Ethical and Policy Considerations for Centenarians—The Oldest Old

To illustrate the incongruence of ethical standards and fiscal and policy constraints on quality care for the oldest old. As the fastest growing demographic segment in the United States, care needs of the oldest old are a special challenge to the health care system.

Design:

Narrative analysis of interviews with centenarians who used nursing home services. The sample was three participants of the Georgia Centenarian Study who had been community dwelling and cognitively intact at the onset of participation (between 1988 and 1997). Interviews were conducted in nursing homes or after discharge.

Methods:

Case histories were constructed from interviews in 1997 to improve understanding of quality of care.

Findings:

Less-than-optimal care was provided for these elders, and little consideration was given to their input to care decisions and prospects for medical improvement. Appropriate consideration was not given to providing least-restrictive environments, appropriate restraint use, and options for community care.

Conclusions:

Six policy reforms are suggested for meeting the needs of the oldest-old before and after institutionalization. These include: integration of resident involvement in care decisions; development of alternate models of care; greater input from nurses concerning nursing care of special populations; more effective family and community involvement in the caring of elderly populations; increased research to promote function and independence; and increased education of personnel and nursing students to allow for more accurate assessment of cognitive and physical status.     

Reed-Sternberg cells in Hodgkin's disease contain fibronectin

Reed-Sternberg cells in the lymph nodes from five patients with Hodgkin's disease were studied. Indirect immunofluorescence on fixed sections with a monospecific anti-serum to fibronectin revealed abundant cytoplasmic fibronectin in approximately 90% of the Reed- Sternberg cells. In addition, the cells were shown by immunofluorescence to contain polyclonal IgG; however, factor VIII antigen, albumin, fibrinogen, alpha-2-macroglobulin, anti-thrombin III, and ceruloplasmin were not present. The abundant cytoplasmic fibronectin suggests that Reed-Sternberg cells are derived from tissue macrophages.     

Anterior temporal lobes and hippocampal formations: normative volumetric measurements from MR images in young adults

Volumes of the right and left anterior temporal lobes and hippocampal formations were measured from magnetic resonance images in 52 healthy volunteers, aged 20-40 years. Subjects were selected by age, sex, and handedness to evaluate possible effect of these variables. Data were normalized for variation in total intracranial volume between individuals. Right-left asymmetry in the volumes of the anterior temporal lobes and hippocampal formations was a normal finding. The anterior temporal lobe of the non-dominant (right) hemisphere was larger than the left by a small (mean right-left difference, 2.3 cm3) but statistically significant amount (P less than .005) in right-handed subjects. No significant effect of age or sex was seen in normalized right or left anterior temporal lobe volume. The right hippocampal formation was larger than the left for all subjects by a small (mean right-left difference, 0.3 cm3) but statistically significant amount (P less than .001). No effect of age, sex, or handedness was seen in normalized hippocampal formation volumes.     

Individual differences in psychotic effects of ketamine are predicted by brain function measured under placebo

The symptoms of major psychotic illness are diverse and vary widely across individuals. Furthermore, the prepsychotic phase is indistinct, providing little indication of the precise pattern of symptoms that may subsequently emerge. Likewise, although in some individuals who have affected family members the occurrence of disease may be predicted, the specific symptom profile may not. An important question, therefore, is whether predictive physiological markers of symptom expression can be identified. We conducted a placebo-controlled, within-subjects study in healthy individuals to investigate whether individual variability in baseline physiology, as assessed using functional magnetic resonance imaging, predicted psychosis elicited by the psychotomimetic drug ketamine and whether physiological change under drug reproduced those reported in patients. Here we show that brain responses to cognitive task demands under placebo predict the expression of psychotic phenomena after drug administration. Frontothalamic responses to a working memory task were associated with the tendency of subjects to experience negative symptoms under ketamine. Bilateral frontal responses to an attention task were also predictive of negative symptoms. Frontotemporal activations during language processing tasks were predictive of thought disorder and auditory illusory experiences. A subpsychotic dose of ketamine administered during a second scanning session resulted in increased basal ganglia and thalamic activation during the working memory task, paralleling previous reports in patients with schizophrenia. These results demonstrate precise and predictive brain markers for individual profiles of vulnerability to drug-induced psychosis.     

AUDIT OF PATIENTS' EXPERIENCES AFTER ENDOSCOPY OF THE UPPER ALIMENTARY TRACT

SUMMARY This study comprises an audit of the experiences of upper alimentary endoscopy by 400 patients examined in 15 hospitals. The patients were asked to complete a 19-section questionnaire regarding their experience of the endoscopy before, during and after the procedure. The audit was carried out in order to evaluate the patients' understanding of the investigation and to determine the impact of the findings on the patients' level of anxiety. Of the 400 patients, 304 (76.0%) returned the questionnaire; overall satisfaction was revealed with the decision to proceed with endoscopy and with the procedure itself, as well as the reassurance provided by the investigation. The study thus supports the role of open-access endoscopy.