Patterns of subjective memory impairment in the elderly: association with memory performance

BACKGROUND: The association of subjective memory impairment (SMI) with cognitive performance in healthy elderly subjects is poor because of confounds such as depression. However, SMI is also a predictor for future dementia. Thus, there is a need to identify subtypes of SMI that are particularly related to inferior memory performance and may represent at-risk stages for cognitive decline.METHOD: A total of 2389 unimpaired subjects were recruited from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe), as part of the German Competence Network on Dementia. Clusters of SMI according to patterns of response to SMI questions were identified. Gender, age, depressive symptoms, apolipoprotein E (apoE) genotype, delayed recall and verbal fluency were included in a Classification and Regression Tree (CART) analysis to identify discriminators between the clusters. RESULTS: We identified three clusters. Cluster 1 contained subjects without memory complaints. Cluster 2 contained subjects with general memory complaints, but mainly without memory complaints on individual tasks of daily living. Cluster 3 contained subjects with general memory complaints and complaints on individual tasks of daily living. Depressive symptoms, as the first-level discriminator, distinguished between clusters 1 and 2 versus cluster 3. In subjects with only a few depressive symptoms, delayed recall discriminated between cluster 1 versus clusters 2 and 3. CONCLUSIONS: In SMI subjects with only a minor number of depressive symptoms, memory complaints are associated with delayed recall. As delayed recall is a sensitive predictor for future cognitive decline, SMI may be the first manifestation of future dementia in elderly subjects without depression.     

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation

Background  

Today, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest.     

Review of deprescribing processes and development of an evidence-based,patient-centred deprescribing process

Inappropriate use of medication is widespread, especially in older people, and is associated with risks, including adverse drug reactions, hospitalization and increased mortality. Optimization of appropriate medication use to minimize these harms is an ongoing challenge in healthcare. The term ‘deprescribing’ has been used to describe the complex process that is required for safe and effective cessation of medication. Patients play an important role in their own health and, while they may complain about the number of medications they have to take, they may also be reluctant to cease a medication when given the opportunity to do so. A review of previously proposed deprescribing processes and relevant literature was used to develop the patient-centred deprescribing process, which is a five-step cycle that encompasses gaining a comprehensive medication history, identifying potentially inappropriate medications, determining whether the potentially inappropriate medication can be ceased, planning the withdrawal regimen (e.g. tapering where necessary) and provision of monitoring, support and documentation. This is the first deprescribing process developed using knowledge of the patients'' views of medication cessation; it focuses on engaging patients throughout the process, with the aim of improving long-term health outcomes. Despite a comprehensive review of the literature, there is still a lack in the evidence base on which to conduct deprescribing. The next step in broadening the evidence to support deprescribing will be to test the developed process to determine feasibility in the clinical setting.     

Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team—a prospective multi-centre analysis

Background  

The number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease.     

Is there a role for bowel rest in nutrition management of Crohn's disease?

In 1988, Greenberg and colleagues published a large randomized controlled trial to address whether bowel rest could lead to improved disease activity in patients with active Crohn's disease. The results of this study provide substantial evidence that bowel rest is not necessary to achieve remission in patients with active Crohn's disease receiving nutrition support. Before this study, great controversy existed about the use of nutrition support and bowel rest in the treatment of active Crohn's disease because of a limited number of conflicting studies providing evidence for and against its application. The results of the publication by Greenberg et al are fundamental because they helped to settle this important argument. Furthermore, this pivotal paper changed the clinical guidelines for the use of nutrition support in the management of active Crohn's disease. Since the publication of this pivotal article, many developments in the field of nutrition and in the treatment of Crohn's disease have helped validate and further its results. Subsequent studies and debate center on the use of enteral nutrition as primary treatment in patients with active Crohn's disease. Data regarding the efficacy, composition, and overall role of adult enteral nutrition in the management of Crohn's disease are presented. This article revisits the Greenberg paper and discusses some of these innovations in nutrition.     

Pharmacophore model of drugs involved in P-glycoprotein multidrug resistance: explanation of structural variety (hypothesis)

A general pharmacophore model of P-glycoprotein (P-gp) drugs is proposed that is based on a highly diverse data set and relates to the verapamil binding site of the protein. It is derived from structurally different drugs using the program GASP. The pharmacophore model consists of two hydrophobic points, three hydrogen bond (HB) acceptor points, and one HB donor point. Pharmacophore patterns of various drugs are obtained, and different binding modes are presumed for some of them. It is concluded that the binding affinity of the drugs depends on the number of the pharmacophore points simultaneously involved in the interaction with P-gp. On the basis of the obtained results, a hypothesis is proposed to explain the broad structural variety of the P-gp substrates and inhibitors: (i) the verapamil binding site of P-gp has several points that can participate in hydrophobic and HB interactions; (ii) different drugs can interact with different receptor points in different binding modes.     

Psychophysiological correlates of peritraumatic dissociative responses in survivors of life-threatening cardiac events

The psychophysiological startle response pattern associated with peritraumatic dissociation (DISS) was studied in 103 survivors of a life-threatening cardiac event (mean age 61.0 years, SD 13.95). Mean time period since the cardiac event was 37 (79 IQD) months. All patients underwent a psychodiagnostic evaluation (including the Peritraumatic Dissociative Experiences Questionnaire) and a psychophysiological startle experience which comprised the delivery of 15 acoustic startle trials. Magnitude and habituation to trials were measured by means of electromyogram (EMG) and skin conductance responses (SCR). Thirty-two (31%) subjects were indexed as patients with a clinically significant level of DISS symptoms. High-level DISS was associated with a higher magnitude of SCR (ANOVA for repeated measures p = 0.017) and EMG (p = 0.055) and an impaired habituation (SCR slope p = 0.064; EMG slope p = 0.005) in comparison to subjects with no or low DISS. In a subgroup analysis, high-level DISS patients with severe post-traumatic stress disorder (PTSD; n = 11) in comparison to high-level DISS patients without subsequent PTSD (n = 19) exhibited higher EMG amplitudes during all trials (repeated measures analysis of variance F = 5.511, p = 0.026). The results demonstrate exaggerated startle responses in SCR and EMG measures - an abnormal defensive response to high-intensity stimuli which indicates a steady state of increased arousal. DISS patients without PTSD exhibited balanced autonomic responses to the startle trials. DISS may, therefore, unfold malignant properties only in combination with persistent physiological hyperarousability.     

Peak inspiratory flow rate after methacholine challenge in asthmatic patients and its impact on the effect of formoterol via different inhalers.

The goal of the present study was to investigate the bronchodilating effects of 6 and 12 microg formoterol delivered by the Turbuhaler, in comparison to salbutamol 200 microg (metered dose inhaler) and to controls without treatment. After inducing acute and severe bronchial obstruction by means of methacholine challenge, peak inspiratory mouth flow (PIMF) was measured through a stenosis, simulating the internal resistance of the Turbuhaler, with the in-check device. In addition the relationship was studied between PIMF and clinical response in the 3 treatment groups. In the 176 patients methacholine caused a mean fall in FEV(1) of 37.1 +/- 6.9% compared to baseline. Ten minutes after bronchodilator inhalation, FEV(1) improved significantly in all three treatment groups. At 30 minutes after bronchodilator administration, only the salbutamol 200 microg and the formoterol 12 microg groups had a significantly greater increase in FEV1 than controls (0.69 +/- 0.43 l and 0.66 +/- 0.37 l vs 0.38 +/- 0.32 l, p < 0.0005), whereas the formoterol 6 microg group showed no significant improvement (0.41 +/- 0.38 l, p = 0.74). Thirteen patients (7.4%) did not reach a minimal PIMF of 30 l/min through the in-check device after challenge. In the four patients in the formoterol 6 microg group with a PIMF below 30 l/min inhalation did not cause bronchodilation. In conclusion, the results demonstrate that 6 microg formoterol via Turbuhaler leads to less and slower onset of bronchodilation compared to the other groups in our setting. If patients fail to generate a PIMF of 30 l/min, 6 microg formoterol via Turbuhaler may provide inadequate relief in a severe asthma attack.     

Endoskopische Bursektomie und Traktopexie am Trochanter major

Zusammenfassung Operationsziel Minimal invasive Entfernung der Bursa trochanterica, gegebenenfalls mit Exostosenresektion und/oder Traktopexie am Trochanter major. Indikationen Chronische, konservativ ausbehandelte Bursitis trochanterica. Bursitis bei Coxa saltans oder infolge Spornbildung am Trochanter major. Kontraindikationen Bakterielle oder rheumatische Bursitis trochanterica. Operationstechnik Über je eine Stichinzision proximal, distal und leicht dorsal der Trochanterspitze wird Spülflüssigkeit (Purisole^®) epitrochantär eingebracht; die Fascia lata wird unter endoskopischer Sicht gespalten. Subtotale Bursektomie mit dem Synovialisresektor. Bedarfsweise Erweiterung des Eingriffs um eine Traktopexie mit resorbierbaren "Ankern" ist möglich. Ergebnisse Insgesamt 34 Patienten (28 weiblich, sechs männlich, Durchschnittsalter 57,8 Jahre) wurden seit 1995 operiert. Die ersten 20 Patienten (18 weiblich, zwei männlich, Durchschnittsalter 52,6 Jahre) konnten nach 20 (zwölf bis 36) Monaten nachuntersucht werden. 15 Patienten waren mit dem Resultat zufrieden. Der Schmerzwert sank in der visuellen Analogskala von 8,9 Punkten präoperativ (10 = stärkster Schmerz) auf 5,2 Punkte postoperativ und 4,3 zum Zeitpunkt der Nachkontrolle. Komplikationen: eine sekundäre Heilung im Bereich einer Stichinzision. Summary Objectives Minimally invasive surgical procedure for removal of the trochanteric bursa and, if necessary, exostosectomy and/or fixation of the iliotibial tract at the greater trochanter. Indications Chronic, unsuccessfully treated trochanteric bursitis. Bursitis caused by snapping hip or due to exostosis at the greater trochanter. Contraindications Infected bursitis or bursitis in rheumatoid patients. Surgical Technique Through 2 approaches, cranial and caudal and slightly posterior to the tip of the trochanter, infiltration of the epitrochanteric area with saline (Purisole^®); the iliotibial tract is divided under endoscopic control. Subtotal removal of the trochanteric bursa using a synovial resector. If necessary, the procedure can be extended to include a fixation of the tract with resorbable suture anchors. Results Since June 1995, we performed an endoscopic bursectomy in 34 patients (28 women and 6 men, average age 57.8 years). The first 20 patients (18 women and 2 men, average age 52.6 years) had an average follow-up of 20 (12 to 36) months. Fifteen patients were satisfied with the result. The degree of pain and functional handicap was assessed using a visual analog scale (10 points for intense pain). This pain score amounted to 8.9 points before surgery, to 5.2 postoperatively, and to 4.3 at follow-up. One instance of secondary healing was seen in a stab incision.     

Systematic review of diagnostic tests for vaginal trichomoniasis

OBJECTIVE: To review critically and to summarize the evidence of diagnostic tests and culture media for the diagnosis of Trichomonas vaginitis. METHODS: We performed a systematic review of literature indexed in MEDLINE of studies that used Trichomonas culture as the reference standard (9,882 patients, 35 studies). Level I studies (5,047 patients, 13 studies) fulfilled at least two of three criteria: 1) consecutive patients were evaluated prospectively, 2) decision to culture was not influenced by test results, and 3) there was independent and blind comparison to culture. RESULTS: The sensitivity of the polymerase chain reaction technique (PCR) was 95% (95% CI 91% to 99%), and the specificity was 98% (95% CI 96% to 100%). One study was classified as Level I evidence (52 patients). The sensitivity of the enzyme-linked immunosorbent assay was 82% (95% CI 74% to 90%), and the specificity was 73% (95% CI 35% to 100%). The sensitivity of the direct fluorescence antibody was 85% (95% CI 79% to 90%), and the specificity was 99% (95% CI 98% to 100%). Sensitivities of culture media were 95% for Diamond's, 96% for Hollander, and 95% for CPLM. CONCLUSIONS: The sensitivity and specificity of tests to diagnose trichomoniasis vary widely.