Curricular framework: core competencies in multicultural geriatric care

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.     

Neural representations of hunger and satiety in Prader-Willi syndrome

OBJECTIVE: To investigate the neural basis of the abnormal eating behaviour in Prader-Willi syndrome (PWS), using brain imaging. We predicted that the satiety response in those with PWS would be delayed and insensitive to food intake. DESIGN AND PARTICIPANTS: The design of this study was based on a previous investigation of the neural activation associated with conditions of fasting and food intake in a nonobese, non-PWS group. The findings were used to generate specific hypotheses regarding brain regions of interest for the current study, in which 13 adults with PWS took part (mean +/- s.d. age = 29 +/- 6; BMI = 31.5 +/- 5.1; IQ = 71 +/- 8, six were female). MEASUREMENTS: Regional cerebral blood flow was measured using positron emission tomography in three sessions: one following an overnight fast and two following disguised energy controlled meals of similar volume and appearance--one of 1674 kJ (400 kcal) and another of 5021 kJ (1200 kcal). Subjective ratings of hunger, fullness and desire to eat, and blood plasma levels of glucose, insulin, leptin, ghrelin and PYY were measured before and after each imaging session. RESULTS: The neural representation of hunger, after an overnight fast, was similar to that found in nonobese individuals in the control study. In contrast, after food intake, the patterns of neural activation previously associated with satiety were not found, even after the higher-energy load. Lateral and medial orbitofrontal cortical activation was associated with consumption of the 400- and 1200-kcal meals, respectively. The medial orbitofrontal activation, however, was only found in those who had shown a large percentage change in fullness ratings following the higher-energy meal. CONCLUSION: We conclude that there is a dysfunction in the satiety system in those with PWS. These findings suggest that brain regions associated with satiety are insensitive even to high-energy food intake in those with the syndrome. This may be the neural basis of the hyperphagia seen in PWS.     

Circulating interleukin-6 is associated with disease progression,but not cachexia in pancreatic cancer

Background

Cachexia is a wasting syndrome characterized by involuntary loss of >5% body weight due to depletion of adipose and skeletal muscle mass. In cancer, the pro-inflammatory cytokine interleukin-6 (IL-6) is considered a mediator of cachexia and a potential biomarker, but the relationship between IL-6, weight loss, and cancer stage is unknown. In this study we sought to evaluate IL-6 as a biomarker of cancer cachexia while accounting for disease progression.

Differential effects of respiratory syncytial virus and adenovirus on mononuclear cell cytokine responses

Respiratory syncytial virus (RSV) and adenovirus (Advs) serotype 3 (Adv3) and 7h (Adv7h) are associated with mild to severe respiratory infection and are indistinguishable during the acute phases of the illnesses. However, outcome and long-term prognosis are different with both infections. RSV infection is associated with later development of asthma, and Adv, mainly Adv7h, with severe lung damage, bronchiectasis, and hyperlucent lung. We hypothesized that this difference could be partly due to different immune responses induced by these viruses. To test this hypothesis we quantified TCD4+, TCD8+, and BCD19+ expressing the interleukin-2 receptor-alpha chain (CD25) and interferon-gamma (IFN-gamma), interleukin (IL)-10, and IL-4 in the supernatant of peripheral blood mononuclear cells (PBMC) from school children infected in vitro with and without RSV, Adv7h, and Adv3 and after phytohemagglutinin (PHA) stimulation in the presence or absence of these viruses at a multiplicity of infection (MOI) of 1. PBMC from every child produced more IL-10 (p 相似文献   

Predictors of hospital transfer and associated risks of mortality in acute pancreatitis

BackgroundThere is limited research in prognosticators of hospital transfer in acute pancreatitis (AP). Hence, we sought to determine the predictors of hospital transfer from small/medium-sized hospitals and outcomes following transfer to large acute-care hospitals.MethodsUsing the 2010–2013 Nationwide Inpatient Sample (NIS), patients ≥18 years of age with a primary diagnosis of AP were identified. Hospital size was classified using standard NIS Definitions. Multivariable analyses were performed for predictors of “transfer-out” from small/medium-sized hospitals and mortality in large acute-care hospitals.ResultsAmong 381,818 patients admitted with AP to small/medium-sized hospitals, 13,947 (4%) were transferred out to another acute-care hospital. Multivariable analysis revealed that older patients (OR = 1.04; 95%CI 1.03–1.06), men (OR = 1.15; 95%CI 1.06–1.24), lower income quartiles (OR = 1.54; 95%CI 1.35–1.76), admission to a non-teaching hospital (OR = 3.38; 95%CI 3.00–3.80), gallstone pancreatitis (OR = 3.32; 95%CI 2.90–3.79), pancreatic surgery (OR = 3.14; 95%CI 1.76–5.58), and severe AP (OR = 3.07; 95%CI 2.78–3.38) were predictors of “transfer-out”. ERCP (OR = 0.53; 95%CI 0.43–0.66) and cholecystectomy (OR = 0.14; 95%CI 0.12–0.18) were associated with decreased odds of “transfer-out”.Among 507,619 patients admitted with AP to large hospitals, 31,058 (6.1%) were “transferred-in” from other hospitals. The mortality rate for patients “transferred-in” was higher than those directly admitted (2.54% vs. 0.91%, p < 0.001). Multivariable analysis revealed that being “transferred-in” from other hospitals was an independent predictor of mortality (OR = 1.47; 95% CI 1.22–1.77).ConclusionsPatients with AP transferred into large acute-care hospitals had a higher mortality than those directly admitted likely secondary to more severe disease. Early implementation of published clinical guidelines, triage, and prompt transfer of high-risk patients may potentially offset these negative outcomes.     

Practice Constraints,Behavioral Problems,and Dementia Care: Primary Care Physicians’ Perspectives

Objectives To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care. Design Cross-sectional qualitative interview study of primary care physicians. Setting Physicians’ offices. Participants Forty primary care physicians in Northern California. Measurements Open-ended interviews lasted 30–60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process. Results Recurring themes (i.e., those present in ≥25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, “reactive” as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches. Conclusion Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.     

Comparison of medication adherence and persistence in type 2 diabetes: A systematic review and meta‐analysis

Limited medication adherence and persistence with treatment are barriers to successful management of type 2 diabetes (T2D). We searched MEDLINE, EMBASE, the Cochrane Library, the Register of Controlled Trials, PsychINFO and CINAHL for observational and interventional studies that compared the adherence or persistence associated with 2 or more glucose‐lowering medications in people with T2D. Where 5 or more studies provided the same comparison, a random‐effects meta‐analysis was performed, reporting mean difference (MD) or odds ratio (OR) for adherence or persistence, depending on the pooled study outcomes. We included a total of 48 studies. Compared with metformin, adherence (%) was better for sulphonylureas (5 studies; MD 10.6%, 95% confidence interval [CI] 6.5‐14.7) and thiazolidinediones (TZDs; 6 studies; MD 11.3%, 95% CI 2.7%‐20.0%). Adherence to TZDs was marginally better than adherence to sulphonylureas (5 studies; MD 1.5%, 95% CI 0.1‐2.9). Dipeptidyl peptidase‐4 inhibitors had better adherence than sulphonylureas and TZDs. Glucagon‐like peptide‐1 receptor agonists had higher rates of discontinuation than long‐acting analogue insulins (6 studies; OR 1.95; 95% CI 1.17‐3.27). Long‐acting insulin analogues had better persistence than human insulins (5 studies; MD 43.1 days; 95% CI 22.0‐64.2). The methods used to define adherence and persistence were highly variable.     

TRY,TRY AGAIN: IMPROVING OLDER ADULTS‘ MEMORY THROUGH PRACTICE

Older, relative to younger, adults may be disadvantaged on typical laboratory memory tasks because of limited experience with them. This study provided task experience over four serial memory trials, on the expectation that practice would be more beneficial for older (mean age 73) than younger (mean age 23) adults, giving them the opportunity to gain task knowledge and devise strategies to enhance memory. Results confirmed these hypotheses. Although older adults remembered less throughout the trials, their memory and strategies improved. Individual differences in strategy use and educational background also predicted performance. Findings challenge the assumption that older adults cannot actively improve their memory.