Inflammation in peritoneal dialysis: a Latin-American perspective.

Peritoneal dialysis (PD) patients present an extremely high mortality rate, but the mechanisms mediating the increased risk of mortality observed in this group of patients are still largely unknown, which limits the perspective of effective therapeutic strategies. The leading hypothesis that tries to explain this high mortality risk is that PD patients are exposed to a number of traditional risk factors for cardiovascular disease (CVD) already at the onset of their chronic kidney disease (CKD), since many of these risk factors are common to both CVD and CKD. Of particular importance, chronic inflammation recently emerged as an important novel risk factor related to multiple complications of CKD. There are many stimuli of the inflammatory response in CKD patients, such as fluid overload, decreased cytokine clearance, presence of uremia-modified proteins, presence of chronic infections, metabolic disturbances (including hyperglycemia), obesity. Many of these factors are related to PD. Latin America has made some progress in economic issues; however, a large portion of the population is still living in poverty, in poor sanitary conditions, and with many health-related issues, such as an increasing elderly population, low birth weights, and increasingly high energy intake in the adult population, which, in combination with changes in lifestyle, has provoked an increase in the prevalence of obesity, diabetes, and CVD. Therefore, in Latin America, there seems to be a peculiar situation combining high prevalence of low education level, poor sanitary conditions, and poverty with increases in obesity, diabetes, and sedentary lifestyle. Since inflammation and mortality risk are intimately related to both sides of those health issues, in this review we aim to analyze the peculiarities of inflammation and mortality risk in the Latin-American PD population.     

Aging and cancer

A substantial increase in the number of elderly people in the populations of developed nations in the coming years has been projected. Persons 65 years and older are at significantly higher risk of developing cancer when compared to younger individuals. There is a resulting increase in cancer incidence as well as mortality in this advanced age group. It is important to know how changes in physiological reserve and functional status in elderly patients, polypharmacy issues, comorbidities, and other age-related problems can affect cancer prognosis and management. Elderly patients are not adequately represented in clinical trials, thus creating a relative lack of information related to specific issues about elderly cancer patients and their care. Nevertheless, there is a substantial amount of guidance available, and in this review we will address selected issues of importance when considering the approach to the older cancer patient.     

Characteristics of mild hypertension in elderly patients

Prevalence of mild hypertension is approximately 40% in 70 years or older. Stratification of risk for evaluation of the prognosis indicates that the risk for cerebrovascular and cardiovascular diseases increases with accumulation of risk factors even in moderate hypertensive patients. Elderly patients already have one of risk factor, that is, age. Therefore, complication of more than one of risk factors such as smoking, diabetes mellitus, dyslipidemia, obesity, microalbuminuria, and family history of premature cardiovascular diseases indicates that cardiovascular risk is moderate or high risk even though their category of blood pressure is mild level. Although number of current smoker and obesity decreases in elderly subjects, prevalence of these risks is still 30%. Prevalence of obesity and diabetes mellitus is similar between mild hypertension and moderate hypertension. HYVET (hypertension in the very elderly) indicates that moderate and severe hypertension should be aggressively treated even those patients are 80 years or older, but evidence of antihypertensive treatment has not been clarified.     

Pharmacotherapy considerations in elderly adults

ABSTRACT: Life expectancy for Americans has increased dramatically since 1900, as have the available pharmacotherapeutic options. Unfortunately, pharmacotherapy mishaps occur commonly in the older adult population. This problem greatly affects the morbidity and mortality of elderly patients and greatly increases healthcare costs. To improve patient care among elderly adults, healthcare practitioners must consider several issues when developing a pharmacotherapy plan. A thorough understanding of pharmacokinetics, pharmacodynamics, adverse drug reactions, drug interactions, and several other factors is necessary for practitioners to develop a safe and effective drug therapy plan for older adults. This review provides a general but comprehensive review of the issues pertaining to pharmacotherapy in elderly people and offers several suggestions for improving their pharmaceutical care.     

Parenting styles and treatment of adolescents with obesity

Professional caregivers have an important task in building a trusting relationship with parents and adolescents and in supporting parents in their parental roles. Our clinical experience of some 300 adolescents with obesity between 9 and 18 years of age and their parents has convinced us that consideration of parenting styles is fundamental in the treatment of children and adolescents with obesity. Typical case situations supporting the significance of parenting styles and illustrating the relationships between parents and adolescents with obesity can be identified. Group sessions with parents are the preferred mode for discussing typical parenting issues in the management of obese adolescents. The purpose of this paper is to describe different parenting styles, and to present a set of typical case situations and treatment strategies for nurses working with adolescents with obesity.     

Childhood overweight: parental perceptions and readiness for change.

Although the national health crisis of childhood obesity is a well-documented problem, few if any clinical interventions have had success in curbing its growth. In fact, childhood obesity, along with its associated morbidities, continues to climb even in the face of increased awareness. Research shows that factors contributing to obesity are almost entirely modifiable on some level. Furthermore, specific behavior changes have been shown to result in positive outcomes, yet these changes have not been widely implemented by practitioners, families, or individuals. The transtheoretical model of health behavior change offers insight into assessing individuals and targeting interventions for behavior change. This article focuses on guiding school nurses to assess parents of school-age children at risk for obesity for readiness for health behavior change, then choosing parent-focused interventions based on their stage of readiness for change.     

1例老年妇女健康评估的报告

为发现当代老年人存在的健康问题和他们的健康需要 ,对一位澳洲老年妇女实施了全方位的评估 ,包括系统的护理问诊和一次彻底的体格检查。结果表明通过全方位的评估 ,可以做出正确的护理诊断和护理计划。通过此次评估发现老年人存在许多不正常的生理和心理上的改变 ,对此需要特殊的心理和身体护理 ,包括特殊的皮肤护理、日常生活护理和疾病护理。     

In vivo age-related changes in hepatic drug-oxidizing capacity in humans

Very few studies have been carried out looking at how the effects of drugs and their toxicity in humans change during their lifespan (developing and ageing). The purpose of this study is to review the literature on the changes in probe-drug metabolism, classified by cytochrome P450 (P450 or CYP) at five stages in life: neonates < 4 weeks, infants < 12 months, children < 19 years, young/mature adults 20–64 years, and elderly adults >65 years. The main probe drugs include caffeine and theophylline, whose metabolism is catalysed by CYP1A2, tolbutamide, phenytoin and ibuprofen, catalysed by CYP2C9, amitriptyline and nortriptyline, catalysed by CYP2C19, acetaminophen, catalysed by CYP2E1 and lidocaine, midazolam and terfenadine, catalysed by 3A3/4. From the published in vivo studies two different patterns of drug metabolism can be identified: (i) activity is low immediately after birth, increases, then peaks at the young/mature adult level and, finally, decreases in old age (drugs catalysed by CYPlA2, CYP2C9, CYP2C19, CYP2D6 and CYP3A3/4) and (ii) activity increases rapidly after birth to reach a level equivalent to that in the young/mature adult, then gradually decreases and finally decreasing faster in old age (drugs catalysed by CYP2E1). Further study of the changes in P450 with age is warranted to help prevent adverse reactions and to guide us in tailoring therapy better for the individual patient.     

Pain in the elderly: Psychosocial issues

Individuals age at varying rates and along physical, cognitive, psychosocial, and sociocultural trajectories.Thus, the elderly comprise the most heterogeneous segment of the population. An understanding of the aging process therefore is crucial as the framework for understanding pain in the elderly.Although pain is not a natural consequence of aging, many elderly persons have health conditions that cause pain. Some elderly persons have cognitive conditions that impair their ability to communicate pain.The psychosocial circumstances of the elderly, particularly dependency issues, have implications for treatment design and goal setting. Sociocultural factors can contribute to misunderstandings between elderly persons and the typically younger clinicians who treat their pain. Beyond treatment efforts, the processes of aging have implications for our study and understanding of pain. Relevant issues include ageism, the definition of pain, association between pain and suicide in the elderly, and distinction between age differences (intercohort variability) and age effects (intra-individual change across the life span).     

Sepsis-induced intestinal microvascular and inflammatory responses in obese mice

Although clinical obesity is associated with increases in the morbidity and mortality of sepsis, little is known about the mechanisms that underlie the influence of obesity on sepsis. The objective of this study was to determine (a) whether obesity is associated with exaggerated inflammatory and thrombogenic responses in the intestinal microvasculature of septic mice and (b) whether these microvascular alterations are related to changes in the serum levels of cytokines that are produced by adipose tissue. Intravital microscopy was used to quantify leukocyte and platelet adhesion in intestinal postcapillary venules of lean wild-type (WT) mice, and two murine models of obesity, that is, ob/ob and db/db mice. Sepsis was induced by cecal ligation and perforation (CLP). Serum cytokine levels were measured using a cytometric bead assay, whereas adipokines were quantified using enzyme-linked immunosorbent assay. Cecal ligation and perforation elicited significant increases in the adhesion of leukocytes and platelets in venules of lean WT mice. These CLP-induced adhesive interactions were much more pronounced in the microvasculature of both ob/ob and db/db mice. Cecal ligation and perforation was associated with significant increases in serum cytokines in both WT and ob/ob mice, but such changes were not detected in db/db mice. However, db/db (but not WT or ob/ob) mice did exhibit significant increases in serum leptin and adiponectin levels after CLP. Sepsis promotes more intense inflammatory and thrombogenic responses in the gut microcirculation of obese mice than in their lean counterparts. The obesity-enhanced microvascular dysfunction in septic mice shows no consistent correlation with serum cytokines or adipokines.     

Obesity significantly increases the difficulty of patient management in the emergency department

Objective: To determine which aspects of ED management are adversely affected by patient obesity, to determine the level of obesity above which management is made more difficult and to make recommendations on how these effects might be mitigated. Methods: This was a cross‐sectional survey of patients and the staff caring for them in a single ED. Doctors, nurses and radiographers managing consecutive patients, during a range of enrolment periods, completed a self‐administered questionnaire. Each was asked to record how the level of their patient's obesity increased the difficulty of specific management items, using a Likert scale. Staff also provided recommendations to mitigate the effects of obesity for each patient, if applicable. For each management item, body mass index (BMI) and management difficulty were correlated (Spearman's rank correlation). Results: Seven hundred and fifty patients and their ED carers were enrolled. Patient BMI was positively correlated with all aspects of ED clinical management examined (correlation coefficient range 0.28–0.57, P < 0.001). BMI most strongly correlated with difficulty in finding anatomical landmarks, venous pressure measurement, physical examination, patient positioning and procedures generally, especially cannulation and venipuncture (coefficient > 0.5, P < 0.001). Doctors reported more difficulties than nurses and radiographers. Generally, management difficulty did not increase until the BMI was in the obese or morbidly obese range. Most staff recommendations related to issues of patient mobility including equipment, staffing and bariatric devices. Conclusion: Patient obesity significantly increases the difficulty of ED patient management. Staff recommendations to mitigate these effects were few but may inform changes in ED practice.     

Amputees and Tightropes: A Pilot Study to Measure Postural Control Post-Amputation

Abstract

It is widely accepted that postural instability increases with age, making falls and subsequent injury likely. Amputees have been identified as having a higher risk of falling than comparable non-amputees. A few laboratory studies have examined postural changes post-amputation, but no clinical study has been identified. This pilot study tested whether clinical balance tools used with elderly populations could be used to measure postural changes in recent transtibial amputees. Seven subjects were tested during their initial rehabilitation, using the Berg balance scale, the 'timed up and go' (TUG) test and Tinetti's Falls Efficacy Scale (FES). Any falls or near misses were also recorded. The TUG test and FES showed changes over time. The Berg scale showed a possible floor and ceiling effect. Patients did experience falls during the study time. Larger studies are needed to determine whether these are appropriate clinical tools for use with amputees.     

Functional assessment: a holistic approach to rehabilitation of the geriatric client

Functional assessment of the elderly client provides a structured approach to the complex and multidimensional issues in rehabilitation. Rehabilitation nurses may be familiar with some of the long-standing functional assessment tools, such as Barthel's index. It is important to have a working knowledge of a variety of tools, as well as an ongoing awareness of newer ones as they are developed (e.g., the Functional Independence Measure). Functional assessment is part of comprehensive geriatric evaluation. After initial assessment by rehabilitation team members, the team considers the patient's strengths and supports and develops a problem list (NIH, 1987). The individualized plan of care is developed with the elderly client to achieve maximum rehabilitation potential. Functional assessment tools assist in measuring rehabilitation progress and in clinical decision making. They also can be used in clinical research in geriatric rehabilitation. The number of elderly persons in this country is growing rapidly. Rehabilitation nurses will need to expand their clinical skills to integrate holistic geriatric assessment.     

老年恶性血液肿瘤合并其他脏器肿瘤的临床护理问题及对策

目的 分析老年恶性血液肿瘤合并其他脏器肿瘤患者的护理问题,探讨护理对策.方法 回顾总结在对19例老年恶性血液肿瘤合并其他脏器肿瘤患者的护理中遇到的临床问题及处理经验.结果 19例患者均出现不同程度的精神症状（全部存在睡眠障碍,2例明确诊断抑郁症）,11例出现感染,5例出现营养不良,9例出现皮肤问题（不同程度淤点、淤斑）,10例出现癌性疼痛,8例出现大便形态及次数的改变（腹泻、便秘）,19例留置管道（1例留置胸腔引流管、1例留置腹腔引流管、1例同时留置胸腹腔引流管、3例留置大静脉管、16例留置PICC管、1例留置直肠造瘘口）.此组患者在得到有针对性的护理措施后,生活质量得到改善,生命得到了延长.结论 通过分析总结老年恶性血液肿瘤合并多脏器肿瘤患者的临床护理问题,提供优质的身心整体相结合的护理干预措施,使患者积极配合治疗,取得良好的效果,提高了其生存质量.     

Obesity in Infancy: Questions, More Questions, and Few Answers

Current literature presents conflicting views about the existence of infant obesity and its role as a risk factor for later life obesity and comorbidity. This article reviews extant literature and addresses the issues raised about obesity and overweight status in the first 2 years of life. The epidemic increase in childhood obesity stimulates questions about the effects of body weight changes during infancy upon future health status. The influence of maternal obesity and family inheritance patterns is a significant risk for childhood obesity, yet the picture is unclear for birthweight, infant weight gain, and growth parameters in the earliest years of life. Prevention, management, and treatment are indicated when families present with obesity patterns among their members.     

Issues in adolescent health: a challenge for nursing

The young people of today are the greatest investment we as adults have in our future. The care and nurturing we afford the adolescent is just as important as that which we afford to children or the elderly. Although most adolescents have a preoccupation with their bodies, they do not always engage in activities that will protect and develop them. Adolescents are often exposed to peer pressure, the effects of which may impact negatively on their behaviour and their health. Many adolescent health and behavioural issues evolve from developmental changes and can manifest in a confrontational attitude toward society, parents and others. They are hormonally 'fully charged', and their adolescent sexuality can have enormous effects on their future physical, psychosocial, moral and sexual development. Nurses have a pivotal role to play in ensuring children and adolescents learn the facts relating to the consequences of engaging in unhealthy behaviour and lifestyle. Nurses must also encourage parents to model and reinforce good health practices, such as serving balanced and nutritious meals at regular times and planning positive family activities. In this paper we review some of the salient issues in adolescent health today.     

Thiazolidinediones, insulin resistance and obesity: Finding a balance

The clinical efficacy of currently available thiazolidinediones (TZDs) in improving glycaemic control and ameliorating several risk factors for cardiovascular disease (linked to their insulin-sensitising actions as well as direct vascular effects) is well established. Treatment-associated weight gain, however, which has been identified as a class effect of the TZDs, is seen in a number of patients. The magnitude of weight gain correlates in part with improved metabolic control, i.e. better responders are more prone to increases in body weight. The cardiovascular risk associated with obesity appears to be depot specific; while peripheral obesity is associated with a low risk of cardiovascular complications, central obesity confers a greater degree of risk. Evidence is reviewed that increases in body weight associated with TZD treatment are associated with neutral effects (or even, decreases) in visceral fat, the adipose depot that is associated with central obesity.     

A review of heart failure management in the elderly population

Background: In the United States, the incidence of heart failure (HF) in the elderly population (age, ≥65 years) approached 10 per 1000 population in 2006, and HF was a common reason for hospitalization. Many clinical features and the management of HF differ in elderly patients compared with their younger counterparts due to changes in physiology and the presence of comorbidities.Objective: The aim of this review was to explore the risks and benefits of different classes of HF pharmacotherapy for chronic HF management in the elderly population.Methods: Peer-reviewed articles were identified from MEDLINE and Current Contents database (both, 1966–May 21, 2009) using the search terms HF, elderly, geriatrics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-blockers, aldosterone antagonists, diuretics, digoxin, and vasodilators. Citations from available articles were also reviewed for additional references. Randomized, double-blind, controlled studies that assessed the effects of HF pharmacotherapy on morbidity and mortality outcomes were included. The American College of Cardiology/American Heart Association (ACC/AHA) Clinical Guidelines on Management of Chronic HF and associated studies are discussed.Results: A total of 40 clinical studies were included in the present review. The ACC/AHA recommended that evidence-based therapy for HF be used in elderly patients, with individualized consideration of the elderly patient's altered ability to metabolize or tolerate standard medications. HF pharmacotherapies that have been associated with mortality benefits in elderly patients with left ventricular systolic dysfunction include ACE inhibitors or ARBs; β-blockers; aldosterone antagonists; and, in patients who cannot tolerate ACE inhibitors or ARBs or who are black, a combination of hydralazine and nitrates. For symptom control and morbidity benefit, therapies include diuretics and digoxin. For HF with preserved ejection fraction (HF-PEF), no particular pharmacotherapeutic agent has been found to have mortality benefits. Managing the underlying cause for the HF symptoms is the key approach to treatment of HF-PEF. There was a lack of clinical trials that assessed the effects of HF treatment exclusively in elderly patients. Most clinical trials of HF pharmacotherapy have not specified the number of elderly patients included, or they included 30% to 50% elderly patients. This lack of data in the elderly leads to the necessity of applying clinical judgment to individual patient cases, together with consideration of their altered ability to metabolize or tolerate standard medications. Elderly patients also have variable responses to HF pharmacotherapy and might be susceptible to adverse events, such as orthostatic hypotension, renal dysfunction, electrolyte disturbances, and interactions with medications being received for the treatment of comorbidities. Elderly patients undergoing HF therapy should be closely monitored. The HF-related mortality rate is high in elderly patients. Discussing end-of-life issues and providing palliative care in patients with advanced disease are parts of an optimal care plan.Conclusions: HF therapy that has published mortality and morbidity benefits in nonelderly patient populations has been associated with benefits in elderly patients. Elderly patients may have variable pharmacologic responses to these agents and may be susceptible to adverse events and drug-drug interactions due to concurrent treatments for comorbidities. Close monitoring of elderly patients undergoing HF treatment is essential to ensure optimal outcomes.     

African Americans and obesity: implications for clinical nurse specialist practice

PURPOSE/OBJECTIVE: The purpose of this article is to examine the connection between genes, culture, and environment in the development of obesity and its impact on the health of African Americans. This information will be utilized to facilitate the design of weight management programs for African Americans. RATIONALE: Literature review of the connection between the above variables revealed a disproportionate amount of health risks associated with excess weight in African Americans. Several nonfatal consequences of obesity were noted to impact quality of life but improved significantly with small reductions in body weight. However, factors that affect weight in a culturally relevant context were seldom addressed and few intervention programs were specifically designed to treat minorities with obesity issues. DESCRIPTION: This article describes the role that genetic, cultural, and environmental factors play in energy regulation. Factors that impact lifestyle changes, self-esteem, public awareness, participation, and community involvement are highlighted. OUTCOME: Providing healing environments that are culturally acceptable can empower individuals to commit to goals as well as influence others who are resistant to change. Public awareness tools designed by clinical nurse specialists (CNSs) that appeal to ethnic values can facilitate cooperation and enhance successful outcomes. CONCLUSION: Despite genetic susceptibility to obesity, research on the African diaspora emphasized that obesity tends to be expressed in environmental conditions that are markedly different from ancestral origin. (Kruger A, Kruger HS, MacIntyre U, et al. S Afr J Sci. 2000;96:505-513. Available at: www.nrf.ac.za/sajs/absepooj.stm. Accessed April 11, 2004.) Black adults therefore have much to gain from weight management strategies that address the complexity of the disorder and are sensitive to cultural issues. IMPLICATIONS FOR NURSING PRACTICE: CNSs with advanced knowledge of the impact of obesity on health and wellness are in a unique position to utilize research-based data in the design of weight management programs for diverse populations. In practice, cultural variables that significantly impact the complex issues of weight control should be addressed in the study and treatment of obesity in black populations. By researching what is available to the community, CNSs can evaluate programs that may require adaptation to encourage greater participation.