Anticholinergic Exposure in a Cohort of Adults Aged 80 years and Over

Anticholinergics are frequently prescribed for older adults and can lead to adverse drug events. The novel MARANTE (Muscarinic Acetylcholinergic Receptor ANTagonist Exposure) scale measures the anticholinergic exposure by incorporating potency and dosages of each medication into its calculations. The aims were to assess prevalence and intensity of the anticholinergic exposure in a longitudinal cohort study of community‐dwelling patients aged 80 years and over (n = 503) and to study the impact on mortality and hospitalization. Chronic medication use at baseline (November 2008–September 2009) was entered and codified with the Anatomical Therapeutic Chemical classification. Time‐to‐event analysis until first hospitalization or death was performed at 18 months after inclusion, using Kaplan–Meier curves. Cox regression was performed to control for covariates. Mean age was 84 years (range 80–102), and mean number of medications was 5 (range 0–16). Prevalence of anticholinergic use was 31.8%, with 9% taking ≥2 anticholinergics (range 0–4). Main indications for anticholinergics were depression, pain and gastric dysfunction. Female gender, the level of multi‐morbidity and the number of medications were associated with anticholinergic use. Mortality and hospitalization rate were 8.9% and 31.0%, respectively. After adjustment for the level of multi‐morbidity and medication intake, multi‐variable analysis showed increased risks of mortality (HR 2.3, 95% CI: 1.07–4.78) and hospitalization (HR 1.7; 95% CI: 1.13–2.59) in those with high anticholinergic exposure. The longitudinal study among Belgian community‐dwelling oldest old demonstrated great anticholinergic exposure, which was associated with increased risk of mortality and hospitalization after 18 months.     

Kinetics of palmitic acid transport in insulin-dependent diabetic pregnancies: In vitro study

BACKGROUND: The paucity of data relating to transport kinetics of free fatty acids (FFA) in pregnant diabetic women prompted the undertaking of the present study. METHODS: Transport kinetics of a model FFA, palmitic acid, have been investigated in Type I diabetic pregnancies, using in vitro perfusion of isolated placental lobules. National Cancer Tissue Culture medium diluted with Earle's buffered salt solution was used as the perfusate and control placental lobules were perfused for comparison. RESULTS: In five Type I diabetic women, the palmitic acid transport fraction (TF) averaged 5.6 +/- 0.42% of injected maternal bolus dose, representing 11.8 +/- 2.1% that of tritiated water used as reference. In control perfusions (n = 5), the palmitic acid TF represented 10.2 +/- 1.3% of tritiated water TF. Differential transport rates of palmitic acid for 10, 25, 50, 75 and 90% of efflux in fetal veins differed significantly from the corresponding values for tritiated water in both study and control series. However, palmitic acid transport rates for the various efflux fractions in the two series were not significantly different. For kinetic parameters, such as area under the curve, clearance, elimination constant, time for maximum response, absorption rate and elimination rate, the values for palmitic acid in the diabetic and control series also did not differ significantly. CONCLUSION: Transport kinetics of palmitic acid in Type I human diabetic pregnancies in in vitro conditions do not differ significantly from those observed in normal pregnancies.     

Measurement of Serum N-Acetyl ß Glucosaminidase Activity in Patients with Breast Cancer

N-acetyl-β-glucosaminidase (NAG) activity measured in sera from 129 breast cancer patients was elevated (mean 18.2 units/l) compared with that in sera from 28 healthy women (11.6 units/l) (p=0.001). There was a weak correlation between NAG activity and carcinoembryonic antigen (CEA) and CA-153, but no relationship to age, menopausal status, node status, stage, histology of tumour or to steroid receptors. NAG, CEA and CA-153 were measured in periodic follow-up samples taken after surgery (up to 26 months) from 17 patients. NAG activity fluctuated within a narrow range, unlike CEA and CA-153. In 70% of cases the pattern was similar to at least one of the other markers, and was generally maintained at a higher level in patients who suffered relapse compared with those who remained disease-free up to the last follow-up, but was not significantly altered before relapse. The measurement of NAG activity is unlikely to be of value in predicting time or occurrence of relapse or of clinical utility in post-surgical therapy. Increased appearance in serum may aid metastasis by degrading the extracellular matrix and it may be better investigated as a predictor of progression from in situ to invasive and metastatic cancer.     

Prevalence, characteristics, and impacts of work-related musculoskeletal disorders: a survey among physical therapists in the State of Kuwait

Background  

Physical therapists working in the State of Kuwait are at risk of work-related musculoskeletal disorders (WMSDs). However, prevalence rates and risk factors are not well documented. The objective of this study was to determine the prevalence, characteristics, and impacts of WMSDs among physical therapists in the State of Kuwait.     

Systematic appraisal of dementia guidelines for the management of behavioural and psychological symptoms

Background

Within the treatment of dementia, management of behavioural and psychological symptoms (BPSD) is a complex component.

Purpose

We wanted to offer a pragmatic synthesis of existing specific practice recommendations for managing BPSD, based on agreement among systematically appraised dementia guidelines.

Data sources

We conducted a systematic search in MEDLINE and guideline organisation databases, supplemented by a hand search of web sites.

Study selection

Fifteen retrieved guidelines were eligible for quality appraisal by the Appraisal of Guidelines Research and Evaluation instrument (AGREE), performed by 2 independent reviewers.

Data extraction

From the 5 included guidelines, 18 specific practice recommendations for BPSD were extracted and compared for their level of evidence and strength.

Data synthesis

No agreement was found among dementia guidelines for the majority of specific practice recommendations with regard to non-pharmacological interventions, although these were recommended as first-line treatment. Pharmacological specific practice recommendations were proposed as second-line treatment, with agreement for the use of a selection of antipsychotics based on strong supporting evidence, but with guidance for timely discontinuation.

Limitations

The appraisal of the level of agreement between guidelines for each specific practice recommendation was complicated by variation in grading systems, and was performed with criteria developed a posteriori.

Conclusion

Despite the limited number of recommendations for which agreement was found, guidelines did agree on careful antipsychotic use for BPSD. Adverse events might outweigh the supporting evidence of efficacy, weakening the recommendation. More pivotal trials on the effectiveness of non-pharmacological interventions, as well as guidelines specifically focusing on BPSD, are needed.     

Anaemia is an independent predictor of poor outcome in patients with chronic heart failure

Background: Mild anaemia frequently occurs in patients with chronic heart failure (CHF), particularly in the advanced stages of the disease. The correction of anaemia with erythropoietin is a therapeutic possibility. The aim of this study was to assess prospectively the relationship between the prevalence of anaemia (haemoglobin level≤120 g/l) and prognosis in an unselected CHF population. Methods: All consecutive patients with a diagnosis of CHF admitted to our department between January 2000 and April 2000 were considered for the present study. Those with secondary causes of anaemia were excluded. Patients were followed up until November 2001 (>18 months in all survivors), and the end-point of the study was all-cause mortality. Results: A total of 176 patients were enrolled (mean age: 63 years, New York Heart Association (NYHA) classification I/II/III/IV: 15/81/51/29; left ventricular ejection fraction (LVEF): 42%, ischaemic aetiology in 62%). In the whole population the mean haemoglobin level was 140±15 g/l. Anaemia was found in 18 (10%) patients, and was significantly more common in women than in men (18 vs. 7%, respectively, P=0.02) and in those with most severe CHF symptoms (frequency in NYHA I/II/III/IV: 0/9/10/21%, respectively; NYHA IV vs. I–III, P=0.03), but not related to the other clinical indices. Univariate analysis revealed NYHA class III–IV (hazard ratio 3.8, 95% CI: 1.6–8.9, P=0.003), low LVEF <35% (hazard ratio 2.3, 95% CI: 1.0–4.9, P=0.04) and anaemia (hazard ratio 2.9, 95% CI: 1.2–7.2, P=0.02) as predictors of 18-month mortality. In multivariate analysis, anaemia remained an independent predictor of death when adjusted for NYHA class and LVEF (hazard ratio: 2.6, 95% CI: 1.0–6.5, P=0.04). In anaemic patients, 18-month survival was 67% (95% CI: 45–89%) compared to 87% (81–92%) in patients with a normal haemoglobin level (P=0.016). Conclusions: Mild anaemia is a significant and independent predictor of poor outcome in unselected patients with CHF. Correction of low haemoglobin level may become an interesting therapeutic option for CHF patients.     

Coarse-grained stochastic processes for microscopic lattice systems

Diverse scientific disciplines ranging from materials science to catalysis to biomolecular dynamics to climate modeling involve nonlinear interactions across a large range of physically significant length scales. Here a class of coarse-grained stochastic processes and corresponding Monte Carlo simulation methods, describing computationally feasible mesoscopic length scales, are derived directly from microscopic lattice systems. It is demonstrated below that the coarse-grained stochastic models can capture large-scale structures while retaining significant microscopic information. The requirement of detailed balance is used as a systematic design principle to guarantee correct noise fluctuations for the coarse-grained model. The coarse-grained stochastic algorithms provide large computational savings without increasing programming complexity or computer time per executive event compared to microscopic Monte Carlo simulations.     

A consistent course of events or a series of coincidences: nursing in Poland from the 19th to the 21st century

The development of nursing began in Poland much later than it did elsewhere, for instance in the United Kingdom, the United States, or Germany, and it came up against difficult conditions. After a brief twenty‐year period of development between 1918 and 1939, it almost stalled during the war (1939–45), only to be followed by nearly twenty years of chaos. Nursing started to come out of this difficult period at the beginning of the 1960s. The turn of the 21st century saw the emergence of extensive professional development and training opportunities for nurses. This change was brought about as much by political, social and economic issues, health care requirements, and the advancement of science, medicine, the birth of humanitarism, the growth of the feminist movement, the European Agreement on the Instruction and Education of Nurses, the WHO European Strategy for Nursing and Midwifery Education, the Bologna declaration, as well as the activities undertaken by the European Union, the International Council of Nurses, the American and Polish Red Cross, the Rockefeller Foundation, the Polish Association of Nurses, and the professional self‐governing body. The transformation of nursing into an independent profession was further boosted by physicians deeply involved in the issue and female pioneers of nursing.