Continuum of care for Alzheimer's disease: a nurse education and counseling program

This study evaluated a one year long course education and counseling program with 93 family caregivers of elders afflicted with Alzheimer's disease. The elders had received treatment for agitation in an inpatient setting and were subsequently discharged to the caregivers' home. Caregivers were randomly assigned to an experimental group (n = 68) and a control group (n = 25). Baseline assessments (Time 0) were conducted while the elder was an inpatient. Postdischarge interventions and assessments were conducted at 2 weeks, 6 weeks, 12 weeks, and 6 and 12 months (Times 1-5 respectively). There were no significant treatment effects for care recipient agitation, caregiver stress, depression, and physical health, and no significant differences between groups in rates of institutionalization for afflicted elders. Longitudinal data, however, revealed several important trends. Afflicted elders' agitation rose steadily for control group subjects at Times 3 through 5 but declined for experimental group subjects. Caregiver depression increased for control group subjects at Time 5, but declined for experimental group subjects. Caregiver physical health declined for control group subjects at Times 4 and 5 but was maintained for experimental group subjects. A significantly higher number of afflicted elders were still at home among experimental group subjects at the end of the one year study. The difficulties in demonstrating efficacy of interventions with family caregivers of Alzheimer's disease are discussed. Finally, the issue of data collection being perceived as support by control group subjects is evaluated.     

Enhanced Blood Conservation and Improved Clinical Outcome After Valve Surgery Using Heparin-Bonded Cardiopulmonary Bypass Circuits

Abstract Background: Recently, heparin-bonded (HBC) cardiopulmonary bypass circuits (CPB) were formed to be associated with improved outcome after coronary artery bypass grafting. There are very few reports on the efficacy and safety of these circuits in valve surgery. Methods: A retrospective cohort study of all patient populations undergoing first time valve surgery from 1992 to 1995 in a tertiary teaching hospital. Outcomes of 120 patients undergoing valve surgery using HBC and lower anticoagulation HBC were compared to 232 patients treated with conventional circuits and full heparinization (nonheparin-bonded-circuit [NHBC]). Results: Postoperative 24-hour chest tube drainage (558 ± 466 mL vs 1054 ± 911 mL, p < 0.00001), and reoperation for bleeding (2.5% vs 8.2%, p = 0.04) were lower in the HBC group. HBC patients required significantly less transfusions (total donor exposure of 6.9 ± 13.0 units vs 18.6 ± 26.2 units, p < 0.00001). Multiple linear regression analysis identified CPB time as a predictor of increased homologous blood transfusions, and the use of HBC, a large body surface area, and elective procedure as predictors of decreased transfusions. Perioperative mortality was similar (HBC 2.5%, NHBC 4.7%, p = 0.24). Overall complications were lower in the HBC group (42% vs 56.2%, p = 0.02). Perioperative myocardial infarction (0.8% vs 1.3%, p = 0.58) and cerebrovascular accident (3.3% vs 3.9%, p = 0.53) were similar. Two (1.7%) HBC patients had valve re-replacement compared to none in the NHBC (p = 0.22). Multiple logistic regression model revealed that age and CPB time were associated with increased complications, and the use of HBC with reduced complications. Conclusion: Use of HBCs with lower anticoagulation in valve surgery resulted in a significant reduction of transfusion requirements and improved clinical outcome. Because of a potential for early mechanical valve thrombosis, until further data is available, conventional levels of systemic anticoagulation should be achieved when using HBC in valve surgery.     

Activation of gadolinium-sensitive ion channels in cardiomyocytes in early adaptive stages of volume overload-induced heart failure

OBJECTIVE: The objective of this study was to investigate whether gadolinium (Gd(3+))-sensitive stretch-activated ion channels (SAC) are basally active in left ventricular (LV) myocytes in early stages of heart failure (HF) induced by volume overload. METHODS: The aortocaval fistula (ACF) model was employed to induce HF due to volume overload in rat. At specific time-points, LV myocytes were acutely isolated using a modified Langendorff apparatus. Whole-cell currents were measured using the patch-clamp technique and intracellular Ca(2+)(Ca(2+)(i)) was examined using fluorescence imaging and the Ca(2+)-sensitive dye Fura-2. RESULTS: Current-voltage data were obtained from sham and ACF myocytes at 5-d and 2-, 6-, 8- and 10-wk post surgery. Compared to data from matching sham rats, a 10 microM Gd(3+)-sensitive current at -100 mV comprised a larger fraction of total current in myocytes from 5-d, 2-wk, and 6-wk ACF rats. In general, the Gd(3+)-sensitive current contributed to inward currents at mV< or =-80 and outward currents at >+20 mV. The enhanced Gd(3+)-sensitive current was absent in myocytes from 8- and 10-wk ACF rats. 10 or 100 microM Gd(3+) had no appreciable effect on resting Ca(2+)(i) of myocytes from 5-d ACF or corresponding sham rats. The Gd(3+)-sensitive current in 5-d ACF myocytes was i) sensitive to the cation-selective SAC inhibitor, GsMTx-4, ii) non-selective for Na(+)/K(+), and iii) impermeable to Ca(2+). CONCLUSION: A basally-active, Gd(3+)- and GsMTx-4-sensitive SAC current that is non-selective for Na(+) and K(+), but impermeable to Ca(2+) under resting conditions is transiently elevated in LV myocytes from rats in early stages of volume overload-induced HF.     

Aggressive invasive recurrence of a right atrial myxofibrosarcoma

A 58‐year‐old man presented with left‐sided chest discomfort 9 years ago. At that time a 12‐centimeter extrapleural mass was resected via left thoracotomy. Surgical pathology revealed a low‐grade myxofibrosarcoma. Since that time, he had undergone three separate resections of recurrent left extrapleural masses with sternotomy and thoracotomy. He proceeded to have a five‐year disease‐free interval after which a pericardial mass invading into the right atrial free wall, the atrioventricular groove, and the right coronary artery was identified. Surgical resection was performed with negative margins and the right atrium and atrioventricular groove were reconstructed without any residual tricuspid regurgitation.     

Assessment instruments measuring malingering used with individuals who have mental retardation: potential problems and issues

Malingering, the exaggeration or fabrication of physical and/or psychological symptoms, can threaten the psychological assessment process (American Psychiatric Association, 2000). To enhance the validity of psychological evaluations, researchers have studied trends in malingering and developed instruments for its detection (Rogers, Bagby, & Dickens, 1992; Tombaugh, 1996). These instruments, however, may not be appropriate for individuals with significant subaverage intellectual functioning. Four instruments assessing malingering, frequently used in forensic evaluations, were administered to individuals with mental retardation. Results show that by utilizing established cut-off scores, we were able to classify a significant percentage of participants as "malingering," in spite of directions to perform optimally. Practical implications as well as directions for future research are discussed.     

Mu opioid receptor knockout mouse: Phenotypes with implications on restless legs syndrome

Restless legs syndrome (RLS) is characterized by an irresistible need to move the legs while sitting or lying at night with insomnia as a frequent consequence. Human RLS has been associated with abnormalities in the endogenous opioid system, the dopaminergic system, the iron regulatory system, anemia, and inflammatory and auto-immune disorders. Our previous work indicates that mice lacking all three subtypes of opioid receptors have a phenotype similar to that of human RLS. To study the roles of each opioid receptor subtype in RLS, we first used mu opioid receptor knockout (MOR KO) mice based on our earlier studies using postmortem brain and cell culture. The KO mice showed decreased hemoglobin, hematocrit, and red blood cells (RBCs), with an appearance of microcytic RBCs indicating anemia. Together with decreased serum iron and transferrin, but increased ferritin levels, the anemia is similar to that seen with chronic inflammation in humans. A decreased serum iron level was also observed in the wildtype mice treated with an MOR antagonist. Iron was increased in the liver and spleen of the KO mice. Normal circadian variations in the dopaminergic and serotoninergic systems were absent in the KO mice. The KO mice showed hyperactivity and increased thermal sensitivity in wakefulness primarily during what would normally be the sleep phase similar to that seen in human RLS. Deficits in endogenous opioid system transmission could predispose to anemia of inflammation and loss of circadian variations in dopaminergic or serotonergic systems, thereby contributing to an RLS-like phenotype.