and manual searches, was made of studies on patient priorities with regard to primary health care. Data-extraction was performed by two researchers, followed by systematic analyses of study features. 57 studies were included. The aspects of care and methods used showed a wide variation. Aspects most often included were "informativeness", "humaneness" and "competence/accuracy". Based on an analysis of 19 studies, the following aspects were seen by patients as most important in more than 50% of the studies that included them: "humaneness", "competence/accuracy", "patients' involvement in decisions", "time for care", "other aspects of availability/accessibility", "informativeness", "exploring patients' needs", "other aspects of relation and communication" and "availability of special services".