Gastrointestinal bleeding in the elderly.

Gastrointestinal bleeding is a problem encountered frequently in the elderly. This article reviews its diagnosis and management, focusing on issues particularly relevant in geriatric care. The article begins with an overview of acute gastrointestinal (GI) bleeding and follows with more focused descriptions of upper GI bleeding, lower GI bleeding, and the growing problem of bleeding of obscure origin. The article concludes with recommendations for the evaluation of positive fecal occult blood tests.

Ondansetron with propofol reduces the incidence of emesis in children following tonsillectomy.

PURPOSE: This study tested the hypothesis that the antiemetic effects of a combination of ondansetron and propofol were superior to propofol alone in children undergoing tonsillectomy surgery. METHODS: A prospective, randomized, double-blind, placebo-controlled study design was employed. Young children underwent mask induction with halothane, nitrous oxide and oxygen and then had i.v. access established: older children had i.v. induction with propofol. All patients received 0.3 mg x kg(-1) mivacurium and 2-4 microg x kg(-1) fentanyl i.v. and 30 mg x kg(-1) acetaminophen pr to a maximum dose of 650 mg. Following induction, patients received either 100 microg x kg(-1) ondansetron or placebo. Anaesthesia was maintained with 120-140 microg x kg(-1) x min(-1) propofol, nitrous oxide and oxygen to maintain vital signs within 20% of baseline. After surgery, in all patients the tracheas were extubated in the operating room without use of neuromuscular reversing agents. Episodes of emesis were recorded by PACU nurses for four to six hours. A telephone interview on the following day was also used for data recovery. Groups were compared in relation to age using the Mann-Whitney test, and with respect to sex and number of episodes of vomiting using the Fisher Exact Test. RESULTS: Three of the 45 patients who received ondansetron vomited (6.7%), whereas 10 of the 45 patients who received placebo vomited (22.2%). (P = 0.035) CONCLUSION: Ondansetron in a dose of 100 microg x kg(-1), when combined with propofol for children undergoing tonsillectomy reduced the incidence of postoperative vomiting to very low levels.

Rapidly progressive cutaneous vasculitis in a patient with chronic myelomonocytic leukemia.

This case report reviews the unique development of a vasculitic syndrome involving medium-sized arteries in a man with chronic myelomonocytic leukemia (CMMoL). This case has many features in common with cutaneous polyarteritis nodosa (CPAN), and this may represent the first instance in which CPAN developed in the setting of CMMoL.

Selective muscle activation following electrical stimulation of the collateral ligaments of the human knee joint.

The objective of this study was to establish the presence of a local neurosensory reflex are from mechanoreceptors in human collateral ligaments and joint capsule to knee muscles and to determine if these muscles could be selectively activated as varus or valgus stabilizers using randomized trials. All studies were performed in the research department laboratories. Eleven subjects were recruited from the university staff and students based on no prior history of knee ailments. Subjects laid supine on an experimentation table as a current-modulated electrical stimulation was provided through the medial (MCL) or lateral collateral (LCL) knee ligaments. Latency of activation was measured for seven muscles, four by surface electrodes (semitendinosus, biceps femoris long head, vastus medialis, and lateralis), and three by intramuscular electrodes (sartorius, gracilis, tensor fascia lata). In the protocol, selective activation was defined as the relative increase in the activity of four muscles with medial moment arms following MCL stimulation compared with corresponding activity following LCL stimulation. For lateral muscles, the opposite was assumed (ie, that more activity would follow LCL than MCL stimulation). Monte Carlo simulations were performed on the data to determine significant selective muscle activation (p < .05). Statistically significant increases in activation were observed, most consistently, in the vastus medialis following MCL stimulation and in the vastus lateralis following LCL stimulation. These results suggest that a neurosensory reflex are from ligament mechanoreceptors may provide varus and valgus stabilization and knee muscles may be selectively activated to counter varus or valgus loads.

A primer on coding and reimbursement for gastrointestinal endoscopy.

The days when a physician could rely solely on "the front office" to deal with coding, billing, and reimbursement have passed. Only the practitioner knows specifically what service or procedure has been performed, and for which diagnosis. There is no substitute for remaining up-to-date on the rules and regulations for coding and payment. The safest approach to reporting services and procedures is to keep abreast of changes and heed the axiom "do what you say and say what you do."

Diffuse hemorrhagic gastroenteropathy: report of a new entity.

An apparently novel entity, diffuse hemorrhagic gastroenteropathy (DHG), in a 70-year-old female who had an unremitting course of chronic gastrointestinal blood loss for 3 years requiring transfusion of more than 200 units of packed red blood cells over this period is reported here. Endoscopy showed diffusely hemorrhagic mucosa in the stomach, duodenum, and small bowel. Full-thickness biopsy of the stomach and small intestine revealed luminal narrowing of capillaries and post-capillary venules within the lamina propria due to swelling and some proliferation of the endothelial cells with margination and emigration by neutrophils as well as partial occlusion of some vessels by fibrin thrombi. DHG may represent a new entity characterized by mucosal hemorrhage due to local mucosal ischemia of the gastrointestinal tract secondary to a small vessel "vasculopathy" apparently restricted to this site.

Lower GI bleeding: updated diagnosis and management.

Lower GI bleeding in the elderly can be attributed to diverticula or vascular ectasias in most cases. Usually, a diagnosis is established by colonoscopy, but often this test must be supplemented by radiographic and additional endoscopic techniques, especially in the evaluation of obscure GI bleeding. Responsible lesions are frequently remediable by non-operative therapy. However, if surgical intervention is called for, it should not be delayed solely because of the patient's advanced age.

Upper GI bleeding in the elderly: diagnosis and management.

Because the rates of morbidity and mortality from gastrointestinal (GI) bleeding in the elderly are substantially higher than those seen in younger patients, practitioners caring for the elderly should be familiar with aspects of GI bleeding that are unique to this population. A discussion of the differential diagnosis of upper GI tract bleeding is followed by a review of approaches for diagnosis and treatment.

Tests of cognition and their relationship to psychiatric diagnosis and demographic variables.

Psychiatric and control subjects were given a test of cognition consisting of orientation, spelling the word "world" backward, serial 7's test, and recalling three words. The interrelationships among test scores, diagnosis, and demographic variables were determined. Dementia was differentiated from nonorganic psychiatric disorder using only orientation and recall of three words. Depressed, schizophrenic, and bipolar patients were significantly different from controls in their ability to recall three words. In nondemented subjects, the serial 7's test was positively correlated with years of education; spelling "world" backward was negatively correlated with age. Sex, marital status, and orientation showed no significant correlation and hence were bias free.

Persistent tardive dyskinesia in bipolar patients.

The prevalence and outcome of persistent tardive dyskinesia (TD) was studied in 131 bipolar patients. There were 34 cases of persistent TD in the subgroup (n = 96) with a history of neuroleptic treatment (prevalence, 35.4%; 95% confidence interval, 25% to 45%); there were no cases of persistent TD in the subgroup (n = 35) without such treatment history. Except in one patient, signs of TD persisted in spite of lithium carbonate treatment in 23 patients (median duration, 16 months; range, five to 24 months), of whom 15 remained off of a neuroleptic regimen during the study period for a median duration of 14 months (range, four to 24 months). Using multiple regression analysis, two variables were found to predict the presence of persistent TD and account for 36% of the variance: longer cumulative duration of maintenance neuroleptic treatment and shorter duration of previous lithium carbonate treatment. There appears to be a significant risk of persistent TD among neuroleptic-treated bipolar patients. High-risk subgroups within this category need to be identified.

The efficacy of ECT in phencyclidine-induced psychosis.

Four patients are described who had a history of PCP abuse, prolonged psychosis, and poor neuroleptic response. Three of these patients were given ECT; all showed a dramatic response after the third or fourth treatment. The authors recommend that ECT be tried in psychotic patients who have used PCP if they fail to respond to antipsychotic medications after 1 week of inpatient treatment.

Misdiagnosis of schizophrenia in bipolar patients: a multiethnic comparison.

The records of 76 bipolar (DSM-III) patients were reviewed for a history of previous misdiagnosis of schizophrenia. Multivariate analyses identified three variables significantly associated with previous misdiagnosis--auditory hallucinations, early age at onset, and ethnicity. Ethnicity remained significantly associated with misdiagnosis of bipolar patients as schizophrenic even after all other significant variables were partialled out of the equation. It appears from these data that black and Hispanic (Puerto Rican) bipolar patients may be at a higher risk than whites for misdiagnosis as schizophrenic, particularly if they are young and experience auditory hallucinations during affective episodes.

Tardive dyskinesia in psychiatric outpatients: a study of prevalence and association with demographic, clinical, and drug history variables.

We examined 153 psychiatric outpatients, on a maintenance regimen of neuroleptics, for tardive dyskinesia (TD) and parkinsonism. Demographic, clinical, and drug history data were collected to assess whether any of these factors were significantly associated with TD. After initial univariate screening, significant variables were analyzed by multivariate statistical methods. Tardive dyskinesia was significantly associated with the use of high-potency or high-dosage neuroleptics and depot fluphenazine, whereas low-potency neuroleptics were negatively correlated with moderate TD. Age, but not sex, correlated significantly with TD, as did histories of incoherence, grandiose delusions, and teeth or denture problems. Parkinsonism and TD were strongly associated. Although the prevalence of TD was quite high, there were no severe involvements of any of the Abnormal Involuntary Movement Scale body areas.

Adult calendar calculators in a psychiatric OPD: a report of two cases and comparative analysis of abilities.

Two case reports are presented of psychiatric patients discovered in an adult psychiatric OPD who were proficient calendar calculators. Both were found to have similarities in history, clinical presentation, and symptomatology, Reaction times of both subjects on a set of 192 test dates were not random but were significantly predicted by the year and the month. In one subject (Tim), performance based on a visual stimulus differed little from that from an auditory stimulus. Although one subject was faster and more accurate, their response times significantly correlated. Statistical analysis revealed that this shared common variance resided in the month and year. It is hypothesized that they both employ their memory organized around a calendar-based system that entails keying off from December 1 of the test year.