Predictors of cognitive improvement after reality orientation in Alzheimer's disease

BACKGROUND: there is increasing evidence to support the efficacy of reality orientation in cognitive deficits in patients with Alzheimer's disease. The clinical characteristics of patients who respond to reality orientation are poorly understood; this knowledge could be important, given that the provision of reality orientation therapy is labour-intensive and may provoke emotional distress. AIM: to evaluate retrospectively which demographic and clinical characteristics of Alzheimer's patients predict cognitive outcomes. METHOD: we analysed 38 mild-to-moderately demented outpatients who regularly attended a one-month formal reality orientation programme. The mini mental state examination score changes from baseline-and immediately after-reality orientation were correlated with demographic and pre-treatment clinical characteristics by a linear regression analysis. RESULTS: short-term responsiveness to reality orientation was significantly predicted by a lower level of cognitive functioning (as measured by the mini mental state examination) at baseline and by the absence of euphoria, accounting together for 57.6% of variance. CONCLUSION: a lower mini mental state examination and the absence of euphoric behaviour in patients with mild-to-moderate Alzheimer's disease may predict a good cognitive outcome of reality orientation therapy.     

Exploiting the antidiabetic properties of incretins to treat type 2 diabetes mellitus: glucagon-like peptide 1 receptor agonists or insulin for patients with inadequate glycemic control?

Type 2 diabetes mellitus is associated with progressive decreases in pancreatic beta-cell function. Most patients thus require increasingly intensive treatment, including oral combination therapies followed by insulin. Fear of hypoglycemia is a potential barrier to treatment adherence and glycemic control, while weight gain can exacerbate hyperglycemia or insulin resistance. Administration of insulin can roughly mimic physiologic insulin secretion but does not address underlying pathophysiology. Glucagon-like peptide 1 (GLP-1) is an incretin hormone released by the gut in response to meal intake that helps to maintain glucose homeostasis through coordinated effects on islet alpha- and beta-cells, inhibiting glucagon output, and stimulating insulin secretion in a glucose-dependent manner. Biological effects of GLP-1 include slowing gastric emptying and decreasing appetite. Incretin mimetics (GLP-1 receptor agonists with more suitable pharmacokinetic properties versus GLP-1) significantly lower hemoglobin A1c, body weight, and postprandial glucose excursions in humans and significantly improve beta-cell function in vivo (animal data). These novel incretin-based therapies offer the potential to reduce body weight or prevent weight gain, although the durability of these effects and their potential long-term benefits need to be studied further. This article reviews recent clinical trials comparing therapy with the incretin mimetic exenatide to insulin in patients with oral treatment failure, identifies factors consistent with the use of each treatment, and delineates areas for future research.     

Prevalence of monoclonal gammopathy in patients presenting with acquired angioedema type 2

PURPOSE: Acquired angioedema type 1 is characterized by a C1 inhibitor deficiency in patients with lymphoproliferative disorders, whereas acquired angioedema type 2 is characterized by anti-C1 inhibitor antibodies, and has not been thought to be associated with lymphoproliferative disease. We studied the clinical features, complement profiles, and associated diseases in 19 new patients with diagnosed acquired angioedema type 2. SUBJECTS AND METHODS: Plasma concentrations and functional activity of complement components were measured by conventional techniques. Functional C1 inhibitor activity was assessed by a chromogenic assay. Autoantibodies to C1 inhibitor were detected using an enzyme-linked immunosorbent assay. RESULTS: The 11 men and 8 women (median age, 60 years) presented with recurrent attacks of angioedema. All patients had detectable anti-C1 inhibitor antibodies in serum. A monoclonal gammopathy was detected in 12 patients (63%) at the time of diagnosis, 11 of whom had an immunoglobulin peak of the same heavy- and light-chain isotypes as the acquired anti-C1 inhibitor antibody. Three of these 12 patients developed a malignant lymphoproliferative disease. CONCLUSION: As with type 1 disease, a large proportion of patients with acquired angioedema type 2 have a lymphoproliferative disorder.     

Comparison of two functional independence scales with a participation measure in post-stroke rehabilitation

The objectives of the study were to compare the association and responsiveness of the functional autonomy measurement system (SMAF) and functional independence measure (FIM) as outcome measures addressing functional independence in stroke patients involved in an intensive rehabilitation program and to compare their relationships with a social participation measure after rehabilitation period. One hundred and thirty-two people who had a stroke were evaluated with the SMAF and FIM during the rehabilitation period (T1: admission; T2: discharge; n=132) and twice after discharge (T3=2 weeks; n=118; T4=6 months later; n=102). At T3 and T4, a participation measure, the assessment of life habits (LIFE-H), was added. The main findings are: (1) the total scores on the SMAF and FIM are strongly correlated together (r=0.93 to 0.95; p<0.001); 2) the responsiveness of both functional independence scales is similar even though the SMAF total score is more responsive to change than the FIM total score (standardized response mean: 1.20 vs. 0.97; p<0.01); (3) the SMAF and FIM are related similarly to the daily activities domain of the participation scale; and finally (4) the social roles domain of the participation scale is less related to the SMAF and MIF than the daily activities domain; however, the SMAF score is more related to the social roles domain than the MIF. Our results support the need to use supplementary measures, such as participation measure, that cover not only physical function but also the other domains of participation, such as interpersonal relationships and leisure, that can be disrupted following a stroke.     

Creation and testing of the Geriatric Self-Efficacy Index for Urinary Incontinence

OBJECTIVES: To report on the content development, construct validity, and reliability testing of the Geriatric Self-Efficacy Index for Urinary Incontinence (GSE-UI).
DESIGN: Prospective cohort study.
SETTING: Six UI outpatient clinics in Quebec, Canada.
PARTICIPANTS: Community-dwelling incontinent men and women aged 65 and older.
MEASUREMENTS: Thirty-eight items were generated using a literature search and interdisciplinary panel of experts. Item reduction was achieved through field-testing with 75 older men and women with UI attending an information session. The final 20-item draft, measuring older adults' level of confidence in preventing urine loss, was administered to a new group of consecutive patients 1 week before and at the time of their first visit to the UI clinic to enable evaluation of test–retest reliability. A 3-day voiding diary, quantifying the frequency of UI, and the Incontinence Quality of Life questionnaire were used to test construct validity.
RESULTS: One hundred sixteen of 300 eligible patients (39%) participated (mean age±standard deviation 74±6, range 65–87). The GSE-UI items showed normal distributions and no ceiling effects. Self-efficacy scores ranged from 16 to 193 (mean 104±41, possible range 0–200) and correlated positively with quality of life scores ( r =0.7, P <.001) and negatively with UI severity ( r =−0.4, P <.001). Internal consistency for the GSE-UI was 0.94 (Cronbach alpha). Initial test–retest reliability of the 20 items using intraclass correlations ranged from 0.50 to 0.86.
CONCLUSION: The GSE-UI will enable measurement of whether a person's confidence in their ability to prevent urine loss is an important mechanism contributing to improvements in UI.     

Patient acceptable symptom state and minimal clinically important difference for patient-reported outcomes in systemic sclerosis: A secondary analysis of a randomized controlled trial comparing personalized physical therapy to usual care

Background

To estimate patient acceptable symptom state (PASS) and minimal clinically important difference (MCID) for patient-reported outcomes in systemic sclerosis (SSc).