Clostridium difficile-associated diarrhea in the elderly

OBJECTIVE: It is widely believed that Clostridium difficile (C. difficile)-associated diarrhea is a more severe disease in the elderly than in the young, associated with increased morbidity and mortality. These beliefs are largely anecdotal, and there are few data supporting them. METHODS: We conducted an evaluation in an urban, tertiary care hospital of 89 inpatients in whom C. difficile-associated diarrhea was identified. These patients were evaluated prospectively, and the group was divided by age into those < 60 yr of age (younger) and those > or = 60 yr (elderly). RESULTS: There was no difference in mortality or morbidity in elderly individuals with C. difficile-associated diarrhea when compared with younger persons similarly infected. The response to standard treatment was similar in both groups. Older patients were more likely to have an elevated white blood cell count in association with C. difficile-associated diarrhea (60% vs 26%, p < 0.05), and were more likely to have acquired their infection in the hospital (89% vs 50%, p < 0.0001). CONCLUSIONS: In the elderly, C. difficile-associated diarrhea is almost always acquired in institutions, and may not be obvious among patients' other problems. The elderly do not seem to have an increase in C. difficile diarrhea-associated morbidity or mortality. There is no evidence that C. difficile-associated diarrhea is more severe in the elderly than it is in the young.     

Sociodemographic characteristics of the neighborhood and depressive symptoms in older adults: using multilevel modeling in geriatric psychiatry.

OBJECTIVE: Neighborhood sociodemographic characteristics may be important to the mental health of older adults who have decreased mobility and fewer resources. Our objective was to examine the association between neighborhood context and level of depressive symptomatology in older adults in a diverse geographic region of central North Carolina. METHODS: The sample included 2,998 adults 65 or older residing in 91 census tracts. Depressive symptoms were measured using the Center for Epidemiologic Studies-Depression scale (CES-D). Neighborhoods were characterized by five census-based characteristics: socioeconomic disadvantage, socioeconomic advantage, racial/ethnic heterogeneity, residential stability, and age structure. RESULTS: In ecologic level analyses, level of census tract socioeconomic disadvantage was associated with increased depressive symptoms. To determine whether neighborhood context was associated with depressive symptoms independently of individual characteristics, the authors used multilevel modeling. The authors examined the ability of each of five neighborhood (level 2) characteristics to predict a level 1 outcome (CES-D symptoms) controlling for the effects of individual (level 1) characteristics. Younger age, being widowed, lower income, and having some functional limitations were associated with increased depression symptoms conditional on census tract random effects. However, none of the neighborhood characteristics was significantly associated with depression symptoms, conditional on census tract random effects, either unadjusted or adjusted for individual characteristics. CONCLUSION: Any observed association between neighborhood sociodemographic characteristics and individual depressive symptoms in our sample may reflect the characteristics of the individuals who reside in the neighborhood rather than the neighborhood characteristics themselves. The use of multilevel modeling is important to separate these effects.     

Protecting the uninsured human research subject.

Currently, research institutions are not mandated to provide free medical care or compensation to research participants for research-induced injuries. Research studies offering financial compensation or the possibility of treatment often attract more of the working poor who are less likely to have health insurance. Thus uninsured or underinsured participants face a heavier burden and greater risk than those with insurance. Based on a theoretical examination of the Belmont principles of beneficence and justice, the authors' IRB analysis, and an analysis of the changing health care and research arenas, the authors provide reasons to amend the Federal Code of Regulations.     

Cold hemagglutinin disease associated with IgG cold-reactive antibody

Six patients with chronic idiopathic cold hemagglutinin disease were studied whose serum cold agglutinin was not inactivated or was incompletely inactivated with the IgM-reducing agent dithiothreitol. In five of these patients, isolation of the antibodies revealed that two patients had predominantly IgG cold-reactive antibody, which was associated with smaller amounts of IgM in one patient and with IgA in the other; two patients had predominantly IgM cold agglutinin with lesser amounts of cold-reactive IgG; and one patient had an IgG cold agglutinin only. Both patients with predominantly IgG cold-reactive antibodies were treated with splenectomy and subsequently had a rise in more than hemoglobin levels that has been maintained for over 36 months without additional therapy. Two of the other three patients were treated with glucocorticoids only and responded similarly. These data indicate that a subset of patients with cold hemagglutinin disease have IgG cold-reactive antibodies. In contrast to patients with typical cold agglutinin disease, this subset appears responsive to glucocorticoids and splenectomy.     

Prostate-specific membrane antigen-targeted photodynamic therapy induces rapid cytoskeletal disruption

Prostate-specific membrane antigen (PSMA), an established enzyme–biomarker for prostate cancer, has attracted considerable attention as a target for imaging and therapeutic applications. We aimed to determine the effects of PSMA-targeted photodynamic therapy (PDT) on cytoskeletal networks in prostate cancer cells. PSMA-targeted PDT resulted in rapid disruption of microtubules (α-/β-tubulin), microfilaments (actin), and intermediate filaments (cytokeratin 8/18) in the cytoplasm of LNCaP cells. The collapse of cytoplasmic microtubules and the later nuclear translocation of α-/β-tubulin were the most dramatic alternation. It is likely that these early changes of cytoskeletal networks are partly involved in the initiation of cell death.     

Assessment of social relationships in elderly patients

This article provides an overview of measures for assessing the importance of social relationships to the outcome of illness in the elderly. Review of the evidence associating social relationships with the variability in health outcome emphasizes the need for separating social relationships into three components: Social network structure and composition; Type and amount of social support provided through the network; and, perceived adequacy of the social support. Because of physical and social changes during the life cycle, care must be exercised in selecting and interpreting social relationship measures for use with the elderly. Available measures relevant for assessing the three components of social relationships in the elderly are described.