Functional Ability in Executive Variant Alzheimer's Disease and Typical Alzheimer's Disease

A frontal, or executive, variant of Alzheimer's disease (EAD) has been described in the literature in which frontal dysfunction accompanies temporal and parietal changes in the early stages of the illness. However, no study has empirically investigated associated aspects, such as neuropsychiatric symptoms, instrumental activities of daily living, or caregiver burden in this EAD subgroup. We compared the performance of two subgroups of mild Alzheimer's disease patients (e.g., EAD and typical Alzheimer's disease; TAD) on neuropsychological and associated measures. Results revealed that the EAD group, selected based on poor executive scores, did not significantly differ from the TAD group on nonexecutive neuropsychological tests of intelligence, language, verbal and nonverbal memory, or visual-spatial abilities. However, the EAD group evidenced more severe neuropsychiatric symptoms, impaired activities of daily living, and greater caregiver distress than the TAD group. Thus, the EAD subgroup is characterized by executive dysfunction, neuropsychiatric symptoms, and functional disability in excess of that seen in TAD. Whether our EAD subgroup represents an actual frontal variant of Alzheimer's disease awaits replication in a larger sample including neuroimaging and pathological confirmation, as well as longitudinal assessment of cognition and neuropsychiatric symptoms.     

Effects of a nationwide Hib vaccine shortage on vaccination coverage in the United States

Background

A shortage of Haemophilus influenzae type b (Hib) vaccine that occurred in the United States during December 2007 to September 2009 resulted in an interim recommendation to defer the booster dose, but to continue to vaccinate as recommended with the primary series during the first year of life.

Objectives

To quantify effects of the Hib shortage on vaccination coverage and to determine if any demographic subgroups were disproportionately affected.

Methods

Data from the 2009 National Immunization Survey (NIS) were divided based on child's age at the onset of the shortage. Comparisons were made in primary series coverage by 9 months between children <7 months versus ≥7 months at the start of the shortage. Comparisons in primary series plus booster dose completion by 19 months were made between children who were <12 months versus ≥12 months at the start of the shortage.

Results

Nationally, there was a difference in Hib primary series completion by 9 months among children age <7 months versus ≥7 months at the start of the shortage (73.9% versus 81.2%, P < 0.001). There was a large difference in the percentage of children fully vaccinated with the primary series plus booster dose by 19 months among children age <12 months versus ≥12 months at the start of the shortage (39.5% versus 66.0%, P<0.001). There were differential effects of the shortage on primary series coverage among states and for some demographic characteristics.

Conclusions

As expected booster dose coverage was reduced consistent with interim recommendations, but primary series coverage was also reduced by 7 percentage points nationally.     

The bronchial arteries and their anastomoses with the coronary arteries]

We studied bronchial arteries (BA) and their anastomoses with coronary arteries in 53 adult subjects (30 female and 23 male, mean age 82) and one 2 month old child. Each subject had 1 to 4 BAs, born from an area on the anterior side of the descending aorta measuring less than 2 cm in diameter in 62 percent of the cases and never exceeding 4 cm in the other cases. In 6 cases BAs vascularize the left auricle; more than half of all cases had an anastomose with the coronary arteries: 11 with the right coronary artery and 9 with the left one. These anastomoses preserve the vascularization of the carina after a cardio-pulmonary transplantation. The may have a function of vascular supply in some coronarian patients and the study of associated coronary pathology gives confirmation of it in one fourth of the cases.     

Posttraumatic stress associated with delayed recall of sexual abuse: A general population study

This study examined delayed recall of childhood sexual abuse in a stratified random sample of the general population (N=505). Of participants who reported a history of sexual abuse, 42% described some period of time when they had less memory of the abuse than they did at the time of data collection. No demographic differences were found between subjects with continuous recall and those who reported delayed recall. However, delayed recall was associated with the use of threats at the time of the abuse. Subjects who had recently recalled aspects of their abuse reported particularly high levels of posttraumatic symptomatology and self difficulties (as measured by the IES, SCL, and TSI) at the time of data collection compared to other subjects.     

Impact of methodological choices on a meta-analysis of real-world evidence comparing non-vitamin-K antagonist oral anticoagulants with vitamin K antagonists for the treatment of patients with non-valvular atrial fibrillation

Objective: The aim of this study was to investigate the impact of methodological choices in a meta-analysis of real-world evidence (RWE) comparing three non-vitamin-K antagonist oral anticoagulants with vitamin K antagonists (VKAs) for the treatment of patients with non-valvular atrial fibrillation (NVAF).

Methods: The meta-analysis was based on a systematic review of RWE studies enrolling incident and prevalent patients aged ≥18 years with NVAF and receiving either rivaroxaban, dabigatran, apixaban or a VKA. Five different scenarios were considered to explore the impact of the initial meta-analysis assumptions: (1) using studies that involved only incident patients; (2) excluding studies that only reported crude values and did not consider any adjustment; (3) including all studies independently of possible database overlap; (4) using studies with data on different dosages for rivaroxaban and dabigatran; and (5) assigning quality weights to studies to assess quality of reporting. These scenarios were run on three outcomes: ischemic stroke (IS), myocardial infarction (MI) and intracranial hemorrhage (ICH).

Results: Across all scenarios, rivaroxaban was associated with significantly lower risks of IS and ICH than VKAs. In most scenarios, dabigatran was associated with significantly lower risks of IS and ICH. In all scenarios, apixaban was associated with a significantly lower risk of ICH.

Conclusions: Sensitivity analyses showed the impact of similar assumptions was different depending on the outcome and the drug considered. The development of recommendations and guidelines for the inclusion of RWE in meta-analyses could prove useful in evaluating the effectiveness of health care interventions.     

Management of patients with essential thrombocythemia: current concepts and perspectives

Essential thrombocythemia must now be regarded as a heterogeneous disease. Recent availability of clonality studies have repeatedly shown that a significant number of female patients diagnosed as E.T. according the most stringent criteria had a definitely polyclonal myelopoiesis. Although the incidence of patients newly diagnosed every year is low, there is in fact a conspicuous population of E.T., followed as outpatients in every department of hematology or internal medicine, including a large number of young females. These eventualities should be integrated in further discussions of the benefit/risk ratio of cytoreduction with the presently available drugs. The combination of several evidence-based data is the basis of a widely accepted stratification of high-risk patients defined by any of the following features. Age > 60 to 65. History of thrombosis or embolic or major ischemic events. Platelet counts in excess of 1000 or 1500 x 10(9)/L. In the question of chemotherapy in E.T., growing concern comes from the potential leukemogenic risk associated with the presently available drugs and extends beyond Melphalan, Busulfan and other alkylating agents and includes non-alkylating agents like Hydroxyurea. At the same time, much attention has been paid to the introduction of very precise initial diagnostic criteria directed to elimination of other myeloproliferative or myelodysplastic disorders with an increased risk of transformation. Present treatment of E.T. is a compromise between prevention of E.T. related thrombotic and bleeding complications on one hand and long term side effects and toxicity of the presently available drugs on the other hand. The recent availability of non mutagenic drugs like Interferon and most of all Anagrelide; the recognition of the role of antiaggregating agents in the treatment of platelet related microvascular ischemic events gives the opportunity for further comparative prospective trials. The use of aspirin in the management of pregnant E.T. patients is now widely accepted but there is still controversies concerning the use of Interferon in this situation.     

Faut-il réanimer les patients admis pour tentative de suicide ?

Since 1998, different national programs of action against suicide have been set up to reduce the number of persons ending voluntary their life. These 15 years have also led to consider suicide and attempted suicide otherwise. If the World Health Organization defines suicide as a “deliberate act”, a French consensus conference in 2000 led to focus not only on the suicidal act, but also on the crisis that makes the individual considers suicide as the ultimate solution to end a high psychological tension, life becaming unbearable. Management of suicidal patients, focusing on the double physical and psychiatric assessment, is reviewed. Obviously, the role of each physician is clearly defined (diagnosis, care, prevention). However, a contradiction exists between the patient “who wishes to die” and the physician in his role as caregiver. But, most of the time, suicide is not a simple deliberate act but rather an act that occurs in a great feeling of ambivalence. Recognition and acceptance of such ambivalence are helpful to consider the question suicide.