A sperm peptide enhances long-term memory in female Drosophila.

Can mating influence cognitive functions such as learning and memory in a permanent way? We have addressed this question using a combined behavioral and in vivo imaging approach, finding that aversive long-term memory performance strongly increases in Drosophila females in response to sperm transfer following mating. A peptide in the male sperm, the sex peptide, is known to cause marked changes in female reproductive behavior, as well as other behaviors such as dietary preference. Here, we demonstrate that this sex peptide enhances memory by acting on a single pair of serotonergic brain neurons, in which activation of the sex peptide receptor stimulates the cyclic adenosine monophosphate/protein kinase A pathway. We thus reveal a strong effect of mating on memory via the neuromodulatory action of a sperm peptide on the female brain.

Left ventricular geometry and operative mortality in patients undergoing mitral valve replacement.

BACKGROUND: Distortion of left ventricular (LV) shape is often associated with LV dysfunction and is thought to be an independent predictor of survival in patients with coronary disease. HYPOTHESIS: The purpose of this study was to examine the relationship between LV geometry and hospital mortality in patients with mitral regurgitation (MR) undergoing mitral valve surgery. METHODS: A consecutive series of patients (aged 68+/-12 years, 47% men) (n = 149) with MR who underwent cardiac catheterization, left ventriculography, and mitral valve surgery from 1995 to 1996 at Mount Sinai Medical Center was studied. Left ventriculograms, clinical records, and hemodynamics were reviewed. Left ventricular volumes and ejection fraction were calculated using standard techniques. Left ventricular shape in diastole and systole was evaluated using the sphericity index, which is defined as the end-systolic LV volume (x 100) divided by the volume of a sphere whose diameter is equal to the LV long axis. RESULTS: In the patients studied, the etiology of mitral insufficiency was mitral valve prolapse in 40.9%, ischemic heart disease in 40.3%, rheumatic heart disease in 11.4%, and prosthetic valvular dysfunction in 7.4%. The average ejection fraction was 65%+/-17. Systolic sphericity index (SSI) was 36%+/-15 in patients who died, compared with 25%+/-11 in patients who lived (p < 0.001). A multivariate model was constructed using hemodynamic and angiographic indices derived during preoperative cardiac catheterization. Systolic sphericity index (odds ratio = 1.6 for each point increase, p < 0.01) was found to be an independent predictor of postoperative survival in the global population, as well as in patients with coronary disease (p<0.01). CONCLUSION: Left ventricular geometry is an independent angiographic risk factor for survival following mitral valve replacement. Sphericity index is a simple method for assessing LV geometry which should be calculated in patients as part of risk stratification.

Refractory priapism of unknown etiology in a pediatric patient.

Priapism is a urologic emergency that can occur in any age group and every patient should receive prompt urologic consultation. Management of priapism is based on the recognition of underlying pathophysiology; ready differentiation between high-flow and low-flow priapism; reversal of any potential precipitating factors; the use of corporal aspiration irrigation combined with intracavernosal alpha adrenergic therapy; and when necessary, a shunting procedure. Delay in recognition or treatment can be crucial as the incidence of long-term complication rises substantially with the duration of the priapism.

Squamous cell carcinoma of the pancreas with cystic degeneration.

Most nonendocrine pancreatic neoplasms are adenocarcinomas of ductal cell or acinar origin. Primary carcinomas of the pancreas with squamous differentiation are rare enough to warrant a search for other primary tumors. In the past few decades, well-documented individual reports and large series reviews support the view that these squamous neoplasms are indeed of pancreatic origin and not uncommonly exhibit cystic degeneration. Late manifestation and unfavorable prognosis seem to be uniform features. We report a case with many of these features.

A comparison of the initial to the later stream urine in children catheterized to evaluate for a urinary tract infection.

BACKGROUND: To avoid potential contamination, it is recommended that the first few drops of urine be discarded when obtaining a catheterized urine sample from a child being evaluated for a urinary tract infection (UTI). The existing evidence to make such a recommendation is scant. Our goal, therefore, was to determine whether the urinalysis, Gram stain, and culture results were significantly different from the initial and later urine samples collected from catheterized children. METHODS: A prospective diagnostic discrimination between early and later urine samples was conducted on a convenience sample of pediatric patients being evaluated for a UTI in an urban emergency department. Results of the urinalysis, Gram stain, and quantitative culture were compared between the early and later stream urine samples. RESULTS: Data from 86 children were analyzed. Four of 80 patients had a false identification of low colony count bacteruria from the early but not from the later stream. For patients with negative cultures, the early stream was also more likely to falsely identify > or =5 wbc/hpf (P<0.01) or bacteruria (P<0.05) on urinalysis than the later stream. CONCLUSIONS: There is a small but potentially meaningful contamination of the early stream urine compared with the later stream in young children catheterized to evaluate for a urinary tract infection.

A multicenter double-blind study of controlled-release physostigmine for the treatment of symptoms secondary to Alzheimer's disease. Physostigmine Study Group.

OBJECTIVE: A multicenter trial to evaluate the efficacy of controlled-release physostigmine salicylate, a cholinesterase inhibitor, was conducted in 1,111 mild-to-moderate Alzheimer's disease (AD) subjects. DESIGN: During dose titration, subjects received 18, 24, or 30 mg of physostigmine or placebo daily. After a 2-week washout period, 366 subjects with putative improvement were randomized to receive either placebo or their best dose of physostigmine in a 6-week double-blind trial. Nonresponding patients (439) were randomized to receive in a separate double-blind trial either placebo or their highest tolerated dose of physostigmine. The primary efficacy measures included the cognitive subscale of the Alzheimer Disease Assessment Scale (ADAS) and a Clinical Global Impression of Change (CGIC). Secondary measures included the Mini-Mental State Examination and two activities-of-daily-living scales. RESULTS: At the end of the 6-week double-blind phase, physostigmine-treated patients scored 1.75 points higher than placebo-treated patients on the ADAS (p = 0.003) and 0.26 points higher on the CGIC (p = 0.012) in the intent-to-treat analysis. There was no significant improvement on the secondary outcome measures. Patients failing to respond to physostigmine during the dose titration phase failed to respond on any of the outcome measures during the double-blind period of re-exposure. Common adverse events included nausea, vomiting, diarrhea, and anorexia. There were no significant changes in liver function tests. CONCLUSION: This study demonstrated statistically significant differences between physostigmine and placebo on both a performance-based cognitive functioning instrument and a clinician's global evaluation. The magnitude of the effect size was small and occurred only in the subset of patients who responded in the initial dose titration study period. Nevertheless, the results suggest that in a subset of patients, physostigmine can induce a degree of cognitive improvement over 6 weeks of treatment.

Selective management of acute type B aortic dissection: long-term follow-up.

BACKGROUND: Since 1985, we have selectively treated acute type B aortic dissections. Initial treatment lowered blood pressure and heart rate. Transesophageal echocardiography and computed tomographic scans were used to diagnose and follow up the patients. Patients were operated on for organ ischemia, pain, hypertension, or increasing subpleural fluid on computed tomographic scan. METHODS: We retrospectively reviewed consecutive patients admitted over a 10-year period to the Mt. Sinai Hospital. RESULTS: From August 1985 to May 1995, 68 patients were seen. Three died soon after admission during initial diagnostic evaluation. Seventeen patients underwent operation without mortality or paraplegia (group 1). Forty-seven of 48 patients treated nonoperatively were discharged; 1 patient died of rupture on day 7 (group 2). Actuarial survival for all 68 patients at 1 and 5 years was 92% +/- 4% and 82% +/- 8%. Group 1 survival was 93% +/- 4% and 68% +/- 5%, and group 2 survival was 90% +/- 6% and 87% +/-14%. There were no differences between groups. Late intervention was required in 2 group 1 patients (12%) and in 12 of 48 group 2 patients (25%), again without mortality or paraplegia. CONCLUSIONS: This experience suggests that selective management of acute type B aortic dissection results in acceptable short-term and long-term survival. Avoiding early operation did not compromise late results.

Geriatric assessment in the diagnosis and treatment of elder abuse.

With the growing problem of elder abuse, it is imperative that physicians become aware of the warning signs of elder abuse. In addition, physicians must be knowledgeable in the diagnosis and treatment of elder abuse. Educated physicians can help to alleviate this problem.

Subtypes of acute aortic dissection.

The technique of open distal anastomosis using deep hypothermic circulatory arrest was used in 69 cases of acute type A aortic dissection. These cases were subcategorized by site of intimal tear, which was found in the ascending aorta in 41 patients (60%), in the arch in 22 patients (32%), and in the descending aorta in 5 patients (7%). Clinical characteristics and complications are described for these subtypes. Hospital mortality, which was 14.5% overall for acute type A dissections, was 14.6% for ascending tears, 18.2% for arch tears, and 0% for descending aortic tears. Six-year survival was 69% +/- 15% for ascending tears, 69% +/- 22% for arch tears, and 80% +/- 25% for descending tears (mean +/- SEM, p = NS). A classification system for aortic dissection is proposed, based on both site of origin and propagation.

Acute delirium and functional decline in the hospitalized elderly patient.

BACKGROUND: Delirium is often considered a transient cognitive syndrome. Its effect on long-term physical function, however, has not been well defined. METHODS: In a prospective study of 325 hospitalized community and nursing home elderly, we analyzed the effect of in-hospital delirium on subsequent physical function. ADL performance was assessed prior to admission, and at 3 and 6 months after hospital discharge. RESULTS: There was a strong univariate (unadjusted) association between incident delirium and functional decline (p < .02). Delirious subjects lost a mean of almost one ADL, as measured 3 months after hospital discharge. Using multivariate linear regression analysis, with adjusted change in function as the dependent variable, delirium persisted as the sole predictor of loss of function (p = .009) at 3 months after discharge. The functional decline persisted at 6 months after hospital discharge. CONCLUSION: This finding of a nontransient, perhaps permanent consequence of delirium invites reexamination of the definition of delirium from that of an acute, reversible syndrome to one of acute onset with long-term sequelae.

Recreational weight lifting and aortic dissection: case report.

Although there have been previous cases of ascending (type I) aortic dissection recognized in young weight lifters, this is the first reported instance of a descending (type III) dissection in such an individual. Successful treatment included aortic fenestration and an aortoiliac bypass. A new entity of aortic dissection in young weight lifters may be emerging.

Risk factors for delirium in hospitalized elderly.

OBJECTIVE: To determine risk factors for delirium in elderly hospitalized patients. DESIGN: Cohort analytic study. Using a reliable and valid instrument for detection of delirium, we prospectively followed up a cohort of elderly patients admitted to an acute care hospital. Using standardized criteria, we collected risk factor data from patient medical records. SETTING: General medical and surgical wards of a tertiary-care hospital. PATIENTS: Patients (n = 325) were 65 years of age or older, from either a geographically defined community or a long-term-care institution. We studied those patients (n = 291) not delirious on first evaluation. Fifty-seven patients or their families refused participation. MAIN OUTCOME MEASURES: Incidence of delirium and risk factors calculated as adjusted odds ratios (ORs). MAIN RESULTS: Delirium developed in 91 patients. By stepwise logistic regression, the independent risk factors for in-hospital delirium included prior cognitive impairment (OR, 8.97; 95% confidence interval [CI], 3.99 to 20.14), age over 80 years (OR, 5.22; 95% CI, 2.60 to 10.46), fracture on admission (OR, 6.57; 95% CI, 2.23 to 19.33), symptomatic infection (OR, 2.96; 95% CI, 1.42 to 6.15), and male sex (OR, 2.40; 95% CI, 1.19 to 4.84). Among medication groups, only neuroleptic use (OR, 4.48; 95% CI, 1.82 to 10.45) and narcotic use (OR, 2.54; 95% CI, 1.24 to 5.18) were independently associated with delirium. Anticholinergic use was not associated with delirium. CONCLUSIONS: Delirium in hospitalized patients is most closely associated with factors already present on admission such as prior cognitive impairment, advanced age, and fracture. In the hospital, use of neuroleptics and narcotics and the presence of infection are less strongly associated with this syndrome.

Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients.

We evaluated the occurrence and persistence of delirium in 325 elderly patients admitted to a teaching hospital from either a defined community or a long-term care facility. Of the study participants, 34 (10.5%) had Diagnostic and Statistical Manual of Mental Disorders, Third Edition--defined delirium at initial evaluation; of the remaining patients, 91 (31.3%) developed new-onset delirium. An additional 110 patients also experienced individual symptoms of delirium without meeting full criteria. Preexisting cognitive impairment and advanced age were associated with increased risk of incident delirium in the community sample but not the institutional one. Delirium was not associated with an increased risk of mortality, but it was associated with a prolonged hospital stay and an increased risk of institutional placement among community-dwelling elderly. Only five patients (4%) experienced resolution of all new symptoms of delirium before hospital discharge, and only 20.8% and 17.7%, respectively, had resolution of all new symptoms by 3 and 6 months after hospital discharge. These data suggest that delirium is a common disorder that may be substantially less transient than currently believed and that incomplete manifestations of the syndrome may be frequent.

Phase II trial of 4' deoxydoxorubicin (DXDX) for unresectable non-small cell bronchogenic carcinoma. An Illinois Cancer Council study.

A phase II trial of 4' Deoxydoxorubicin (DXDX) was conducted in unresectable previously untreated non-small cell lung cancer patients. DXDX was administered every 3 weeks by short intravenous infusion at a starting dose of 30 mg/m2, with dose escalation to 40 mg/m2 toxicity permitting. Four responses, all partial, were observed in 35 evaluable patients, for a response rate of 11% (95% confidence limits 3.2% and 26.7%). Myelosuppression was the dose-limiting toxicity. Cardiotoxicity was not seen. DXDX has minimal activity against non-small cell lung cancer as a single agent at the dosage used in this study.

How we teach and how they learn.

Residents need to learn how to assess and accommodate to a variety of behaviors and affective styles presented by patients and their families. This requires those skills which enable them to facilitate interactions with people in a positive, effective, and efficient manner. The teaching of these interpersonal and communication skills should incorporate a multi-disciplinary model. The development and implementation of a successful resident training program requires careful attention to the establishment of goals and objectives, learning activities and evaluation strategies that will meet the needs of the resident. The utilization of a multi-teaching, multi-media, and collaborative team approach intensifies the effectiveness of the overall training program. This article describes a training program that focuses on communication skills while being mindful of the various settings in which residency training occurs. These include the use of video-tape of physician/patient interaction in continuing care clinic, communication with children in non-medical settings and audio-tape reviews of physicians telephone management in a pediatric emergency care setting. The evaluation instruments developed to assess interpersonal and communications skills are reviewed and discussed as an integral component of this educational and training model.