Impediments to timely diagnosis of Alzheimer's disease in African Americans

The purpose of this study was to identify early patterns of care for Alzheimer's disease (AD) in a cohort of African-American patients and their caregivers presenting at an inner city clinic and a suburban memory assessment clinic. Caregivers (N=79) of patients diagnosed with probable AD were interviewed. Data were collected about the delay from noticing first AD signs until recognition that a problem existed and delay from problem recognition until first physician consultation. Patients and caregivers had lower educational status, and patients had been diagnosed more recently at the inner city clinic than at the suburban clinic, although MMSE scores of patients at the two clinics did not differ; median delays in caregivers' recognizing a problem and in consulting a physician were also similar across clinics. Delay was as long as 7 years between noticing symptoms and problem recognition and between problem recognition and physician consultation. Although patients attending the suburban clinic were more likely to have previously seen a physician than those attending the inner city clinic, they were no more likely to have received a prior diagnosis of AD. Lack of physician contact is likely to be widespread in families caring for African Americans with AD. Physician consultation is more characteristic of more highly educated families but may not yield a correct diagnosis for the patient. Intensive efforts are needed to connect African-American families with physicians and to achieve more timely diagnosis of AD to enable families to understand the illness, plan for patient safety, and make long-term plans.     

Dialysis Facility Characteristics and Variation in Employment Rates: A National Study

Background: Investigation of factors associated with variation in dialysis patient employment has focused primarily on patient-level factors. Little is known about facility-level factors that may be associated with patient employment.Design, setting, participants, and measurements: The ESRD Facility Survey (CMS-2744A) began in 2004 to collect counts of employed patients aged 18 to 54, in addition to dialysis unit census, types and timing of treatments offered, and staffing. Using the 2004 ESRD Facility Survey File, we investigated dialysis unit characteristics and facility employment rate of patients aged 18 to 54 in a logistic regression analysis that included hospital-based chronic renal care facilities, nonhospital renal disease treatment centers, independent special purpose renal dialysis facilities, and renal disease treatment centers.Results: Across all facilities, 18.9% of prevalent patients aged 18 to 54 were employed, but facility employment rates ranged from 0 to 100%. Facility employment rate was positively associated independently with availability of a 5 p.m. or later dialysis shift (odds ratio (OR) 1.54, 95% confidence interval (CI) 1.42 to 1.68), availability of peritoneal dialysis or home hemodialysis (HD) training (OR 1.19, 95% CI 1.11 to 1.28), and provision of frequent HD (OR 1.26, 95% CI 1.07 to 1.49), after adjusting for patient/social worker ratio, rurality of unit location, and unit size. In addition, patient receipt of Vocational Rehabilitation (VR) services was more often reported in facilities with higher employment rates.Conclusions: Promoting gainful employment among ESRD patients continues to be a quality improvement need. A dataset that allows adjustment for patient-level variables would facilitate increased understanding of the contribution of dialysis facility variables to patient employment.Gainful employment among “the maximum practical number of patients” was specified as a goal in 1986 Congressional legislation governing responsibilities of End-Stage Renal Disease (ESRD) Networks (1). ESRD Network Organizations, which function as liaisons between the federal government and providers of ESRD services (2), subsequently began to collect annual counts of employed patients in each dialysis facility within their respective Network geographic areas. Variation in facility employment rates and the association of these rates with facility characteristics has not been investigated, however.Studies of factors associated with variation in dialysis patient employment have focused primarily on patient-level factors, especially individuals’ educational background, occupational status before dialysis, treatment modality, and health status/comorbidity. Higher educational level and prior occupational status are the patient-level factors that have been most consistently identified as predictors of patient employment (3–8). A study by Rasgon et al. (9) showed, however, that facility-level variables may also influence patient employment status. The researchers found that blue-collar workers receiving dialysis in a facility that provided a multidisciplinary predialysis program designed to assist patients in maintaining employment were significantly more likely to continue employment than blue-collar workers who were treated at facilities that did not provide such a program.We undertook this study to examine the potential association of facility characteristics with variation in patient employment rates across dialysis facilities, using a national database. We investigated dialysis facility characteristics and aggregate employment within facilities of prevalent patients aged 18 to 54, as reported on the 2004 ESRD Facility Survey. The ESRD Facility Survey is completed annually for the Centers for Medicare and Medicaid Services (CMS) by all Medicare-approved facilities providing outpatient services to ESRD patients. In 2004, the survey began to collect aggregate information on the number of patients aged 18 to 54 in the facility and the number of patients aged 18 to 54 who were employed at the end of the calendar year, in addition to counts of patients entering and leaving the facility and counts of patients in specific treatment modality categories at the end of the survey period. The survey also annually captures several facility characteristics that are recognized as potentially relevant for patient employment, i.e., availability of a late dialysis shift (10), availability of home dialysis treatment options (11), provision of frequent hemodialysis (HD) treatment (12), and level of social worker staffing (13).     

Trauma-related guilt and posttraumatic stress among journalists

This study explored the psychological impact of exposure to work-related trauma among journalists. It was hypothesised that positive associations would exist between (a) exposure and PTSD symptoms, (b) exposure and guilt cognitions, and (c) guilt cognitions and PTSD symptoms, and that the relationship between exposure and PTSD symptoms would be mediated by guilt cognitions. The sample consisted of 50 journalists (response rate = 15%), who had recently been exposed to work-related trauma. They were predominantly male, aged 40 years or older, well-educated, and most had worked in journalism for at least 15 years. Participants completed an online questionnaire that explored their work-related experiences of trauma, PTSD symptoms, and trauma-related guilt cognitions. The findings showed that higher levels of exposure to work-related trauma were significantly associated with higher levels of PTSD symptoms (r = .36) and trauma-related guilt cognitions (r = .29). Guilt cognitions were significantly and positively independently associated with PTSD symptoms (r = .12) and were consistent with partial mediation of relationship between exposure to work-related trauma and PTSD symptoms. This study provides greater insight into the psychological processing of work-related traumatic events among journalists and emphasizes the importance of posttrauma appraisals of guilt regarding their experiences.     

Feasibility of magnetic resonance-guided fine-needle percutaneous biopsy]

Fluoroscopic, US, and CT guidance to aspiration cytology are valuable tools for oncologic diagnosis. MR imaging is now replacing CT as the imaging method of choice to guide biopsy mainly in the abdomen and pelvis. The standard needles used for CT-guided biopsy are unsuitable for MR guidance because ferromagnetic artifacts shade the underlying anatomy. A new needle specifically designed for MR guidance allowed MR-guided aspiration biopsies to be carried out in a group of 17 patients with different neoplastic diseases. To locate the lesion and to assess its depth, a glass pipette containing a diluted solution of paramagnetic contrast medium (Gd-DTPA) was placed on the skin surface. In 13/17 patients (76.5%), biopsy was successful and histology and/or cytology allowed a diagnosis to be made. In spite of their longer measurement times, T1-weighted SE images clearly demonstrated both needle and lesion. On the contrary, fast images (FLASH, 15 degrees-90 degrees), with/without breath holding, although much shorter (7 s), were often useless, due to artifacts, mainly in small lesions.     

The role of magnetic resonance imaging in the evaluation of neoplastic lesions of the breast

Thirty-seven patients were evaluated for suspected breast cancer by magnetic resonance imaging (MRI) using 0.5- and 1.5-Tesla. We examined the patterns in breast images and the use of MRI in evaluating neoplasms. At the moment the cost/benefit ratio is unfavorable, mainly because of the availability of alternative methods of high accuracy and low cost, like mammography and ultrasonography. Furthermore fine needle aspiration biopsy is not possible with MRI. The widespread use of MRI for breast pathology seems not to be justified by the results obtained.     

Girl World: a primary prevention program for Mexican American girls

Theories about women's health have not traditionally been extended to include the healthy development of young women. This article applies a women's health perspective to the implementation and evaluation processes of a gender-specific primary prevention program that worked with 9- to 14-year-old Hispanic girls in a low-income community. Although community-based after-school programs can be an important venue for education and girls' development, long-term effects are elusive to evaluate. The authors used ethnographic techniques to learn more about girls and their interactions with the program and to assess short-term program impact. Three themes were found: Program environment can contribute to girls' expression and behavior, issues of struggling families can slide girls into early adulthood, and mentoring can benefit both girls and adult women. Community-based primary prevention programs, although an essential part of a social safety net available to low-income girls, provide researchers with a unique set of evaluation challenges.     

Anæsthesia for Intracranial Vascular Surgery1

The surgery of intracranial vascular lesions provides special challenges for the anesthetist. The control of intracranial pressure, the prevention of cerebral ædema and the preservation of cerebral perfusion and oxygenation are leading requirements, to which are added measures to improve surgical access and to lower intravascular pressure in order to increase operability. Appropriate techniques and general provisions for meeting these requirements are discussed.     

Neuroblastoma: radiological findings in 124 cases (author's transl)

All the pertinent radiographs of 124 patients with histologically proven neuroblastoma were evaluated. The radiological features of the primary tumor and radiographic characteristics of metastases were also analyzed. Finally the value of radiological investigations to define the diffusion of the disease in comparison with laboratory and clinical findings were considered.