Spontaneous Fall Research Articles

Identifying determinants for falls among Iranian older adults: insights from the Bushehr Elderly Health Program

BackgroundFalls are a common cause of fractures in older adults. This study aimed to investigate the factors associated with spontaneous falls among people aged ≥ 60 years in southern Iran.MethodsThe baseline data of 2,426 samples from the second stage of the first phase of a prospective cohort, the Bushehr Elderly Health (BEH) program, were included in the analysis. A history of spontaneous falls in the year before recruitment was measured by self-report using a standardized questionnaire. Demographic characteristics, as well as a history of osteoarthritis, rheumatoid arthritis, low back pain, Alzheimer’s disease, epilepsy, depression, and cancer, were measured using standardized questionnaires. A tandem gait (heel-to-toe) exam, as well as laboratory tests, were performed under standard conditions. A multiple logistic regression model was used in the analysis and fitted backwardly using the Hosmer and Lemeshow approach.ResultsThe mean (standard deviation) age of the participants was 69.34 (6.4) years, and 51.9% of the participants were women. A total of 260 (10.7%, 95% CI (9.5–12.0)%) participants reported a spontaneous fall in the year before recruitment. Adjusted for potential confounders, epilepsy (OR = 4.31), cancer (OR = 2.73), depression (OR = 1.81), low back pain (OR = 1.79), and osteoarthritis (OR = 1.49) increased the risk of falls in older adults, while the ability to stand ≥ 10 s in the tandem gait exam (OR = 0.49), being male (OR = 0.60), engaging in physical activity (OR = 0.69), and having high serum triglyceride levels (OR = 0.72) reduced the risk of falls.ConclusionThe presence of underlying diseases, combined with other risk factors, is significantly associated with an increased risk of falls among older adults. Given the relatively high prevalence of falls in this population, it is crucial to pay special attention to identifying and addressing these risk factors.

Self-Destruction of Idols in Arab Muslim Historiography

Abstract The article deals with a potential source and the subsequent borrowing of the motif of the self-destruction of the pagan idols. This motif is common in Eastern Christian apocrypha and hagiographic tales and also in the Arab Islamic tradition. In Muslim historiography, among stories about the destiny of ancient Arabian images, such a motif is found only twice. Both legends are connected with pre-Islanic Ḥaḍramawt, the autonomous region in Yemen. One legend deals with the idol called al-Djalsad, an object of veneration mostly by a tribe of al-Sakūn. It was represented in the shape of a white anthropomorphic rock with a black head. The other tale narrates about the domestic statue made of cornelian that belonged to the local notable Wā’il b. Ḥudjr. The subject of the spontaneous fall of idols appears to reflect a rivalry, especially in the spiritual sphere, between the tribal confederation al-Sakūn and the descendants of the indigenous sedentary population of Ḥaḍramawt. Their struggle for power in the early Islamic empire manifested in the most apparent way in Egypt, where they could borrow the motif of idols’ self-destruction from the Copts. Thus, in Chapter LXXIX of the Chronicle by John of Nikiu compiled in the late 7th–early 8th century AD obviously in Greek a tale about the childhood of St Theophilus, the Coptic Patriarch in AD 385–412, is preserved. According to it, in his presence, the statues of Artemis and Apollo became overthrown in a shrine situated in the district of Memphis.

A Postural Assessment Utilizing Machine Learning Prospectively Identifies Older Adults at a High Risk of Falling.

Introduction: Falls are the leading cause of accidental death in older adults. Each year, 28.7% of US adults over 65 years experience a fall resulting in over 300,000 hip fractures and $50 billion in medical costs. Annual fall risk assessments have become part of the standard care plan for older adults. However, the effectiveness of these assessments in identifying at-risk individuals remains limited. This study characterizes the performance of a commercially available, automated method, for assessing fall risk using machine learning.Methods: Participants (N = 209) were recruited from eight senior living facilities and from adults living in the community (five local community centers in Houston, TX) to participate in a 12-month retrospective and a 12-month prospective cohort study. Upon enrollment, each participant stood for 60 s, with eyes open, on a commercial balance measurement platform which uses force-plate technology to capture center-of-pressure (60 Hz frequency). Linear and non-linear components of the center-of-pressure were analyzed using a machine-learning algorithm resulting in a postural stability (PS) score (range 1–10). A higher PS score indicated greater stability. Participants were contacted monthly for a year to track fall events and determine fall circumstances. Reliability among repeated trials, past and future fall prediction, as well as survival analyses, were assessed.Results: Measurement reliability was found to be high (ICC(2,1) [95% CI]=0.78 [0.76–0.81]). Individuals in the high-risk range (1-3) were three times more likely to fall within a year than those in low-risk (7–10). They were also an order of magnitude more likely (12/104 vs. 1/105) to suffer a spontaneous fall i.e., a fall where no cause was self-reported. Survival analyses suggests a fall event within 9 months (median) for high risk individuals.Conclusions: We demonstrate that an easy-to-use, automated method for assessing fall risk can reliably predict falls a year in advance. Objective identification of at-risk patients will aid clinicians in providing individualized fall prevention care.

New solution to increase the safety of operating system with hydrostatic drive

Hydraulic actuators that commonly used in machine work systems are not equipped with protection features preventing the autonomous insertion and extension of a piston rod because of the influence of external forces. Consequently, a spontaneous fall of working circuits in the event of the loss of tightness of supply lines of an actuator may occur. Currently applied safety features that are sometimes mounted directly on hydraulic cylinders as in the case of mining machinery intended for exploitation in black coal mines protect working systems from uncontrolled lowering. However, their design forces the drive to be started to make it safe to leave the work system. If, for any reason, the drive system of a machine cannot be started and the work system is raised, its lowering can take place only by unsealing the hydraulic system, which is unforeseeable for constructors and carries the danger of crushing a person or persons involved. The paper presents a new solution for hydraulic cylinders, which enables, among other things, the controlled and safe insertion of a piston rod under load without the need for having the drive system started.

Outcomes of kidney paired donation transplants in relation to shipping and cold ischaemia time.

To assess the impact of shipping distance and cold ischaemia time (CIT) of shipped organs in a kidney paired donation (KPD) programme, we evaluated the outcomes of the initial 100 kidney transplants performed in the Australian KPD programme. In a 44-month period, 12 centres were involved in fifteen 2-way, twenty 3-way, one 4-way and one 6-way exchanges. Sixteen kidneys were transplanted at the same hospital (CIT 2.6 ± 0.6 h) and 84 required transport to the recipient hospital (CIT 6.8 ± 2.8 h). A spontaneous fall in serum creatinine by at least 10% within 24 h was observed in 85% of recipients, with no difference between nonshipped and shipped kidneys. There were two cases of transient delayed graft function requiring dialysis and patient and graft survival at 1 year were 99% and 97%, respectively. There was no difference in recipients of nonshipped compared with shipped kidneys with regard to serum creatinine at 1 month (mean difference (MD) 7.3 μmol/l, 95% CI -20.2 to 34.8, P = 0.59), 1-year graft survival (MD 3.9%, 95% CI -5.4 to 13.2, P = 0.41) or patient survival (MD -2.4%, 95% CI -10.0 to 5.2, P = 0.54). Despite prolonged CIT for interstate exchanges, the programme's decision to ship donor kidneys rather than the donor appears to be safe.

A Boulder in the Brain

A 43–year–old man presented to the casualty department with history of spontaneous fall while working in the fields. He had headache and few episodes of vomiting. He reported history of repeated such falls in the past 3 years but had never consulted a physician. The patient was irritable but coherent and scored 14 on Glasgow coma scale (eye opening-spontaneous- 4, verbal response- oriented-5, motor response-localises pain-5). The neurologist referred the patient for computed tomography of the head. Non-contrast axial computed tomography of the head [Table/Fig-1] revealed haemorrhagic contusions in both frontal lobes (a) and a well-defined, densely calcified, round lesion in the right parieto-occipital region. Calcification was peripheral as well as central curvilinear. The lesion shows undulating membranes (b) which is almost diagnostic for hydatid cyst. Calcified membranes were attached to the choroid plexus (c). Coronal CT revealed the peripheral calcification and floating membranes. Intraoperatively, the cyst was attached to the choroid plexus. It was excised in toto without rupture and sent for histopathology which confirmed the diagnosis of hydatid. Hydatid cyst of the brain accounts for 1-2 % of all Echinococcal infections [1]. Usually these are seen in the paediatric population [2] and in the supratentorial compartment [1]. It is extremely rare for hydatid cysts to occur at intraventricular site [3]. Hydatid disease produced by the larval stage of the Echinococcus tapeworm is a worldwide zoonosis. Among the many carnivorous definite hosts of echinococcus, the most common is the dog. The intermittent hosts are all mammals (often sheep and cattle). Humans get infected secondarily through the faeco-oral route by ingestion of contaminated food or milk. The contamination occurs by dog faeces containing ova of the parasite or by direct contact with dogs. The eggs are digested in the stomach, releasing the embryos. The embryos pass through the wall of the intestinal mucosa into the portal system and are carried to the liver where most larvae get lodged in the hepatic capillaries. Some may reach the lungs and occasionally, some may get entry into the systemic circulation, at times reaching the brain. The wall of Echinococcal cyst is composed of 3 layers: the outermost pericyst, the middle laminated layer and the inner germinal layer. Calcification of hydatid cysts usually manifests with a curvilinear or ring-like pattern representing calcification of the pericyst [4]. During the natural evolution towards healing, dense calcification of all components of the cyst occurs. The undulating membrane sign seen at computed tomography in our case is due to contained rupture of the endocyst. The hydatid fluid escapes into the potential space between the pericyst and endocyst; and the endocyst collapses. On CT and MR imaging, hydatid cysts are well-defined cystic lesion with signal intensity similar to that of cerebrospinal fluid. There is no associated oedema, the lesion does not enhance after intravenous administration of contrast material, and calcification is extremely rare [5]. A recent classification based on MRI findings classifies the cysts on the basis of their fertility activity and imaging morphology. Type 1 cystic echinococcosis (CE1) are fertile active cysts and appear as unilocular cysts with or without any visible wall. Type 2 cysts (CE2) are active and seen as a unilocular cyst containing multiple vesicles arranged peripherally . Type 3 (CE3) is a transitional form containing scolices and are seen as cysts filled by multiple daughter cysts. CE4 cysts show detached membranes and CE5 are calcified lesions. CE4 and CE5 are inactive forms of hydatid cysts that have lost their fertility [6]. [Table/Fig-1]: Non-contrast axial computed tomography of the head showing haemorrhagic contusions in both frontal lobes (a) and a well-defined, densely calcified, round lesion in the right parieto-occipital region. The lesion shows undulating membranes (b) which are ... Differential diagnosis may include arachnoid cysts, porencephalic cysts and epidermoid tumors. Arachnoid cysts and porencephalic cysts are neither spheric nor are they entirely surrounded by brain tissue. The absence of significant rim enhancement, perifocal edema and mural nodules differentiates hydatid cysts from brain abscess and cystic astrocytoma [7]. The differential leukocyte count shows eosinophilia in many cases. Exploratory cyst puncture is dangerous as accidental rupture may cause anaphylaxis or secondary seeding. Stool, sputum or vomit samples can be studied for scolex if the cyst has ruptured into intestine, bronchus or bile duct. In routine laboratory diagnosis, the Enzyme-Linked Immunosorbent Assay (ELISA), the indirect immunofluorescence antibody test, immunoelectrophoresis (IEP) and immunoblotting (IB) are used [8].

Unsolved Issues in the Management of High Blood Pressure in Acute Ischemic Stroke

High blood pressure is common in acute stroke patients. Very high as well as very low blood pressure is associated with poor outcome. Spontaneous fall of blood pressure within the first few days after stroke was associated both with neurological improvement and impairment. Several randomized trials investigated the pharmacological reduction of blood pressure versus control. Most trials showed no significant difference in their primary outcome apart from the INWEST trial which found an increase of poor outcome when giving intravenous nimodipine. Nevertheless, useful information can be extracted from the published data to help guide the clinician's decision. Blood pressure should only be lowered when it is clearly elevated, and early after onset, reduction should be moderate but may be achieved rapidly. No clear recommendations can be given on the substances to use; however, care should be taken with intravenous calcium channel blockers and angiotensin receptor antagonists. Two ongoing randomized trials will help to solve the questions on blood pressure management in acute stroke.

Response to Meta-Analysis of the Effects of Treating Blood Pressure on Cardiovascular Outcomes of Dialysis Patients

HomeHypertensionVol. 54, No. 1Response to Meta-Analysis of the Effects of Treating Blood Pressure on Cardiovascular Outcomes of Dialysis Patients Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Meta-Analysis of the Effects of Treating Blood Pressure on Cardiovascular Outcomes of Dialysis Patients Rajiv Agarwal Arjun D. Sinha Rajiv AgarwalRajiv Agarwal Indiana University School of Medicine, Indianapolis, Ind, Richard L. Roudebush Veterans’ Affairs Medical Center, Indianapolis, Ind Search for more papers by this author Arjun D. SinhaArjun D. Sinha Indiana University School of Medicine, Indianapolis, Ind Search for more papers by this author Originally published26 May 2009https://doi.org/10.1161/HYPERTENSIONAHA.109.133124Hypertension. 2009;54:e7Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 26, 2009: Previous Version 1 Goldsmith and Covic1 rightly conclude that it is premature to attribute cardiovascular benefits of antihypertensive drug use in hemodialysis patients to blood pressure (BP) lowering alone. Our meta-analysis points out the sharp difference between cohort studies and randomized trials; the former show harm with spontaneous fall in BP, whereas the latter show a benefit with antihypertensive drug use.2 Heerspink et al,3 in their meta-analysis concluded, “treatment with agents that lower blood pressure should routinely be considered for individuals undergoing dialysis to reduce the very high cardiovascular morbidity and mortality rate in this population.” However, given the problems with the current randomized trials and the heterogeneity in results, we concluded that, “adequately powered randomized trials are required to confirm these observations, especially among those with hypertension.” Our meta-analysis should not be taken as “proof” that BP should be lowered in hemodialysis patients. Indeed, our conclusions are consistent with the urgent call by Goldsmith and Covic1 for well-designed, randomized trials in this vulnerable population.We had 3 fewer studies in our meta-analysis compared to the 1 by Heerspink et al.3 Two of the 3 studies in the meta-analysis of Heerspink et al3 were published in abstract form. The third study was done in peritoneal dialysis patients to test the notion of whether angiotensin-converting enzyme inhibitors protect the decline in residual renal function; this study was substantially different from other studies in hemodialysis patients, which were designed to study cardiovascular protection.4 Accordingly, we feel that the results of our meta-analysis accurately reflect the state of the art, at least in hemodialysis patients. We, like Heerspink et al,3 found heterogeneity between studies, but unlike these authors we found that the effect on cardiovascular risk was modified by consideration of hypertension status. Therefore, studying hypertensive patients should have a more urgent priority compared with lowering BP among normotensive patients on hemodialysis. If such a trial is undertaken, we recommend that BP monitoring be performed outside of the dialysis unit rather than simply measuring BPs before and after dialysis.5,6DisclosuresNone.1 Goldsmith DJA, Covic AC. Meta-analysis of the effects of treating blood pressure on cardiovascular outcomes of dialysis patients. Hypertension. 2009; 54: e6.LinkGoogle Scholar2 Agarwal R, Sinha AD. Cardiovascular protection with antihypertensive drugs in dialysis patients: systematic review and meta-analysis. Hypertension. 2009; 53: 860–866.LinkGoogle Scholar3 Heerspink HJ, Ninomiya T, Zoungas S, de Zeeuw D, Grobbee DE, Jardine MJ, Gallagher M, Roberts MA, Cass A, Neal B, Perkovic V. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet. 2009; 373: 1009–1015.CrossrefMedlineGoogle Scholar4 Li PK, Chow KM, Wong TY, Leung CB, Szeto CC. Effects of an angiotensin-converting enzyme inhibitor on residual renal function in patients receiving peritoneal dialysis: a randomized, controlled study. Ann Intern Med. 2003; 139: 105–112.CrossrefMedlineGoogle Scholar5 Agarwal R, Peixoto AJ, Santos SF, Zoccali C. Pre and post dialysis blood pressures are imprecise estimates of interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol. 2006; 1: 389–398.CrossrefMedlineGoogle Scholar6 Agarwal R, Satyan S, Alborzi P, Light RP, Tegegne GG, Mazengia HS, Yigazu PM. Home blood pressure measurements for managing hypertension in hemodialysis patients. Am J Nephrol. 2009; 30: 126–134.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Horowitz B, Miskulin D and Zager P (2015) Epidemiology of Hypertension in CKD, Advances in Chronic Kidney Disease, 10.1053/j.ackd.2014.09.004, 22:2, (88-95), Online publication date: 1-Mar-2015. July 2009Vol 54, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/HYPERTENSIONAHA.109.133124PMID: 20640196 Originally publishedMay 26, 2009 PDF download Advertisement SubjectsClinical Studies

How Long Shall the Patient Rest Before Clinic Blood Pressure Measurement?

The optimal time at rest before clinic blood pressure (BP) measurement is still undefined. In this study in patients with essential hypertension, the time course of the hemodynamic changes during a 16-min rest in the chair-seated position was evaluated and compared with that observed in a stabilized postural condition, such as after a prolonged supine rest. In 55 untreated essential hypertensive patients, BP, heart rate, stroke volume (impedance cardiography), and systemic vascular resistances were measured every other minute during a 16-min rest in the chair-seated position and, in random sequence, in the last 16 min of a 60-min supine rest. Overall, systolic BP (SBP) and diastolic BP (DBP) decreased by 11.6 and 4.3 mm Hg, respectively, during the chair-seated rest; only a 1.8-mm Hg decrease in SBP was observed in the control supine study. The chair-seated fall in BP was associated with a decrease in systemic vascular resistances, in the absence of significant changes in cardiac index. From the logarithmic curve of SBP and DBP decrements, a half-time of 5.8 and 5.5 min respectively, was calculated. Decrements in SBP, but not DBP, were inversely related to the corresponding baseline values. In untreated essential hypertensive patients a significant decrease in SBP and DBP associated with a systemic vasodilation was observed during a 16-min rest in the chair-seated position. Because approximately 75% of the spontaneous fall in BP occurred within 10 min, it appears that this time at rest before clinic BP evaluation could improve the precision and accuracy of the measurement.

Long-Term Active Orthostatic Stress Test (AOST) in Patients with Epilepsy, Syncope, or Psychogenic falls: A Video-EEG Study

Introduction: Many patients are referred to our epilepsy center for the differential diagnosis (DD) of sudden unexplained falls or loss of muscle tone with or without loss of consciousness (SUF). We prospectively evaluated a diagnostic protocol including an active orthostatic stress test in 115 patients. Patients: Evaluation included all consecutive patients referred for DD of SUF between 05/02 and 06/04 in whom syncope was a probable diagnosis. Patients had neurological and cardiological evaluation (incl. normal tilt-table test) without a definite diagnosis. Age was 12 to 88 years with a median of 36 years, 59 were female, 56 male. Methods: Evaluation included a meticulous history of falls, in nearly all cases an observer was interviewed. The AOST was performed in the video-EEG lab following 24–48h video-EEG with 10/20 scalp EEG + ECG electrodes (Neurofile XP, ITmed). Until 12/03, blood pressure was measured intermittently by an automatic device, since 2004 all 42 patients were evaluated with a non-invasive beat-to-beat blood pressure device (Task Force Monitor, CNSystems). After 15min lying supine the patients actively stood for 30min or until a spontaneous fall. Results: In 48 patients (42%) the AOST was classified as abnormal. In 31 patients (27%) a fall (24) or presyncope (7) occurred, comorbid epilepsy was present in 6, cataplexy in 1 of the patients. Of the 24 falls, 15 were classified as neurocardiogenic syncope and 9 as psychogenic (active falling, no changes in blood pressure or pulse). Presyncope was diagnosed when the patient became symptomatic (e.g., dizziness) and a significant change in blood pressure or heart rate occurred. Diffuse high amplitude theta or delta EEG activity was seen in 13/15 patients with neurocardiogenic syncope, 3/7 patients with presyncope, and 0/9 patients with psychogenic falls. In 17 other cases (15%) postural orthostatic tachycardia occurred. Discussion: The AOST is of great diagnostic value in selected patients during video-EEG. It is preferable to tilt-table test because of the more physiological situation, the high rate of psychogenic falls, and abnormal results in patients with previous normal tilt-table tests. The video can be shown to compare the documented fall with other falls. Conclusions: EEG is helpful in discriminating psychogenic falls from syncope with generalized EEG-slowing. Continuous measurement of blood pressure is necessary, since changes may be too short to be detected by intermittent measurements.

Pseudoartrosis vertebral en la espondilitis anquilosante

Spinal pseudoarthrosis is an uncommon complication in patients with advanced ankylosing spondylitis which consists in destruction of the discovertebral junction. Two cases of spinal pseudoarthrosis at the thoracolumbar level after a spontaneous fall are reported. Because of the neural arch involvement and the spinal cord compression a stabilization was required. Different imaging techniques are complementaries in the study of this entity, conventional radiographs and computed tomography may depicte bone abnormalities, but magnetic resonance allows a correct evaluation of spinal cord and soft tissue involvement.

A NEW TEST ACCURATELY IDENTIFIES THE THORACIC EPIDURAL SPACE

S311 Introduction: The most common method used to identify the thoracic epidural (TE) space is the manual loss of resistance (LOR) to air or saline. [1] Occasionally, the LOR obtained may be equivocal, and the operator may be unsure whether the TE space has been identified. In such situations a test sensitive for the TE space would be of value. Since pressure drops as the epidural space is entered [1], a fluid column (FC) attached to a correctly placed TE needle should fall, especially with inspiration. Conversely, absence of a FC drop may suggest that the needle is located outside of the epidural space. We hypothesize that the FC drop technique is useful as a confirmatory test for the identification of TE space. The purpose of this study is to evaluate the clinical application of the FC drop test and determine its sensitivity and specificity as a marker of a correctly identified TE space. Methods: Following IRB approval and oral consent, 131 consecutive TE catheters (T2-L1) were placed in either the sitting (108) or lateral (23) positions via the midline (92) or paramedian (39) approach. After identification of the TE space by the LOR technique to air, a 50 cm extension tube filled with preservative free normal saline was attached to the 17 g Hustead epidural needle. We held the fluid filled tubing upright so that the full length of the tubing was above the level of the needle except at the point of attachment. A 10 cc filling syringe was then removed from the top of the extension tubing, and the fluid column meniscus was observed by the operator. The fluid column drop was assessed to be either spontaneous (immediately coinciding with syringe detachment), inspiratory (no spontaneous fall, but meniscus fell after patient instructed to take deep breath), or absent. A spontanous or inspiratory drop of the FC meniscus > 4 cm (two finger breaths) was considered a positive test by the operator. No movement or less than a 4 cm drop of the FC meniscus was considered a negative test. Catheters were inserted 4 cm beyond the needle regardless of the FC test result and were then dosed as clinically appropriate. Catheters were considered to be functional if a band of analgesia was present either pre or post operatively. Results: 132 catheters were placed in a total of 120 patients. 119 of the 121 functional catheters exhibited a positive FC test (119 true positives) with a FC drop ranging from 7-39 cm (mean drop 20 cm). Three functional catheters displayed a negative FC test (3 false negatives). Of the 11 non functional catheters, 8 had a negative FC test (8 true negatives), while three displayed a positive FC test (3 false positives). In the patients with a false positive test, one catheter was determined to be in a vein, while the other was identified by the surgeon during thoracotomy and appeared to have pierced the parietal pleura. The location of the third false positive catheter was not known. The extent of the FC drop (# of cm the meniscus fell from top of tubing) did not correlate with patient position, age, weight, midline or paramedian approach, or thoracic level. All false negatives and false positive tests were obtained in epidurals placed in the sitting patients via the midline approach but at various thoracic levels. The sensitivity (true positive/true positive + false negative) and specificity (true negative/true negative + false positive) of the FC test were determined to be 98% and 72% respectively. The test had a positive predictive value of 98% and a negative predictive value of 72%. The accuracy of the test was 96%. Discussion: The FC test has not been previously described, although pressure characteristics of the TE space have been extensively examined. [2,3] The high sensitivity (98%) indicates that a needle placed in the TE space will exhibit a positive FC test. Therefore, a negative FC test (no FC drop) indicates that the TE space has not been identified, and that the epidural needle needs to be repositioned. However, not all positive tests indicate correct needle placement (specificity = 72%). Intravenous and intrathoracic catheters are sources of false positives. Despite its lower specificity, the FC test is a fast, easy, inexpensive, and highly sensitive confirmatory test for the identification of the TE space by LOR technique.

Prevalence and Significance of Urethral Instability in Women with Detrusor Instability

The phenomenon of urethral instability has been poorly defined and its significance is disputed. The aim of this study was to investigate the prevalence and significance of urethral instability in a group of women with idiopathic detrusor instability. Urethral instability was defined as a spontaneous fall in maximum urethral pressure of one-third or more, in the absence of detrusor activity, over a 2-min period. Urethral instability occurred in 42% of patients with detrusor instability and was strongly associated with the sequence of relaxation of the urethra prior to unprovoked detrusor contraction. Women with detrusor instability and a stable urethra exhibited primary contraction of the detrusor. The symptom of stress incontinence was more common in women with urethral instability. Women with detrusor instability may be subdivided into 2 groups on the basis of urethral instability, the presence of which suggests a primary dysfunction of the urethra. Such patients may derive more benefit from treatment with an alpha adrenoceptor agonist in addition to (or instead of) standard anticholinergic therapy.

Reproducibility of late phase pulmonary response to exercise and its relationship to bronchial hyperreactivity in children with chronic asthma.

To determine the reproducibility of the delayed response to exercise and its effect on bronchial hyperreactivity, we had 26 asthmatic children perform treadmill exercise challenge on two occasions 1 week apart. Both challenges were preceded by 2 control days and 1 histamine challenge day, and were followed by another histamine challenge day. Peak expiratory flow rate (PEFR) was measured hourly for 12 hours on each control day and for 12 hours after each exercise or histamine challenge. During the first week, five patients showed a late reaction (PEFR change > 15%) after exercise, which was present in only two of them the following week. These two patients, however, also showed a spontaneous fall > 15% of PEFR from baseline during the other control study days. A similar pattern was seen in two other patients who had a late response during the second exercise challenge but not during the first. No significant change occurred in histamine PC-20 FEV1 between before and after the exercise challenges. An apparent late asthmatic response after exercise challenge may represent a within-day fluctuation in pulmonary mechanics that develops spontaneously in children with asthma.

Diagnostic tests of hyperventilation syndrome

In 90 patients referred to the pulmonary function laboratory for evaluation of hyperventilation syndrome (HVS) and in whom somatic causes of the complaints had been excluded, we investigated the degree of concordance between three widely applied diagnostic methods: 1) the standardized Nijmegen questionnaire on major daily complaints; 2) the reproduction of the same symptoms during the hyperventilation provocation test (HVPT); and 3) the responses of end-tidal CO2 fraction (FETCO2) during the HVPT. In 86% of the patients a concordance was found between Nijmegen questionnaire (i.e. score of 24/64 or more) and symptom reproduction during HVPT (i.e. recognition of at least 2 major daily complaints). Based on these combined data we made a definite diagnosis of HVS in 37 patients, of non-HVS in 40 patients, and we retained only a possible HVS in 13 patients. Each of the 16 complaints in the questionnaire contributed significantly to the distinction between HVS and non-HVS patients, and a striking similarity in rank order of daily complaints and reproduced symptoms was found. The responses in FETCO, during HVPT had little additional diagnostic value. A spontaneous fall of at least 0.25% FETCO2 during the 5 min adaptation period before the HVPT, was most reliably correlated with the aforementioned diagnostic criteria of HVS: specificity 83%, sensitivity 57%, and accuracy 70%. Neither the 3 min FETCO2 ratio nor the 5 min FETCO2 ratio during recovery after the HVPT showed a good correlation with the other diagnostic criteria. The response of FETCO2 during HVPT did especially not provide additional useful diagnostic information in the 13 patients with only possible HVS.

Evaluation of the clinical usefulness of capnography curves during a hyperventilation provocation test in the diagnosis of hyperventilation syndrome.

We evaluated the diagnostic usefulness of capnography curves during and following a hyperventilation provocation test (HVPT) in the hyperventilation syndrome (HVS). The diagnosis of HVS was based on the Nijmegen questionnaire and on the reproduction of symptoms during HVPT. Capnography curves of 40 HVS patients, 40 non-HVS patients with psycho-somatic complaints and 26 healthy controls were analyzed. There was no difference in baseline end-tidal CO2-level (FETCO2) between the 3 groups. The spontaneous fall of FETCO2 during the adaptation phase was clearly different in HVS patients versus non-HVS patients or controls: -0.12 mmol/l (95% confidence limits -0.18 to -0.06) versus +0.01 mmol/l (95% confidence limits -0.04 to +0.16) (p = 0.002). The 3 minutes FETCO2 recovery ratio and the 5 minutes ratio were not significantly different between the groups. In conclusion, in this study the spontaneous fall of FETCO2 during the adaptation phase of the HVPT was the only valuable part of the capnography test to discriminate between HVS and non-HVS patients.

Spontaneous fall in blood pressure and reactivity of sympathetic nervous system in hospitalized patients with essential hypertension.

We evaluated whether reduction in sympathetic reactivity plays a major role in the spontaneous falls in blood pressure (BP) experienced during hospitalization by patients with essential hypertension. In the present case BP fell on the 2nd day of hospitalization. The responses of plasma catecholamines (CA) and BP to both handgrip and tilting were not altered during either the first 24 hours or the entire 7 days of hospitalization. The effect of phentolamine on BP was similar on the 1st, 2nd and 7th days. However, the resting levels of plasma norepinephrine before handgrip, tilting and phentolamine were significantly diminished on the 7th day, but not on the 2nd day. In conclusion, the diminution of sympathetic activity may be partly responsible for the hospitalization-induced fall in BP in the late stages.

Lymphocyte transformation by grass pollen allergens: a study of atopic patients receiving immunotherapy. Part II. Patients during maintenance treatment.

We have previously reported on peripheral blood lymphocyte (PBL) transformation by allergen, PPD as a control antigen and PHA as a mitogen during and after a preseasonal immunotherapy period. The present report describes similar parameters during and after the ensuing maintenance treatment period. Ten patients with grass pollen rhinitis were treated with Allpyral extract and 10 with Conjuvac two-grass mixture. Lymphocyte transformation responses to grass antigen continued to be low for PBL from patients during the maintenance treatment. Postseasonal values were higher during treatment. In late autumn 1980, when treatment had been stopped, there was a spontaneous fall in lymphocyte stimulation values. Occasional high values were noticed in some patients, two of whom had treatment side effects (urticaria). Clinical data during the whole treatment period (skin prick test, provocation tests, serological parameters, total IgE, grass-specific IgE, grass-specific IgG, pollen counts, symptom scores, clinical effect and adverse reactions) have been published separately.

Effects of food-deprivation on migratory restlessness and diurnal activity in the garden warbler Sylvia borin.

The present study describes the effects of food-deprivation on migratory restlessness and diurnal activity in the garden warbler, a long-distance migrating passerine. Fourteen first-year birds were held from August through March in individual registration cages and exposed to daylength changes experienced by birds that winter at the equator. With the beginning of the fall migratory season the birds increased their body weights due to fat deposition and showed nocturnal migratory restlessness characteristic for this species. After the birds had deposited more than about 4 g of fat they were food-deprived until their body mass had declined to a value about 1 g above fat free mass. Subsequently they were re-fed. This procedure was repeated through fall and winter, beyond the termination of spontaneous fall migratory restlessness. - Food deprivation consistently caused an increase in duration and intensity of nocturnal activity. After the end of spontaneous migratory restlessness and before the onset of winter molt it led to a reinduction of nocturnal activity. When nocturnal activity increased, the duration of diurnal activity decreased, whereas its intensity increased. With regard to the performance of free-living migrants these results suggest (1) that nocturnal migratory activity is enhanced in birds travelling across areas with unprofitable resting places; (2) that nocturnal migratory activity may be reactivated in birds that have settled for the winter in an area with deteriorating food supply; and (3) that the pattern of diurnal activity may change conspicuously when nocturnal migratory activity is enhanced or resumed.

Spontaneous fall in panel reactive antibody (PRA) is associated with a decreased risk of sensitization by donor-specific transfusion : Calvin D. Lou, Beth W. Colombe, William Amend, Juliet Melzer, Oscar Salvatierra, Jr., and Marvin R. Garovoy; Immunogenetics and Transplantation Laboratory and Transplant Service, University of California, San Francisco, CA

Spontaneous fall in panel reactive antibody (PRA) is associated with a decreased risk of sensitization by donor-specific transfusion : Calvin D. Lou, Beth W. Colombe, William Amend, Juliet Melzer, Oscar Salvatierra, Jr., and Marvin R. Garovoy; Immunogenetics and Transplantation Laboratory and Transplant Service, University of California, San Francisco, CA