[Puffy hand in long-term intravenous drug users]. / Volumineux oedèmes des mains chez des patients toxicomanes intraveineux au long cours.

Narcotic addiction may induce systemic and local complications. Intravenous injections of drugs can cause venous thrombosis, and septic or embolic complications. The puffy hand sign is a more uncommon complication of hard-core injection addicts. Three long-term intravenous drug users, two males, one female, mean age 30.6 years (26-37) presented puffy hands. These patients had been drug addicts for four to twelve years (mean duration 7.3 years) and had stopped heroin injections for 3-5 years (mean 4.6), participating in a buprenorphine substitution program. The edema appeared several years after drug cessation (1.5-5, mean 2.3). Typically the puffiness was bilateral, the hands swollen from the proximal segments of the fingers to the wrist. In one patient, the edema was localized both in the hands and in the feet. The edema was not pitting and unaffected by elevation. Duplex ultrasound examination of the extremities was normal. Lymphangiography performed in one patient was consistent with deep lymphatic destruction. Puffy hand syndrome appears to be the end result of lymphatic obstruction. Repeated injections of drugs in or outside the veins destroy the lymphatics. Buprenorphine may play an important role in the puffy hand sign. Although it is supposed to be administered orally, many drug addicts use it as an i.v. solution. Because buprenorphine is poorly soluble, it causes lymphatic obstruction. This type of hand for which no therapy exists must be differentiated from deep palmar space infection with dorsal edema which requires incision and drainage.

Incidence and mechanism of presyncope and/or syncope associated with paroxysmal junctional tachycardia.

The objectives of this study were to: (1) define the incidence of presyncope and/or syncope in patients with paroxysmal junctional tachycardias, (2) determine their causes, and (3) determine the outcome of symptoms. Syncope is a frequent problem and is often caused by paroxysmal tachycardia. The mechanism of hemodynamic instability is unknown. The population study consisted of 281 patients, consecutively recruited because they had paroxysmal tachycardia and a sinus rhythm on a normal electrocardiogram. Fifty-two patients (group I) had presyncope and/or syncope associated with tachycardia. The remaining patients (group II) had no loss of consciousness. Transesophageal programmed atrial stimulation used 1 and 2 atrial extrastimuli, delivered in a control state, and if necessary, after infusion of 20 to 30 microg of isoproterenol. Arterial blood pressure was monitored. Vagal maneuvers and echocardiogram were performed in all patients. Paroxysmal tachycardia was induced in 51 group I patients and 227 group II patients. Comparisons of groups I and II revealed that age (50 +/- 21 vs 49 +/- 17 years), presence of heart disease (10% vs 10%), mechanism of tachycardia with a predominance of atrioventricular nodal reentrant tachycardia (70.5% vs 76%), and rate of tachycardia (196 +/- 42 vs 189 +/- 37 beats/min) did not differ between the groups. However, there were differences in both groups with regard to significantly higher incidences of positive vasovagal maneuvers (35% vs 4%, p <0.01), isoproterenol infusion required to induce tachycardia (55% vs 17%, p <0.001), and vasovagal reaction at the end of tachycardia (41% vs 4%, p <0.05). Thirty-seven group I patients underwent radiofrequency ablation of the reentrant circuit, which suppressed presyncope and/or syncope in 36 of the 37 patients. Thus, presyncope and/or syncope frequently complicated the history of patients with paroxysmal junctional tachycardia (18.5%). Several mechanisms are implicated, but vasovagal reaction was the most frequent cause. Treatment of the tachycardia typically suppressed presyncope and/or syncope.

Circadian rhythm and sudden death in heart failure: results from Prospective Randomized Amlodipine Survival Trial.

OBJECTIVE: The purpose of this study was to address the timing of sudden death in advanced heart failure patients. BACKGROUND: Sudden death is a catastrophic event in cardiovascular disease. It has a circadian pattern prominent in the early AM, which has been thought to be due to a surge of sympathetic stimulation. We postulated that the distribution of events in advanced heart failure, with chronic sympathetic activation, would be more uniform implicating other potential mechanisms. METHODS: We analyzed data from Prospective Randomized Amlodipine Survival Trial (PRAISE). Sudden deaths were analyzed by time of death in 4-h and 1-h blocks for uniformity of distribution in the entire cohort, and in the prespecified ischemic and nonischemic stratum. Further analyses were undertaken in the treatment groups of amlodipine and placebo, and among those receiving background therapy of aspirin and warfarin. RESULTS: Sudden deaths in the overall cohort showed a nonuniform distribution with a PM peak but not an AM peak. The ischemic stratum also showed a PM peak, but sudden deaths within the nonischemic stratum were uniformly distributed. Neither amlodipine treatment nor aspirin or warfarin use altered the distribution. CONCLUSIONS: Sudden death in advanced heart failure did not show an AM peak, suggesting that circadian sympathetic activation did not strongly influence these events. The PM peak noted is likely complex in origin and was not affected by antiischemic or antithrombotic medications.

[Organization of health care in geriatric psychiatry: a consensus statement]. / Organisation des soins en psychiatrie gériatrique: un protocole d'accord technique.

This consensus statement, originally published in English by the World Health Organization (WHO), has been produced in collaboration with the Section of Geriatric Psychiatry of the World Psychiatric Association (WPA). During a meeting in Lausanne, Switzerland, from November 14 to 16, 1997, led by Dr Nori Graham, the final declaration was prepared by an interdisciplinary group of representatives from the principle international associations concerned. Professor Cornelius Katona and Dr Nori Graham were Co-Rapporteurs. This statement follows an initial consensus document published by the WHO and the WPA defining geriatric psychiatry (1).

Effect of amlodipine on mode of death among patients with advanced heart failure in the PRAISE trial. Prospective Randomized Amlodipine Survival Evaluation.

Investigations of calcium antagonists in patients with advanced heart failure have raised concern over an increased risk of worsening heart failure and heart failure deaths. We assessed the effect of amlodipine on cause-specific mortality in such patients enrolled in a randomized, double-blind, placebo-controlled trial. In total, 1,153 patients in New York Heart Association class IIIb or IV heart failure were randomized to receive amlodipine or placebo, along with angiotensin-converting enzyme inhibitors, diuretics, and digitalis. Over a median 14.5 months of follow-up, 413 patients died. Cardiovascular deaths accounted for 89% of fatalities, 50% of which were sudden deaths and 45% of which were due to pump failure, with fewer attributed to myocardial infarction (3.3%) or other cardiovascular causes (1.6%). Amlodipine treatment resulted in a greater relative reduction in sudden deaths (21%) than in pump failure deaths (6.6%) overall. When patients were classified by etiology of heart failure (ischemic or nonischemic), cause-specific mortality did not differ significantly between treatment groups in the ischemic stratum. In the nonischemic stratum, however, sudden deaths and pump failure deaths were reduced by 38% and 45%, respectively, with amlodipine. Thus, when added to digitalis, diuretics, and angiotensin-converting enzyme inhibitors in patients with advanced heart failure, amlodipine appears to have no effect on cause-specific mortality in ischemic cardiomyopathy, but both pump failure and sudden deaths appear to be decreased in nonischemic heart failure patients treated with amlodipine.

Organização de cuidados na psiquiatria da pessoa idosa: a Segunda Reunião de Consenso de Lausanne / Organization of care in old age psychiatry: the Second Reunion of Consensus of Lausamme

Em fevereiro de 1996 foi realizada em Lausanne, Suíça, uma reuniäo de Consenso em Psicogeriatria para definir o campo de açäo desta disciplina. A partir desta reuniäo ficou claro que duas reuniöes suplementares eram necessárias, especialmente para desenvolver o tema da organizaçäo dos cuidados em psiquiatria da pessoa idosa e a formaçäo e educaçäo das pessoas que estäo em contato com pacientes idosos sofrendo de transtornos mentais. Professor Jean Wertheimer, presidente da Seçäo de Psiquiatria Geriátrica da Associaçäo Mundial de Psiquiatria, decidiu novamente contribuir para avançar o debate nesta área e realizou em Lausanne, de 14 a 16 de abril de 1997, uma Reuniäo de Consenso sobre a Organizaçäo dos Cuidados em Psiquiatria da Pessoa Idosa. A reuniäo foi organizada sob a égide da Associaçäo Mundial de Psiquiatria - através da sua Seçäo de Psiquiatria Geriátrica - e co-patrocinada pela Organizaçäo Mundial de Saúde. Os participantes da reuniäo redigiram o documento final sabendo que ele näo poderia ser definitivo. Eles assinalaram que os cuidados e os tratamentos estäo em franca evoluçäo, ligados aos avanços das pesquisas e que novas estruturas poderäo ser necessárias para permitir que novos tratamentos sejam usados com sucesso. Os participantes identificaram e descreveram as necessidades em termos de cuidados das pessoas idosas com transtornos mentais e alguns dos recursos atualmente usados em algumas partes do mundo para se lidar com estes. Os participantes solicitam a todos os responsáveis pelo desenvolvimento e aplicaçäo de políticas de cuidados sanitários o estudo destes recursos e açöes em acordo com eles

Organizacao de cuidados na psiquiatria da pessoa idosa: a segunda reuniao de consenso de lausanne

Em fevereiro de 1996 foi realizada em Lausanne, Suica, uma Reuniao de Consenso em Psicogeriatria para definir a campo de acao desta disciplina. A partir desta reuniao ficou claro que duas reunioes suplementares eram necessarias, especialmente para desenvolver o tema da organizacao dos cuidados em psiquiatria da pessoa idosa e a formacao e educacao das pessoas que estao em contato com pacientes idosos sofrendo de transtornos mentais. Professor Jean Wertheimer, presidente da Secao de Psiquiatria Geriatrica da Associacao Mundial de Psiquiatria, decidiu novamente contribui para avancar o debate nesta area e realizou em Lausanne, de 14 a 16 de abril de 1997, uma Reuniao de Consenso sobre a Organizacao dos Cuidados em Psiquiatria da Pessoa Idosa. A reuniao foi organizada sob a egide da Associacao Mundial de Psiquiatria-atraves da sua Secao de Psiquiatria Geriatrica-e copatrocinada pela Organizacao Mundial da Saude. Os participantes da reuniao redigiram o documento final sabendo que ele nao poderia ser definitivo. Eles assinalaram que os cuidados e os tratamentos estao em franca evolucao, ligados aos avancos das pesquisas e que novas estruturas poderao ser necessarias para permitir que novos tratamentos sejam usados com sucesso. Os participantes identificaram e descreveram as necesidades em termos de cuidados das pessoas idosas com transtornos mentais e alguns dos recursos altamente usados em algumas partes do mundo para se lidar com estes. Os participantes solicitam a todos os responsaveis pelo desenvolvimento e aplicacao de politicas de cuidados sanitarios o estudo destes recursos e acoes em acordo com eles.

[Psychiatric disorders in Alzheimer's disease and organization of care]. / Troubles psychiatriques dans la maladie d'Alzheimer et organisation des soins.

The organization of care for a patient suffering from Alzheimer's Disease (AD) must consider the intricate psychiatric and cognitive problems associated with this disorder. It will be complementary to the primary care given by the patient's relatives and offer a large choice of care structures including different possibilities between the patient's home and long term psychogeriatric facilities. It should be flexible and favour transitory solutions. It has to adhere to a basic philosophy which takes into account the patient's personal history, focusing on his behavior seen as the result of his efforts to adapt. Finally, the organization needs to assume, at all care levels, an approach of psychological and psychotherapeutic support to the patient and his family.

Rapid-cycling affective disorder in the elderly: clinical subtype or specific course of manic-depressive illness?

Rapid cycling is a relatively unusual presentation of bipolar affective disorder in the elderly. Four cases or rapid-cycling affective disorder (RCAD) in elderly women (aged 78-86 yr) are presented. Two patients began their bipolar illness in adulthood (aged 30 and 49 yr), and rapid cycles appeared secondarily in their elderly years (82 and 76 yr). The other two began their illness immediately with rapid cycles respectively at the age of 62 and 66. Added to the nine cases of RCAD in the elderly previously reported in the literature, a meta-analysis conducted on this small sample suggests that immediate entry in rapid cycles seems more likely to be associated with a late occurrence of bipolar illness (after 60 years of age)(P = .0035, Fisher's Exact Test, two-tailed), and that very short cycles (< 2 weeks each) are more likely to be associated with female gender (P = .0047, Fisher's Exact Test, two-tailed). Despite the small size of the sample, these results give some arguments to the hypothesis that RCAD is not a homogeneous syndrome but could be considered as a pattern of evolution, as well as clinical subtype, of the bipolar illness.

Psychiatry of the elderly: a consensus statement.

This consensus statement, published by The Division of Mental Health and Prevention of Substance Abuse of the World Health Organisation, was co-sponsored by WHO and the Geriatric Section of the World Psychiatric Association, under the Section presidency of Professor J. Wertheimer. The final statement was prepared by an inter-disciplinary group representing the principal international association, at a meeting in Lausanne, 5-7 February 1996, chaired by Professor H. Hafner. Professor Cornelius Katona and Dr. Nori Graham were co-rapporteurs. A full list of participants is available from Professor Wertheimer.

Psychogeriatric organization in the medico-social network: the experience of the canton of Vaud, Switzerland.

In Switzerland (7 million inhabitants), the organization of health care is in the hand of the cantons and not of the Confederation. The canton of Vaud (600,000 inhabitants), in the south-west part of the country, counts 4 psychiatric sectors, each with a psychogeriatric service. Otherwise the canton has 146 long-stay facilities with a total of 6,000 beds, of which 600 are for psychogeriatric cases. Home care is in charge of a network of 38 medico-social centres with multidisciplinary teams including psychiatric nurses. Several nursing homes, some specialized in psychogeriatrics, are equipped, besides long-stay beds, by units for temporary care, for medico-social emergencies and for medico-social observations. Moreover, in Lausanne (250,000 inhabitants) an 'Orientation Office of Medico-Social Emergencies', with psychiatric nurses, assumes emergencies at home and by-passes hospitalizations of medico-social cases in the General Hospital, by the resource of medico-social emergency beds in the nursing homes. The medico-social network thus designed in this way is profoundly permeated with the reality of psychogeriatrics.

Are personality disorders more frequent in early onset geriatric depression?

This preliminary study evaluates the prevalence of personality disorders (PD) in a sample of 37 elderly recovered depressed and non-demented patients, using the French version of the Vragenlijst voor Kenmezken van de Persoonlijkheid (VKP) or Questionnaire on Personality Traits (QPT). The prevalence of definite personality disorder was 65% with predominance of Cluster C and particularly dependent and avoidant PD. The rate of PDs was higher in early onset (73%) than in late onset (45%) geriatric depression, even though there is only a trend towards statistical significance (Chi square = 2.588, p = 0.107). These results are consistent with those of previous reports using different PD assessment methods, supporting evidence that the QPT could be useful in PD assessment of elderly French speaking patients.

Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group.

BACKGROUND: Previous studies have shown that calcium-channel blockers increase morbidity and mortality in patients with chronic heart failure. We studied the effect of a new calcium-channel blocker, amlodipine, in patients with severe chronic heart failure. METHODS: We randomly assigned 1153 patients with severe chronic heart failure and ejection fractions of less than 30 percent to double-blind treatment with either placebo (582 patients) or amlodipine (571 patients) for 6 to 33 months, while their usual therapy was continued. The randomization was stratified on the basis of whether patients had ischemic or nonischemic causes of heart failure. The primary end point of the study was death from any cause and hospitalization for major cardiovascular events. RESULTS: Primary end points were reached in 42 percent of the placebo group and 39 percent of the amlodipine group, representing a 9 percent reduction in the combined risk of fatal and nonfatal events with amlodipine (95 percent confidence interval, 24 percent reduction to 10 percent increase; P=0.31). A total of 38 percent of the patients in the placebo group died, as compared with 33 percent of those in the amlodipine group, representing a 16 percent reduction in the risk of death with amlodipine (95 percent confidence interval, 31 percent reduction to 2 percent increase; P=0.07). Among patients with ischemic heart disease, there was no difference between the amlodipine and placebo groups in the occurrence of either end point. In contrast, among patients with nonischemic cardiomyopathy, amlodipine reduced the combined risk of fatal and nonfatal events by 31 percent (P=0.04) and decreased the risk of death by 46 percent (P<0.001). CONCLUSIONS: Amlodipine did not increase cardiovascular morbidity or mortality in patients with severe heart failure. The possibility that amlodipine prolongs survival in patients with nonischemic dilated cardiomyopathy requires further study.

Atividade gerontopsiquiátrica no serviço de emergência de um hospital geral: importância da colaboração interdisciplinar / Geriatric psychiatric liaison-consultation in a general hospital emergency: the importance of an interdisciplinary collaboration

Desde o fim de 1992, o Service Universitaire de Psychogériatrie (SUPG) de Lausanne desenvolveu uma atividade de interconsulta no Centre Hospitalier Universitaire Vaudois (CHUV), onde aproximadamente 1/3 das 30.000 admissões feitas no ano de 1993 era de pessoas com pelo menos 65 anos. De primeiro de janeiro de 1993 ao trinta e um de dezembro de 1994, dos 597 pedidos de consulta ao serviço de gernontopsiquiatria no CHUV (num total de 1.303 consultas), 139 (24 por cento) eram do serviço de emergência. Os autores descreveram as características clínicas e demográficas desta amostra assim como a orientação dada a estes pacientes. Eles salientam o interesse de uma intervenção conjunta da interconsulta gerontopsiquiátrica e do Bureau d'Orientation des Urgences Médico-Sociales (BOUM), sob a responsabilidade e no local mesmo do serviço das emergências

Atividade gerontopsiquiatrica no servico de emergencia de um hospital geral: importancia da colaboracao interdisciplinar

Desde o fim de 1992, o Service Universitaire de Psychogeriatrie (SUPG) de Lausanne desenvolveu uma atividade de interconsulta no Centre Hospitalier Universitaire Vaudois (CHUV), onde aproximadamente 1/3 das 30.000 admissoes feitas no ano de 1993 era de pessoas com pelo menos 65 anos. De primeiro de janeiro de 1993 ao trinta e um de dezembro de 1994, dos 597 pedidos de consulta ao servico de gerontopsiquiatria no CHUV (num total de 1.303 consultas), 139 (24 poer cento) eram do servico de emergencia. Os autores descrevem as caracteristicas clinicas e demograficas desta amostra assim como a orientacao dada a estes pacientes. Eles salientam o interesse de uma intervencao conjunta da interconsulta gerontopsiquiatrica e do Bureau d'Orientation des Urgences Medico-Sociales (BOUM), sob a responsabilidade e no local mesmo do servico das emergencias.