Cerebrovascular Comorbidity Research Articles

Challenging the Advanced: Cardiac Surgery without Awareness of a Pheochromocytoma

We report the case of a 75-year-old male patient who underwent bypass surgery. Intraoperatively unstable hemodynamics with excessive arterial blood pressure was observed. This resulted in the tearing of an anastomosis, which subsequently required hemostasis for repeated bleeding. Postoperatively, laboratory findings and diagnostic imaging confirmed the diagnosis made intraoperatively of a pheochromocytoma. Any surgery without awareness of the possibility of a pheochromocytoma will dramatically increase intraoperative and postoperative morbidity and mortality, especially in cardiac surgery. The uncontrolled release of catecholamines raises arterial blood pressure which can become life-threatening and lead to serious intraoperative complications, as well as cerebrovascular and cardiac comorbidity.

Risk-adjusted morbidity, mortality and failure-to-rescue models for internal provider profiling after major lung resection

This work was aimed at developing risk-adjusted outcome models for profiling the internal quality of care after major lung resection. One thousand and sixty-two patients submitted to lobectomy (845) or pneumonectomy (217) from 1994 through 2004 at our unit were analyzed. Risk-adjusted models of 30-day or in-hospital morbidity, mortality and failure-to-rescue (death/complication ratio) were developed by stepwise logistic regression analyses and validated by bootstrap procedures. The regression equations were then used to estimate the outcome risks in 3 successive periods of activity (early: 1994-1997; intermediate: 1998-June/2001; late: July/2001-2004). Observed and predicted morbidity, mortality and failure-to-rescue rates were compared within each period by the z-test. The following regression models were developed: Predicted morbidity: ln R/1-R=-2.1+0.035 x age-0.02 x FVC+0.6 x extended resection+0.7 x cardiac co-morbidity (c-index=0.68). Predicted mortality: ln R/1-R=-7.6+0.08 x age-0.04 x ppoFEV1+1.6 x extended resection+1.2 x cardiac co-morbidity+1.1 x cerebrovascular co-morbidity (c-index=0.83). Predicted failure-to-rescue: ln R/1-R=-6.7+0.06 x age+1.5 x extended resection+1.2 x cerebrovascular co-morbidity (c-index=0.71). No differences were noted between observed and predicted outcome rates within each period, despite apparent unadjusted differences between periods. The use of risk-adjusted outcome models prevented misleading information derived from the unadjusted analysis of performance. We are currently using these models for internal quality-of-care audit purposes.

Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a Falls and Syncope Unit

Dizziness is a common symptom in older people that affects quality of life and increases the risk of falls. Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness that increases in prevalence with age, and is potentially curable. To compare patients with BPPV referred initially to a Falls and Syncope Unit (FSS group) with those initially referred to a Regional ENT/Balance Service (ENT group). Retrospective case-note review. Medical notes, investigations and outcomes were reviewed for all patients. Of 59 patients with BPPV confirmed by Dix-Hallpike test, 31 (53%) were initially referred to the FSS (2.6 patients per month, 71% females) and 28 (47%) were initially referred to ENT (4.7 patients per month, 86% females). Compared to those referred initially to ENT, FSS patients were significantly older (mean +/- SD 69 +/- 13 vs. 55.4 +/- 13 years, p = 0.0003) and had dizzy symptoms for longer before diagnosis (median (range) 12 (4-120) vs. 6 (1-36) months, p = 0.0273). FSS patients were more likely to have more than one type of dizziness (16% vs. 0%, p = 0.001), more likely to have cerebrovascular or cardiovascular co-morbidity (13% vs. 4%, p = 0.0152) and were taking significantly more medications (3.2 vs. 1.7; p = 0.0271). Cure rates on intervention were similar (83% FSS, 86% ENT). BPPV is a potentially curable cause for dizziness in older people. Older people are frequently referred directly to Falls units, who will be seeing increasing numbers of patients with dizziness. A high index of suspicion allows early identification and treatment of this condition.

Predictors of Undiagnosed Renal Artery Stenosis among Japanese Patients with Risk Factors of Atherosclerosis

Atherosclerotic renal artery stenosis (ARAS) is a significant cause of end stage renal dysfunction (ESRD) among the elderly. Although early detection of ARAS and induction of adequate treatment could reduce the incidence of ESRD, there have been few reports about parameters predictive of ARAS among Japanese. In this study, we investigated the clinical indicators that predict ARAS among Japanese with risk factors of atherosclerosis (> 40 years of age plus hypertension, dyslipidemia or diabetes mellitus). After eliminating the patients who had already been diagnosed with renal artery stenosis, 202 patients were enrolled. The renal arteries of all 202 patients were evaluated by magnetic resonance arteriography (MRA), and the stenoses with > 50% reduction in diameter at the ostium of the renal artery were defined as ARAS. MRA detected ARAS in 42 patients (31 hemilateral and 11 bilateral). Between the patients with and without ARAS there was no significant difference in gender distribution, detection of abdominal vascular bruits or smoking habit. The prevalences of diabetic, hypertensive and cerebrovascular comorbidity were also not significantly different. The mean blood pressure, body mass index and total serum cholesterol values were similar between the two groups. However, age, pulse pressure, serum uric acid, serum creatinine, amount of urinary protein, and coronary artery comorbidity were significantly higher, while estimated creatinine clearance was significantly lower in the patients with ARAS than in those without ARAS. A high prevalence of hypertensive retinopathy was also noted among patients with ARAS. Multivariate analysis revealed that older age and renal impairment were independent predictors of ARAS in Japanese patients with atherosclerotic risk factors.

Syncope in the elderly: diagnosis, evaluation, and treatment.

Syncope is more common in older persons than in any other age group. Age-related physiologic impairments of heart rate, blood pressure, baroreflex sensitivity, and cerebral blood flow, in combination with a higher prevalence of comorbid disorders and concomitant medications, account for the increased susceptibility of older persons to syncope. A number of age-related factors confound the assessment of syncope in older persons. Examples include (1). more than one possible attributable diagnosis; (2). polypharmacy; (3). cardiovascular and cerebrovascular comorbidity; (4). amnesia for loss of consciousness; (5). lack of witness accounts; (6). syncopal events presenting as falls; and (7). coexistent cognitive impairment and dementia. Cardiovascular risk factors are increasingly recognized as key triggers for dementia, with enormous potential for early detection and intervention. One such possible risk factor is bradyarrhythmia. Successful interventions for cardiovascular disorders that cause syncope in the elderly have wider implications than control of syncopal events and include reductions in falls and possibly prevention or modification of cognitive impairment and dementia.

Autonomous Neurobiological Pathways to Late-Life Major Depressive Disorder: Clinical and Pathophysiological Implications

The objective of our study was to elucidate distinct paths to depression in a model that incorporates age, measures of medical comorbidity, neuroanatomical compromise, and cognitive status in a sample of patients with late-life major depressive disorder (MDD) and nondepressed controls. Our study was cross-sectional in nature and utilized magnetic resonance imaging (MRI) estimates of brain and high-intensity lesion volumes together with clinical indices of cerebrovascular and nonvascular medical comorbidity. Neuroanatomic and clinical measures were incorporated into a structural covariance model in order to test pathways to MDD. Our data indicate that there are two paths to MDD; one path is represented by vascular and nonvascular medical comorbidity that contribute to high-intensity lesions that lead to depression. Smaller brain volumes represent a distinct path to the mood disorder. Age influences depression by increasing atrophy and overall medical comorbidity but has no direct impact on MDD. These findings demonstrate that there are distinct biological substrates to the neuroanatomical changes captured on MRI. These observations further suggest that neurobiological mechanisms acting in parallel may compromise brain structure/function, thereby predisposing individuals to clinical brain disorders such as depression.

Circumstances around the fall in a multinational hip fracture risk study: a diverse pattern for prevention

Hip fracture is a major public health problem, but with a potential for prevention. Data from a European multicentre study on hip fracture epidemiology with a case control design, the MEDOS study, were used to describe and analyse circumstances around falls associated with hip fracture. The study includes 2185 fracture cases age >50 years from 14 centres in southern Europe: Portugal, Spain, France, Italy, Greece and Turkey. Information was collected by a standardized and validated questionnaire translated into six languages and administered by trained interviewers. Circumstances around the fall were categorized according to: (1) place, age group and time of day; (2) functional disability, co-morbidity; (3) drug consumption including alcohol; and (4) environmental factors. Possibilities for prevention were also analysed. High risk falls were identified using seven reasonably well-established risk factors, and similarly eight risk factors were used to identify high risk fallers. Selected trains of events were also studied. A pattern of great diversity was found both among the fallers and the environment in which they fell and fractured the hip. Those with more than one factor involved constituted only 14.7% of female and 19.7% of male fractures. A majority of cases were not physically disabled before the fall. A majority (66.5%) fell and fractured their hip indoors and only 4.3% outside in darkness. Cardiovascular and cerebrovascular comorbidity were observed with 4.9 and 7.8%, of falls respectively. Falls in a stairway comprised 11% of falls. The correlation between the number of the risk factors of the faller and in the environment was 0.07 and there was no difference between males and females. The pattern of causality behind falls that cause hip fracture and therefore of prevention comprises many sometimes small groups and intricate time sequence. The results suggest that global preventive strategies could presently not be implemented. Instead, the pattern of prevention should include different target groups and be country and site specific. For the high risk group of institutionalized patients prevention can be implemented without delay.