Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program.

BACKGROUND: Patients undergoing hip fracture surgery often experience acute post-operative cognitive dysfunction (APOCD). The pathogenesis of APOCD is probably multifactorial, and no single intervention has been successful in its prevention. No studies have investigated the incidence of APOCD after hip fracture surgery in an optimized, multimodal, peri-operative rehabilitation regimen. METHODS: One hundred unselected hip fracture patients treated in a well-defined, optimized, multimodal, peri-operative rehabilitation regimen were included. Patients were tested upon admission and on the second, fourth and seventh post-operative days with the Mini Mental State Examination (MMSE) score. RESULTS: Thirty-two per cent of patients developed a significant post-operative cognitive decline, which was associated with several pre-fracture patient characteristics, including age and cognitive function, but also the number of peri-operative transfusions. The development of APOCD was also associated with impaired post-operative rehabilitation and an increased length of stay. APOCD was associated with the development of a major medical complication in 35% of all patients. In 65% of patients developing APOCD without a concomitant medical complication, the only risk factors were cognitive level and regular anti-psychotic treatment. CONCLUSION: On the basis of current evidence, APOCD is prevalent amongst hip fracture patients despite multimodal intervention; future research should therefore focus on defining subgroups of hip fracture patients amenable to specific prophylactic or interventional measures against APOCD.

Inflammatory aortic aneurysms: regression of fibrosis after aneurysm surgery.

OBJECTIVES: To evaluate the fate of perianeurysmal fibrosis (PF) following aneurysm surgery. METHODS: In this single centre study, pre- and postoperative abdominal CT-scans on 21 consecutive patients with inflammatory abdominal aortic aneurysms were compared. CT-scans of 10 randomly chosen patients operated on for abdominal aortic aneurysms without PF in the same period, served as reference group. RESULTS: Preoperative thickness of PF was assessed as > 1 cm in 11 and < 1 cm in 10 patients. Ureterolysis was performed in seven patients where the fibrosis caused ureteral obstruction. Postoperative CT-scans performed at a median of 24 (range 3-108) months after surgery showed complete regression of the fibrosis in 29%, partial regression in 57% and no change in 14% of the patients. Progression of the fibrosis or persistence of hydronephrosis was not seen. No sign of fibrosis were seen in the 10 controls. CONCLUSION: This study supports the findings that PF tends to regress after repair of the abdominal aortic aneurysm.

[Traumatic lesions of the axillary and brachial artery]. / Traumatiske laesioner af a. axillaris og a. brachialis.

During af six year period 16 patients were treated for an axillary or brachial artery trauma. The vascular injury was caused by fracture in nine cases, contusion in four and penetrating injury in three. Concomitant nerve or tendon lesion occurred in five cases. Five of the 16 events were industrial accidents. Only one case was due to violence. Four patients appeared to be intoxicated with alcohol. Fifteen patients were treated surgically, 12 with vascular reconstruction. One patient was treated conservatively. At the time of discharge all extremities were assessed as having normal arterial supply. At follow-up at median 28 months all extremities were preserved. However, two-thirds had minimal to disabling sequels. Four out of 10 who were professionally active before the trauma had lost this ability.

Vascular complications following therapeutic and diagnostic cardiac catheterisation by the femoral artery.

Twenty-one of 6327 (0.33%) patients undergoing cardiac catheterisation via the femoral artery had an acute vascular complication requiring surgical intervention. The complication rate was 0.1% after coronary angiography, 2% after PTCA and 6% after aortic ballon dilatation. The size of the catheter and the duration of catheterisation were found to be risk factors. Most commonly simple arterial repair and/or thrombectomy was performed. No mortality was observed. Only in one case was blood transfusion necessary. The outcome of surgery was in all cases a good revascularisation of the leg. Registration and evaluation of vascular injuries following diagnostic and therapeutic invasive interventions could have a self limitating effect on the complication rate.

Fertility and pregnancy in women with familial adenomatous polyposis.

A questionnaire study was carried out among 58 Danish women with familial adenomatous polyposis concerning fertility, pregnancies, abortions and deliveries. Further data were obtained from obstetric records and general practitioners. The fertility and the course of the pregnancy of women with polyposis, frequency of miscarriages, legal abortions, mature and premature infants corresponds to the frequency among the obstetric population in Denmark. Of the 73 infants, eight (11%) were delivered by caesarean section. Of the 16 women who gave birth after an operation for familial adenomatous polyposis, 5 (31%) had a caesarean section. Of the seven infants who died, two had lethal congenital malformations and three infants were very premature.

Low dose intravesical heparin as prophylaxis against recurrent noninvasive (stage Ta) bladder cancer.

A controlled randomized clinical trial was conducted to examine the efficacy of topical low dose heparin (0.125 gm./l., 25,000 units per l.) as prophylaxis against recurrent noninvasive (stage Ta) transitional cell bladder cancer. Transurethral tumor resection was done with irrigation fluid containing either 1.5% glycine with heparin or glycine solution alone. Tumor recurrence was determined by cystoscopy 4 to 6 months later. There were 70 patients evaluated: 38 in the heparin and 32 in the control group, respectively. The recurrence rate (heparin 74%, control 66%) and the median number of recurrences (heparin 3, range 1 to 15 and control 3, range 1 to 30) were similar (p greater than 0.05) in the 2 groups of patients. These observations show that low dose heparin administered in the irrigation fluid during transurethral resection does not decrease the recurrence rate of noninvasive (stage Ta) bladder cancer.

IUD (Nova-T) insertion following induced abortion.

In a prospective study, 86 women who had an IUD (Nova-T) inserted immediately after induced abortion were compared to 95 abortion patients who started another contraception (control I). Additionally, the rate of complications following IUD insertion in a Family Planning Clinic (control II) were studied in 83 non-pregnant women. The overall infection rate for post-abortion patients was 4.4% (5.8% in the study group, 3.2% in control I). No infections were observed in control group II. Confidence limits (95%) for the three groups were overlapping. Among the women in the study group, bleeding and pain were not more frequent, but if one of these complications occurred, it tended to be more serious and the duration was longer. The number of days before resumption of work after abortion was 3-4 days in both abortion groups. After three months, the continuation rate was 83% (71 of 86) in the study group, 76% (72 of 95) in control I and 93% (77 of 83) in control II. Sixty-nine of the 181 women admitted for legal abortion had been admitted for the same reason previously. In this study, the recurrence rate after 12 months was 0% in the study group and 4.2% (4 of 95) in control group I. The insertion of an IUD at the time of abortion seems to be an effective and acceptable solution to the problem of recurrent abortion.

The elasticity and the tensile strength of tunica albuginea of the corpora cavernosa.

The aim of this study was to determine the tensile strength and the elasticity of the tunica albuginea (TA), and describe morphological structures in the tissue before and after mechanical deformities. Twenty cadavers of men aged between 33 and 83 were examined. Cavernosometry was performed in all specimens. Afterwards in five cadavers the flow rate was increased until a herniation of the TA appeared. A strength about 1500 mm. Hg was found. Similar results were found in four who had an inflatable prosthesis (AMS 700) inserted, and the intraprosthetic pressure increased until a deformity was noted. Slices of TA (thickness 1.3 to 3.3 mm.) from 11 specimens were tested in a tensiometer. The elasticity coefficient was found to be around 10(8) N/m2, and the tensile strength to be 600 to 750 mm. Hg (10(4) to 10(5) N/m2). The difference between the tensile strength achieved in the tensiometer and during saline infusion is possibly caused by the intracavernous framework. Microscopy showed that TA is mainly composed of collagen fibres which are situated in an undulating arrangement, with a few elastic fibres arranged longitudinally which connect the undulating bundles of collagen fibres. When the tissue is overstretched, the elastic fibres are destroyed and the undulating arrangement disappears.

Upper urinary tract deterioration after implantation of artificial urinary sphincter.

The preoperative urodynamic evaluations of twenty patients with myelomeningocele who had had artificial sphincter implantation because of urinary incontinence were reviewed. Four patients developed hydronephrosis and severe impairment of renal function between two and six years after implantation of the artificial sphincter. The condition was partly reversible after removal of the artificial sphincter. The urodynamic evaluation prior to implantation revealed in the four mentioned patients compared to the 16 patients with normal upper urinary tract, a tendency to lower bladder compliance, lower bladder capacity and more severe detrusor hyperreflexia, but it was not possible to make a clear discrimination between the two groups. Attention is drawn to this unfortunate combination of effects after artificial sphincter implantation. Periodic control of the upper urinary tract by urography is recommended.

[Pregnancy in women with congenital heart disease]. / Graviditet hos mødre med medfødt hjertesygdom.

During the past decades, the incidence of pregnant women with heart disease in Denmark has decreased from 0.9% to 0.3%. Heart disease in connection with pregnancy still remains the commonest non-obstetric cause of death. Previously, rheumatic valvular heart disease constituted the majority of all forms of heart disease in pregnant women. At present, congenital heart disease constitutes at least 80% of the maternal heart disease. Progress in heart surgery has had the result that increasingly more complicated forms of cardiac deformities can be corrected so that more survive to adult life. The range of cardiac deformities has therefore increased in recent accounts concerning pregnant women with heart disease. Ventricular septum defect, atrial septum defect and persistent ductus arteriosus still constitute approximately 50% of the forms of heart disease in pregnant women. In Denmark, the incidence of congenital heart disease is approximately 0.6% but between 2.5% and 4.2% of infants of women with congenital heart disease also have heart disease. In counselling about the risks in pregnancy, the NYHA scale provides a good guideline. Alle conditions with pulmonary hypertension are contraindications for pregnancy. The greatest risk for death occurs early in the puerperium. Guidelines for control and treatment of pregnant women with heart disease are presented. It is concluded, that pregnant women with heart disease should be assessed and be followed up in centres with the necessary cardiac, obstetric and anaesthesiologic expertise.

Tricuspid atresia and pregnancy.

Four cases of pregnancies in two women with tricuspid atresia (TA) are described. A review of the literature on this subject revealed 24 reported cases of which only 11 were reported in detail. Eight pregnancies resulted in deliveries (including our 3 cases). TA is still uncommon in adult patients, but due to successful palliative surgery in childhood more patients now reach the age of fertility. Guidelines about the management of these patients are discussed.

Maternal heart disease. A survey of a decade in a Danish university hospital.

Among 87 pregnancies complicated by heart disease, delivered during the decade 1977-86, 70 (81%) had a congenital heart malformation, 7 (8%) an acquired heart disease and 10 (11%) arrhythmias or conduction disturbances. The incidence was 0.3%. The corresponding data from a report from Rigshospitalet during the 1950s were: 42%, 49%, and 9%, respectively, and an incidence of 0.9%. Ventricular septal defect (VSD) and atrial septal defect (ASD) were the most frequent malformations. The women were classified according to the NYHA before, during and after the pregnancy. All women except 4 re-entered their original functional class. In 51 cases, ECG showed completely normal sinus rhythm, while in 36, various degrees of arrhythmia or conduction disturbance were found as well as left or right ventricular hypertrophy and/or strains. Nine infants had congenital defects, 4 of which were a heart malformation (4.6%). One infant died. Gestational duration, weight and perinatal mortality did not differ significantly from that of the general population. Two women died, one of primary pulmonary hypertension and one with a rupture of the thoracic aorta. Rheumatic heart disease is no longer a significant factor in relation to pregnancy in Denmark, but congenital heart disease is still of great importance, because more survive and reach the age of fertility. Today most women can be brought safely through pregnancy, but obstetric, cardiologic and anesthesiologic expertise is still mandatory for a successful course and outcome of pregnancies complicated by heart disease.

Eisenmenger's syndrome and pregnancy.

Two cases of successfully managed Eisenmenger's syndrome during pregnancy are reported. A women suffering from Eisenmenger's syndrome who becomes pregnant should be advised to have her pregnancy terminated. On the basis of the available literature and our own experiences we suggest the following plan, if a woman, despite medical advice, chooses to continue her pregnancy: admission to hospital at approximately 25 weeks of gestation; bed rest during the remaining period of pregnancy; oxygen face-mask during episodes of dyspnoea; determination of serial blood gases to detect changes in the shunt flow. At the onset of labour, arterial and epidural catheters should be inserted, a fall in blood pressure should immediately be counteracted by the administration of norepinephrine and loss of blood by transfusion. The patient should remain in hospital for 7-14 days after delivery.

Rubella in pregnant Danish women 1975-1984.

During the period 1975 to 1984, 1,346 pregnant women had the diagnosis of rubella serologically confirmed. The incidence was one per 530 pregnancies. Of 1,330 women, 623 were subjected to therapeutic abortion. Thirty-five aborted spontaneously and 672 continued pregnancy; among these, four infants were stillborn. In 111 of 520 infants, rubella specific IgM was found in blood drawn from the umbilical cord. The frequency of rubella specific IgM in infants after maternal rubella during the first trimester was 50 percent (7 of 14); in the second trimester, the frequency had been reduced to 14 percent in the 28th week of pregnancy; and in the third trimester, the frequency rose again to 28 percent. Malformation occurred only in infants whose mothers had been infected before the 12th week. Preconceptional rubella was found in 32 cases; seven of these women carried their pregnancies to successful termination. In none of the infants was rubella specific IgM found, and no abnormalities could be found at birth. The importance of immunisation of women in the fertile age group is emphasised. By testing a blood sample from the fetus for rubella specific IgM, it is possible to show prenatally if a fetus has congenital rubella. This method will probably allow reduction of the number of therapeutic abortions after maternal infection between the 12th and the 16th week of pregnancy.

Femoxetine in the treatment of obese patients in general practice. A randomized group comparative study with placebo.

A study was carried out in general practice to compare the effectiveness of femoxetine, a selective serotonin reuptake inhibitor, with the effect of placebo in helper patients more than 20 per cent above their ideal weight to lose weight. Patients were allocated at random to receive either 600 mg femoxetine (36 patients) or placebo (37 patients) daily over a period of 16 weeks. They were also asked to restrict their calorie intake to 1200-1600 kcal. (5.0-6.7 MJ)/day. The results showed that there was no statistically significant greater weight loss in patients treated with femoxetine (median = 8.3 kg) than with placebo (median = 6.2 kg) after 16 weeks. In subgroups of patients with obesity problems for more than 20 years and of patients previously in anorectic treatment, femoxetine tended towards causing a larger weight loss. Side-effects were generally minor in nature, and the incidence and nature of them were almost comparable in the two groups except for gastro-intestinal symptoms, which were reported more often in the femoxetine group. As femoxetine in several randomized group comparative studies in depressive illness has been shown to have an antidepressant efficacy which is comparable with the efficacy amitriptyline and imipramine, femoxetine may be particularly useful in the management of obese patients requiring antidepressant treatment.