No convincing association between post-operative delirium and post-operative cognitive dysfunction: a secondary analysis.

BACKGROUND: Post-operative delirium and post-operative cognitive dysfunction (POCD) are both common but it has not been clarified how closely they are associated. We aimed to assess the possible relationship in a secondary analysis of data from the 'Surgery Depth of anaesthesia and Cognitive outcome'- study. METHODS: We included patients aged ≥ 60 years undergoing non-cardiac surgery planned for longer than 60 min. Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders IV criteria in the post-anaesthesia care unit (PACU) as well as within the first week after surgery. Cognitive function was assessed with a neuropsychological test battery. Multivariable analysis of POCD was performed with consideration of predisposing and precipitating factors. RESULTS: Of 1277 randomized patients, 850 (66.6%) had complete data. Delirium was found in 270 patients (32.9% of 850). We detected POCD in 162 (20.9% of 776) at 1 week and in 52 (9.4% of 553) at 3 months. In multivariable analysis (n = 808), delirium had no overall effect on POCD (P = 0.30). Patients with no delirium in PACU but with postoperative delirium within 7 days had an increased risk of POCD at 3 months (OR = 2.56 (95%-confidence interval: 1.07-6.16), P = 0.035). No significant association was found for the other subgroups. CONCLUSIONS: There is no clear evidence that postoperative delirium is independently associated with POCD up to 3 months.

Incidence and risk factors for cognitive dysfunction in patients with severe systemic disease.

OBJECTIVE: To determine the relevance of surgery and other causative factors to the incidence of postoperative cognitive dysfunction (POCD) in patients with severe systemic disease. METHODS: This observational study included 107 noncardiac surgical patients and 26 nonsurgical control subjects, all of whom had an American Society of Anesthesiologists physical classification status of 3. Cognitive assessment was performed preoperatively and 7 days postoperatively, or with a 7-day interval for the control group. POCD was calculated as a combined Z-score. Mini Mental State Examination (MMSE) was used to exclude patients with pre-existing cognitive deficit (MMSE score ≤ 23). Surgical and other factors including duration of surgery/anaesthesia and length of stay in the intensive care unit (ICU) were recorded. RESULTS: After 7 days, POCD was found in 40/107 (37.4%) surgical patients compared with 4/26 (15.4%) nonsurgical controls. Preoperative MMSE score, duration of surgery/anaesthesia, and length of stay in the ICU and hospital were associated with POCD. Logistic regression analysis revealed that preoperative MMSE score was an independent predictor of POCD. CONCLUSION: Lower baseline MMSE score was the only independent predictor for POCD in patients with severe systemic disease.

[Opportunistic infections and HIV-associated malignancies. An evaluation of 58 autopsy cases within 10 years]. / AIDS--Opportunistische Infektionen und HIV-assoziierte maligne Erkrankungen. Eine Auswertung von 58 Sektionsfällen aus einem Zeitraum von zehn Jahren.

PATIENTS AND METHODS: Of all patients who died of HIV infection within 10 years (1. 1. 1988 to 31. 12. 1997) at the Klinikum Nürnberg 58 autopsy cases were reviewed at the Institute of Pathology of the above mentioned hospital. RESULTS: The male:female ratio was 2.1:1, the mean age being 40.5 years. Most of the patients showed an advanced stage of lymphadenopathy at the moment of death. Non-Hodgkin's lymphoma and Kaposi's sarcoma, both HIV-related malignant diseases, were diagnosed in 6/58 cases, 10.3% each. HIV-related myelodysplastic changes existed in 28/58 patients (48.3%). Twelve patients showed an HIV-associated encephalopathy (20.7%). Opportunistic infections (pneumocystis carinii, cytomegaly, toxoplasmosis, atypical mycobacteriosis) were found in 28/58 patients (48.3%). A mycosis was diagnosed in 9/58 cases (15.5%). Tuberculosis was identified in 4/58 patients (6.9%). Cirrhosis of the liver was ascertained in 8/58 patients (13.8%). 24/58 patients (41.4%) died of respiratory disorder. CONCLUSION: In the acquired immunodeficiency syndrome numerous morphological findings will be helpful in diagnosis and therapy.

Intensive chemotherapy with idarubicin, ara-C, etoposide, and m-AMSA followed by immunotherapy with interleukin-2 for myelodysplastic syndromes and high-risk Acute Myeloid Leukemia (AML).

Intensive chemotherapy followed by treatment with interleukin-2 (IL-2) was evaluated in a prospective, randomized, multicenter trial including 18 patients with refractory anemia with excess of blasts in transformation (RAEB-T), 86 patients with acute myeloid leukemia (AML) evolving from myelodysplastic syndromes, and six patients with secondary AML after previous chemotherapy. Median age was 58 years (range: 18-76 years). Forty-nine patients (45%) achieved a complete remission (CR) after two induction cycles with idarubicin, ara-C, and etoposide, 52% of them aged 60 years (p=0.06). After two consolidation courses, patients were randomized to four cycles of either high- or low-dose IL-2. Patients aged up to 55 years with an HLA-identical sibling donor were eligible for allogeneic bone marrow transplantation. The median relapse-free survival was 12.5 months, with a probability of ongoing CR at 6.5 years of 19%. Overall survival of all patients was 8 months, and 21 months for the CR patients. Median survival was significantly longer among patients aged

Patterns of mycobacterium avium culture and PCR positivity in immunodeficient HIV-infected patients: progression from localized to systematic disease, German Aids Study Group (GASG/IDKF).

Our aim was to establish the frequency and the longitudinal pattern of MAC culture positivity in late stage HIV-infected patients. Two other aims were to analyse risk factors for progression from localized to systemic disease and the value of PCR diagnosis using blood specimens. A total of 107 patients were recruited to be followed for 32 weeks. Prior MAC treatment and CD4 > 100/microliters were exclusion criteria. A total of 56 patients showed M. avium in at least 1 culture. 10/37 patients with MAC detected by culture first in 'non-sterile' specimens (stool, sputum) and urine progressed to systemic disease as determined by positive blood culture. Risk factors associated with this progression were a high symptom score at baseline, lymphadenopathy, anaemia, and low platelets. PCR was less sensitive than culture in detection of M. avium in blood specimens: Only 7/29 patients with positive blood cultures had a positive PCR at the same time. We conclude that symptomatic patients with advanced HIV-infection have a high frequency of MAC detection. Progression from localized to systemic culture positivity is associated with risk factors. Early 'pre-emptive' therapy is discussed.

Treatment of patients with peripheral arterial occlusive disease Fontaine stage IV with intravenous iloprost and PGE1: a randomized open controlled study.

In a randomized open controlled study the clinical effects and tolerability of prostaglandin E1 (PGE1) and the stable prostacyclin (PGI2) analogue, iloprost in the management of diabetic and non-diabetic patients with advanced peripheral arterial occlusive disease (PAOD Fontaine stage IV) were compared. 267 patients were enrolled in this multicentre study and treated for 21-28 days, either by daily infusions of 6 h with iloprost or 2 x 2 h with PGE1. At the end of treatment patients were assessed for evidence of improvement of trophic lesions, relief of rest pain and change of global clinical status. 228 patients were considered as evaluable for efficacy analysis, which revealed 52.7% responders in the iloprost group and 43.1% for PGE1 (p = 0.148). Whereas iloprost showed similar effects in diabetics and non-diabetics (53.3% and 51.4% response rates, respectively), the diabetics treated with PGE1 had a considerably poorer outcome (36.6% versus 53.3%). At 6 months follow-up 62.2% of patients in both groups were alive with a viable limb. Slightly more iloprost patients underwent major amputation (32.1% versus 27.2%), but the number of deaths was reduced by 50% in the iloprost group compared to the PGE1 group (7.5% versus 14.6%, p = 0.10). Side-effects such as headache, flushing and gastrointestinal symptoms were significantly more common in the iloprost group (73.9%) than in the PGE1 group (31.0%), particularly during the first 3 days of dose titration. No specific toxic or unexpected reactions were reported in either group.

Viral culture and p24 antigenemia of human immunodeficiency virus (HIV)-infected individuals correlated with antibody profiles determined with recombinant polypeptides of all HIV-1 open-reading frames.

The association between viral activity and antibody profiles was investigated in 202 individuals infected by the human immunodeficiency virus (HIV) grouped according to their Walter Reed clinical stage. Each study group was subdivided into subjects positive or negative for markers of active viral replication: presence of serum p24 antigen and viral culture. In Western blots using recombinant antigens, sera of HIV-positive individuals with positive viral markers had a significantly lower antibody reactivity to several viral proteins than did individuals without viral markers. Noticeably, proteins of the gag (p24, p17) and env (gp120, COOH-terminal part of gp41) open-reading frames revealed a decreased reactivity. The antibody response to the regulatory proteins revealed no or poor association with viral activity in the host. The results suggest that seroreactivity is mainly influenced by factors reflecting the viral activity of an HIV-infected individual, while the clinical stage of the patient is less important. Especially, reductions in antibodies against gp120 and p17 were useful markers associated with increased viral activity.