The effect of patient sex on the incidence of early adverse effects in a population of elderly patients.

Patient sex is known to influence the response to general and regional anaesthesia and recovery after surgery. However, most studies come from analyses carried out on middle-aged patients. As most of the patients admitted to the post-anaesthesia recovery room in our institution are elderly, we took the opportunity to investigate the association between sex and incidence of early adverse events in this older population of patients after major surgery. Consecutive patients undergoing general, orthopaedic, urological and gynaecological surgery, admitted to the recovery room of our institution over a 15-month period, were retrospectively studied. The following adverse events were considered in the analysis: shivering, postoperative nausea and vomiting, hypotension and hypertensive responses, new arrhythmias requiring treatment, acute respiratory failure and desaturation. A total of 1347 patients (mean age 73.3±15.1 years, 61.4% women) were included. Women showed a higher incidence of shivering (relative difference +48%, P=0.0003), postoperative nausea and vomiting (+91%, P<0.0001), hypotension (+32%, P=0.044) and desaturation (+60%, P=0.0030) than men. The incidence of hypertensive response, arrhythmias and acute respiratory failure were not statistically significantly different. The findings of this exploratory study suggest that women have a higher risk of early postoperative adverse events even in a more elderly population.

Cardiac contusion in blunt chest trauma: a combined study of transesophageal echocardiography and cardiac troponin I determination.

BACKGROUND: The role of cardiac troponin I (cTnI) is well established in acute myocardial ischemia. However, its role in myocardial contusion remains to be clarified. Since transesophageal echocardiography (TEE) appears, at present, to be the best method for the diagnosis of myocardial contusion, the aim of this study was to measure the concentration of cTnI in patients with blunt chest trauma studied using TEE. METHODS: Thirty-two patients (27 males, 5 females, mean age 44+/-20 years), admitted to the Trauma Center of our Institution with clinical and/or radiological signs of acute blunt chest trauma, underwent biplane TEE within 24 hours of injury; serial blood samples were taken to measure cTnI levels (normal values < 0.4 ng/ml), using fluorimetric enzyme immunoassay. RESULTS: Abnormal levels of cTnI were found in 17 patients (53%): 7 patients had levels of cTnI between 0.4 and 1 ng/ml, whereas 10 patients had levels > 1 ng/ml. Segmental wall motion abnormalities consistent with myocardial contusion could be identified by echocardiography in 6/10 patients with cTnI levels > 1 ng/ml (60%) but in no patients with normal cTnI levels or with titers between 0.4 and 1 ng/ml; mean cTnI levels showed a significant difference between the two groups of patients with and without echocardiographic signs of myocardial contusion (2.6+/-1.6 vs 0.6+/-1.4 ng/ml, p < 0.001). CONCLUSIONS: Abnormal titers of cTnI suggesting myocardial contusion may be found in more than half of patients with blunt chest trauma; however, myocardial injury can be detected by TEE only for cTnI levels > 1 ng/ml; cTnI concentrations ranging between 0.4 and 1 ng/ml might be indicative of myocardial microlesions, not detectable by echocardiography, even if TEE is used; cTnI assay could therefore be suggested as a screening test before performing TEE after blunt chest trauma.

"Natural histories" of mitral valve prolapse. Influence of patient selection on cardiovascular event rates.

BACKGROUND: In previous studies the reported incidence of cardiovascular events among mitral valve prolapse patients has differed more than 10 fold. We endeavored to determine the relation between the clinical features and mode of ascertainment of mitral valve prolapse and the resulting event rate. METHODS: Between January 1979 and August 1996, 275 patients (129-47% men, 146-53% women, mean age 43 +/- 19 years), were followed for a mean of 98 months after evaluation in a referral center for valvular heart disease. Comparative data were obtained from a separate, less selected population consisting of 316 patients. RESULTS: A total of 65 events occurred (2.9/100 patient-years): 46 (2.0/100 patient-years) mitral surgery, 12 cardiac deaths (0.5/100 patient-years), 6 neurologic ischemia (0.26/100 patient-years), and 1 infective endocarditis (0.04/100 patient-years). The overall event rate varied significantly according to demographic, clinical and echocardiographic variables (all p < 0.0001). It was higher among males (odds ratio-OR 2.1), subjects > or = 45 years of age (OR 14.7), those with a holosystolic murmur (OR 25.9), an enlarged left ventricle (OR 13.5) or left atrium (OR 34.9) and those with 3-4+ mitral regurgitation at color Doppler echocardiography (OR 40.0). It was lower in those with an audible mid-systolic click (OR 0.05). These ORs closely resembled those we reported previously in a less selected population. At multivariate analysis, male gender (p = 0.013), severe Doppler mitral regurgitation (p = 0.0048), and left atrial enlargement (p = 0.046) were all independent predictors of events. CONCLUSIONS: In a population of mitral valve prolapse patients, including many with significant mitral regurgitation at baseline, we identified similar predictors of events but an overall event rate nearly 3 times higher than that we previously reported for relatively unselected patients or family members in New York City (1/100 patient-years). Therefore, the impact of patient selection on the prevalence of mitral regurgitation, older age and male gender strongly affects the adversity of the "natural history" of mitral valve prolapse.

[Should the patient with an interatrial defect recognized in adulthood always be operated on?]. / Il paziente con difetto interatriale riconosciuto in età adulta deve essere sempre operato?

BACKGROUND: Atrial septal defect (ASD) can be recognized in adult age, mostly in asymptomatic or scarcely symptomatic patients. These patients differ from patients in "historical" clinical series, in whom diagnosis was done on the basis of clinical evidence, and their natural history is probably different. AIM OF THE STUDY: Our aim was to verify retrospectively results of surgery versus medical follow-up in an adult population with ASD with age at first diagnosis > or = 30 years. PATIENTS AND METHODS: Seventy-two patients with ASD, 52 females (72%), observed at our Institution since 1978, were considered. Mean age at diagnosis was 48 +/- 12 years (range 30-79); 36 patients (50%, group A) are still on medical therapy, 36 patients (group B) were operated. As groups A and B did not differ significantly in any demographic, clinical or echocardiographic parameter, they were compared for the incidence of complications. RESULTS: During follow-up (100 +/- 70 months, range 12-240), the incidence of major clinical events showed no significant differences in the two groups, as cardiac death or cardiovascular complications (cerebral ischemic events, severe mitral insufficiency, reoperation) occurred in 4 patients in group A (11%) and in 4 patients in group B (11%). Worsening of NYHA class was observed in 3 patients from group A (8%) and 2 patients from group B (5.5%; p = ns). New onset of supraventricular arrhythmias occurred more frequently in group B (14 patients, 39%) than in group A (5 patients, 14%) (p = 0.01; OR = 3.9; CI 95%: 1.2-12.6). CONCLUSIONS: In an adult population affected with asymptomatic or mildly symptomatic ASD and age at first diagnosis > or = 30 years, surgical closure of the defect did not modify morbidity and mortality at a mid-term follow-up. We suggest that, mostly in older asymptomatic patients, surgery should not be a routine choice and clinical decision-making should be individualized in each case.

A family study of anterior mitral leaflet thickness and mitral valve prolapse.

To determine whether mitral valve prolapse (MVP) with or without mitral leaflet thickening (> or =5 mm) represents distinct heritable conditions, 13 patients with MVP with leaflet thickening and their relatives were compared with 67 patients with MVP with normal leaflets and their relatives. The 2 groups of relatives had similar mitral leaflet thicknesses and similar long-term outcome, arguing against the existence of a distinctive subtype of MVP characterized by increased mitral leaflet thickness.

Attitude towards smoking and oral cancer prevention among northern Italian dentists.

The aim of the study was to evaluate the smoking habits of Northern Italian dental practitioners and their basic skills in the prevention of oral cancer. 217 of the 250 dental practitioners (86.8%) contacted by telephone from September to December 1994, answered a simple questionnaire. One third of the sample interviewed was formed by current smokers; nevertheless 60.8% of them always advise their patients to give up smoking. Only a relatively small percentage of the questioned dental practitioners (10.6%) do not examine the oral mucosa of the patients on a regular basis and 40% of responders had made a clinical diagnosis of oral cancer in the past. The lack of a specific dental education was associated with less scrupulous examination of the oral soft tissues and minor experience of cancer diagnosis. Despite their smoking habit, Northern Italian dental practitioners self-reported encouraging behaviour towards primary and secondary oral cancer prevention.

Platelet and blood clotting activation in patients with mitral valve prolapse.

In patients with mitral valve prolapse (MVP) a high incidence of valvular abnormalities with a history of previous cerebrovascular disease has been reported and an embolic mechanism has been proposed. Aim of this study is the study of platelet and coagulation activation in patients with MVP. Fifty-four patients affected by MVP (mean age 46 +/- 15 yrs, 22 males, 32 females) and 50 control subjects, age- and sex-matched, were tested for platelet activation [P-selectin and GpIIb-IIIa platelet surface expression at rest and after stimuli by flow cytometric analysis, Beta-Thromboglobulin (TG) and Platelet Factor 4 (PF4) plasma levels by ELISA, platelet-rich-plasma (PRP) and whole blood spontaneous platelet aggregation (SPA)] and for activation of blood coagulation (Prothrombin activation fragment F1+2 plasma levels by ELISA). P-selectin, GpIIb-IIIa expression, Beta-TG, PF4 and SPA were found similar in MVP patients and in controls. However, in patients with severe mitral regurgitation (MR) the percentage of activated platelets which express P-selectin after stimuli was slightly but significantly (p < 0.05) lower in comparison to MVP patients without or with mild to moderate MR and to controls. Moreover, in patients with severe MR F1+2 levels (median 1.6 nmol/L, range 0.6-2.6 nmol/L) were significantly higher (p < 0.001) than both in controls (median 0.95 nmol/L, range 0.2-1.4 nmol/L) and in patients without or with mild to moderate MR (median 1.0 nmol/L, range 0.4-2.3 nmol/L). Our findings suggest that MVP is not responsible per se for blood clotting activation, but in patients with severe mitral insufficiency an increase in thrombin generation can occur. These alterations in hemostatic system may represent a mechanism by which MR increases the risk of thromboembolic events in patients with MVP.

Renal resistive index and left ventricular hypertrophy in essential hypertension: a close link.

The aim of this study was to evaluate renal Doppler resistive index in patients with mild to moderate essential hypertension (EH) and to correlate its changes with the presence of left ventricular hypertrophy assessed by echocardiography. Twenty-eight EH patients (19 males, 9 females, mean age 56.2 +/- 8.6 years) and 13 normotensive subjects (7 males, 6 females, mean age 57.6 +/- 7.9 years) were studied; all patients underwent a complete echocardiographic study (M-mode, two-dimensional and Doppler) and a color Doppler echography of renal and intrarenal arteries. After the renal Doppler waveform was obtained, resistive index was calculated by peak systolic velocity (S) and lowest diastolic velocity (D) with the formula S-D/S. EH patients were divided into two subgroups on the basis of left ventricular mass (LVM): Group EH1 with normal LVM (15 patients) and Group EH2 with increased LVM (13 patients). All patients evidenced normal renal morphology and function and received no therapy throughout the entire observation period. Renal resistive index was significantly higher in EH patients than in controls; however, the maximum difference was observed between normotensive subjects and the EH patients with increased LVM (p < 0.00001). At univariate analysis, significant correlations were found between renal resistive index and age, body mass index, left ventricular relative wall thickness and LVM. However, when multiple regression analysis was used, only age (p < 0.01) and LVM (p < 0.05) remained significant predictors of resistive index. In conclusion, our data show that in EH patients resistive index, which is considered an expression of arterial impedance, is well correlated with the presence of left ventricular hypertrophy, presently considered the best index of the severity of hypertensive disease. This correlation may be the expression of the involvement of two target organs in hypertension.

Lack of association between mitral valve prolapse and history of rheumatic fever.

To determine whether rheumatic fever is associated with mitral valve prolapse (MVP) diagnosed by echocardiography, records from 561 subjects participating in a prospective family study were reviewed. The prevalence of a history of rheumatic fever by modified Jones criteria was determined in 92 probands and 112 affected relatives or spouses with M-mode and two-dimensional echocardiographic findings of MVP, accompanied in most instances by classic auscultatory findings, and in 357 family members without MVP. The prevalence of rheumatic fever was 5.4% in both MVP sub-groups and 2.2% in the family members without MVP (p<0.05 vs the combined MVP group). However, people with a history of rheumatic fever were older than the remaining subjects (48 +/- 17 vs 36 +/- 20 years, p<0.01) as expected because of the decline in rheumatic fever in the twentieth century, and subjects with MVP were older than subjects without MVP (39 +/- 16 vs 34 +/- 22 years, p<0.01). Multiple logistic regression showed that after the independent relation of older age with a positive history of rheumatic fever (p<0.01) was taken into account, there was a trend toward a lower likelihood of previous rheumatic fever associated with MVP (odds ration 0.42, p=0.07). These results do not support either a true association or a causal role of rheumatic fever in the pattern of mitral leaflet motion and auscultatory abnormalities in adults, for which the term MVP is generally used.

[Mitral valve prolapse: the clinical and echocardiographic characteristics in a hospital outpatient population]. / Il prolasso della valvola mitrale: caratteristiche cliniche ed ecocardiografiche in una popolazione ambulatoriale ospedaliera.

BACKGROUND: Mitral valve prolapse (MVP) is generally regarded as a benign condition, but serious complications (including severe mitral insufficiency, cerebral ischemia, infective endocarditis, complex arrhythmias and sudden death) have been described in a minority of patients and have been correlated to demographic, clinical and echocardiographic characteristics. Both a lack of standardized definition of MVP in earlier studies and the different ways of recruitment of MVP patients may explain the variability in reported complication rates. METHODS: As an offspring of a larger prospective study this paper focuses on the profile of patients who were found to have MVP by M-Mode and two-dimensional echocardiography in several outpatient hospital departments. A total of 8252 consecutive subjects, examined since March 1990 to February 1991 in the Echo laboratories of the Florence area are considered; according to the presence or absence of structural changes (anterior mitral leaflet thickness > 5 mm, leaflet redundancy and/or anulus dilatation) two groups of patients with MVP (A and B) were identified. RESULTS: A MVP was diagnosed in 288 subjects (3.5%), 170 females (59%) and 118 males (41%), mean age 41 +/- 18 years (range 7-84). 110 (38%) were in Group A, 178 (62%) in Group B. The following parameters differed significantly in the two groups: age (45 +/- 17 vs 39 +/- 17 years; p < 0.003); male gender (50% vs 35%; p < 0.01); auscultatory findings (midsystolic click: 31% vs 68%; p < 0.00001; holosystolic murmur: 22% vs 3%; p < 0.00001); left ventricular diameter (53 +/- 7 vs 48 +/- 5 mm; p < 0.00001) and left atrial diameter (38 +/- 8 vs 33 +/- 5 mm; p < 0.00001). Among patients with mitral regurgitation detected by Color Doppler Echocardiography 65% were in Group A (p < 0.00001). CONCLUSIONS: These patients with MVP are obviously selected by the modality of recruitment; hence there is a higher prevalence of subjects with morphologic abnormalities and mitral regurgitation who are older and more likely to be male if compared to individuals with MVP who are found in the general population. A long-term follow-up of these patients is ongoing: owing to the data of the literature about prognostic predictors, a higher incidence of complications with a different prognosis between the two groups (with or without structural changes of the mitral valve) is expected.

Natural history of mitral valve prolapse.

To assess the rate and predictors of complications in patients with mitral valve prolapse (MVP), 316 subjects (mean age 42 +/- 15 years) with echocardiographic MVP were followed prospectively for a mean of 102 months: 220 (70%) were women, 225 (71%) had clinically recognized MVP, and 91 (29%) were detected in family studies. During follow-up, 11 patients (0.4/100 subject-years) required mitral valve surgery, 6 died of cardiac causes (0.2/100 subject-years), 7 developed cerebral ischemia (0.3/100 subject-years), and 2 developed active infective endocarditis (0.1/100 subject-years). The overall rate of fatal and nonfatal complications (1/100 patient-years) was higher in men than in women (odds ratio [OR] 3.2, p < 0.003), in subjects aged > 45 than < or = 45 years (OR 3.4, p = 0.002), in clinically recognized patients than in affected family members (OR 3.8, p < 0.02), and in those with a holosystolic murmur (OR 26.9, p < 0.00005); the overall rate was lower in those with a midsystolic click (OR 0.3, p < 0.002). Echocardiographic left ventricular or atrial diameter > or = 6.0 or > or = 4.0 cm, respectively, was associated with a 16.7- and 15.1-fold higher likelihood, respectively, of subsequent complications.(ABSTRACT TRUNCATED AT 250 WORDS)