Survey of Geriatricians on the Effect of Fecal Incontinence on Nursing Home Referral

OBJECTIVES: Determine the effect of fecal incontinence (FI) on healthcare providers' decisions to refer patients for nursing home (NH) placement. DESIGN: Survey. SETTING: Questionnaires were e‐mailed to participants' homes or offices. Participants could also volunteer at the 2008 American Geriatric Society annual meeting in Washington, DC. PARTICIPANTS: Two thousand randomly selected physician members and all 181 nurse practitioner members of the American Geriatrics Society were surveyed. MEASUREMENTS: The survey presented a clinical scenario of a 70‐year‐old woman ready for discharge from a hospital and asked about the likelihood of making a NH referral if the patient had no incontinence, urinary incontinence (UI) alone, or FI. Subsequent questions modified the clinical situation to include other conditions that might affect the decision to refer. A second survey of respondents to Survey 1 addressed possible moderators of the decision to refer (e.g., family caregiver presence, diarrhea or constipation, other physical or psychiatric limitations). Significance of differences in the relative risk (RR) for NH referral was tested using the chi‐square test. RESULTS: Seven hundred sixteen members (24.7% response rate) completed the first survey, and 686 of the 716 (96%) completed the second. FI increased the likelihood of NH referral (RR=4.71, P<.001) more than UI did (RR=1.90, P<.001). Mobility restrictions, cognitive decline, and multiple chronic illnesses increased the likelihood of NH referral more than FI alone (P<.001 for each), but in all scenarios, adding FI further increased the likelihood of referral (P<.001). Having family caregivers willing to help with toileting attenuated the likelihood of referral. CONCLUSION: FI increases the probability that geriatricians will refer to a NH. More‐aggressive outpatient treatment of FI might delay or prevent NH referral, improve quality of life, and reduce healthcare costs.     

Multiple primary malignancies in patients with Merkel cell carcinoma1

Background Merkel cell carcinoma (MCC) is a rare malignant cutaneous tumour, the incidence of which is increasing. Second malignancies have been reported to occur with high incidence in these patients. Objectives We report the rate and nature of multiple malignancies in patients with MCC treated over a 10 year period in Addenbrooke’s Hospital in Cambridge, United Kingdom, as well as the temporal relationship of these additional malignancies to the diagnosis of MCC. Results The 27 patients had an approximately equal sex incidence with a median age at diagnosis of 79 years. Seventy percent (n=19) of patients had a second primary malignant tumour; and 7 of these patients had two or more tumours in addition to the MCC. Eighteen patients had additional cutaneous malignancies: melanoma, squamous cell carcinoma and basal cell carcinoma, and 8 patients presented non‐cutaneous malignancy including colorectal, haematological and breast tumours. Of the 28 additional tumours in our patients, half were diagnosed prior to presentation of MCC, 32% within 6 months of diagnosis, and 18% between 6 months and 3 years after diagnosis. Possible reasons for the high rate of additional tumours in this population are discussed. Conclusions Our figures reflect a higher incidence of multiple malignancies in those with Merkel cell tumour than has previously been reported. This has important implications for the care and surveillance of these patients.     

Determination of genetic damage and urinary metabolites in fuel filling station attendants

Fuel (diesel and petrol) constitutes a complex mixture of volatile flammable liquid hydrocarbons among them benzene (BZ), toluene (TOL), and xylene (XYL) are considered to be the most hazardous, predominantly BZ because of its carcinogenic potency. Exposure to these compounds may have an impact on the health of the exposed subjects. Hence, genotoxicity and quantitative analysis of these compounds was performed in blood and urine samples of 200 workers exposed to fuel in filling stations and compared to controls. The level of genetic damage was determined by micronucleus test (MNT) in buccal epithelial cells (BEC) and chromosomal aberrations (CA) assay in peripheral blood lymphocytes (PBL) of fuel filling station attendants (FFSA) and compared to a matched control group. Urine analysis for BZ and its metabolites, phenol (Ph), trans, trans‐Muconic Acid (t, t‐MA), and S‐Phenyl Mercapturic Acid (S‐PMA) was done in all the study subjects. The results of our study revealed that exposure to BTX in petrol vapors induced a statistically significant increase in the frequency of micronuclei (MN) and CA in the exposed subjects than in controls (P < 0.05). There was a significant rise in the levels of urinary BZ, Ph, t, t‐MA, and S‐PMA in the exposed subjects. Our study highlights the significance of MNT, CA, and urinary metabolites as potential biological exposure indices of genetic damage in FFSA. This study suggests the need for regular monitoring of FFSA for possible exposure to BTX as a precautionary and preventive step to minimize exposure and reduce the associated health risks. Environ. Mol. Mutagen., 2011. © 2010 Wiley‐Liss, Inc.     

Venlafaxine treatment stimulates expression of brain-derived neurotrophic factor protein in frontal cortex and inhibits long-term potentiation in hippocampus

Antidepressant action may involve stimulation of brain-derived neurotrophic factor (BDNF). BDNF also regulates long-term potentiation (LTP). We hypothesized that the 5-HT and norepinephrine reuptake inhibitor, venlafaxine, would stimulate BDNF expression and alter LTP more effectively than the selective 5-HT reuptake inhibitor, citalopram. To test this, we administered venlafaxine or citalopram to rats for 1 or 3 weeks; control rats received vehicle only. We measured BDNF protein in hippocampal and frontal cortex homogenates, and serum. We assessed LTP in area cornu ammonis region 1 (CA1) of in vitro hippocampal brain slices. We also examined input/output function to determine if basal synaptic transmission in area CA1 was altered. Compared to vehicle control, frontal cortex BDNF protein was significantly greater after three, but not one, weeks of venlafaxine treatment. In contrast, citalopram (1 or 3 weeks) did not stimulate BDNF. The stimulatory effect of venlafaxine treatment on BDNF was superimposed on a general time-dependent decrease in expression which was seen in both vehicle control and citalopram-treated animals. LTP was significantly impaired in slices from venlafaxine-treated rats after both 1 and 3 weeks of treatment, but LTP appeared normal in slices from citalopram-treated and vehicle control rats. The LTP impairment caused by venlafaxine treatment was independent of changes in BDNF: LTP was impaired after only 1 week of treatment, prior to any effect on BDNF, and LTP magnitude was not correlated with BDNF protein concentration. Input/output function was significantly but equally reduced after 3 weeks of citalopram, venlafaxine, or control treatment. Decreased BDNF protein in citalopram and vehicle control animals, and decreased input/output function may be consequences of individual housing of animals, which we used to ensure proper dosing. Venlafaxine stimulation of BDNF and inhibition of LTP may be related to the reported effectiveness of venlafaxine in treatment of depression.     

Cardiovascular surgery in the elderly

The elderly segment of the population is increasing rapidly, and surgeons are more frequently being requested to operate on this group of patients. A number of reports suggest that elderly patients have a significantly higher incidence of operative mortality and 30-day hospital mortality as compared with younger patients. Elderly patients also had a significantly higher increased incidence of complications, such as renal failure, prolonged ventilation, and incidence of strokes and postoperative cardiac arrest. Regarding coronary artery disease, elderly patients are more acutely sick on admission, are more likely to have triple-vessel disease, more likely have comorbid disease, and are usually less likely to receive an internal mammary artery graft. The presence of valvular disorders with concomitant coronary disease (especially mitral ischemic related valve disease) increases operative time, morbidity, and mortality. Efforts must continue to be made to gather data on outcomes of cardiac surgery in the elderly. Consideration must be given to modify the operative approach that minimizes cardiopulmonary bypass time, mitigates the multisystem organ injury associated with cardiopulmonary bypass, and decreases the likelihood of embolization from the ascending aorta. Future efforts must be made to develop measures to decrease the complications rate identified in elderly patients.     

Association between fragile X premutation and premature ovarian failure: a case–control study and meta-analysis

Aim

The aim of the present study was to investigate the association between FMR1 premutation and premature ovarian failure (POF) patients in Indian population, and a meta-analysis of published results was undertaken to clarify whether FMR1 premutation consistently contributed to the susceptibility.

Methods

A total of 289 POF samples and 360 control samples were included in the study. Repeat variation was checked using GeneScan technique. Results were analyzed with GeneMapper software. Meta-analysis was performed using the Open Meta-Analyst and STATA 12.0 software. The crude odds ratio with 95 % confidence interval (CI) was computed to assess the strength of the associations.

Results

The assayed case and control population showed 29 different CGG repeat sizes (alleles), ranging from 7 to 40. Within this population, we found that the CGG repeat length polymorphisms were within the normal range of 6–55 in both patients as well as control samples. Eleven case–control studies were included in the meta-analysis with a total of 1,313 POF cases and 3,132 control subjects. Our meta-analysis revealed that there was a significant difference in the incidence of FMR1 premutation between POF cases and control subjects with p value <0.001 (OR 5.41; 95 % CI 2.53, 11.61).

Conclusions

We found no significant association between FMR1 CGG repeat premutation and POF in Indian population. However, the meta-analysis showed an increased risk of POF associated with a premutation, especially among populations from European descent. Further functional research should be performed to explain the inconsistent results in different ethnicities and POF susceptibility.