Prevalence of Obesity and Malnutrition in Four Cohorts of Very Old Adults, 2000-2017.

OBJECTIVES: Investigate trends in the prevalence of obesity and malnutrition among very old adults (age ≥ 85 years) between 2000 and 2017. DESIGN, SETTING, PARTICIPANTS, MEASUREMENTS: A study with data from the Umeå 85+/Gerontological regional database population-based cohort study of very old adults in northern Sweden. Every 5 years from 2000-2002 to 2015-2017, comprehensive assessments of participants were performed during home visits (N=1602). Body mass index (BMI) classified participants as underweight (<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2). Mini Nutritional Assessment (MNA) scores classified participants as malnourished (0 to <17), at risk of malnutrition (17-23.5), and having good nutritional status (24-30). Prevalence and trends were examined using analysis of variance and chi-squared tests, including subgroup analyses of nursing home residents. RESULTS: Between 2000-2002 and 2015-2017, the mean BMI increased from 24.8± 4.7 to 26.0± 4.7 kg/m2. The prevalence of obesity and underweight were 13.4% and 7.6%, respectively, in 2000-2002 and 18.3% and 3.0%, respectively, in 2015-2017. The mean MNA score increased between 2000-2002 and 2010-2012 (from 23.2± 4.7 to 24.2± 3.6), and had decreased (to 23.3± 4.2) by 2015-2017. The prevalence of malnutrition was 12.2%, 5.1%, and 8.7% in 2000-2002, 2010-2012, and 2015-2017, respectively. Subgroup analyses revealed similar BMI and MNA score patterns among nursing home residents. CONCLUSIONS: Among very old adults, the mean BMI and prevalence of obesity seemed to increase between 2000-2002 and 2015-2017. Meanwhile, the nutritional status (according to MNA scores) seemed to improve between 2000-2002 and 2010-2012, it declined by 2015-2017.

The NHS visitor and migrant cost recovery programme - a threat to health?

BACKGROUND: In April 2014 the UK government launched the 'NHS Visitor and Migrant Cost Recovery Programme Implementation Plan' which set out a series of policy changes to recoup costs from 'chargeable' (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced. METHODS: There were 3342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP. RESULTS: We included 2237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p < 0.001). Median time-to-treatment also increased for the UK-born population from 75.5 days to 89.5 days (p = 0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13-1.66, p value 0.001). CONCLUSION: Since the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.

Protocol for a cluster randomised control trial evaluating the efficacy and safety of treatment for latent tuberculosis infection in recent migrants within primary care: the CATAPuLT trial.

BACKGROUND: The identification and treatment of LTBI is a key component of the WHO's strategy to eliminate TB. Recent migrants from high TB-incidence countries are recognised to be at risk TB reactivation, and many high-income countries have focused on LTBI screening and treatment programmes for this group. However, migrants are the group least likely to complete the LTBI cascade-of-care. This pragmatic cluster-randomised, parallel group, superiority trial investigates whether a model of care based entirely within a community setting (primary care) will improve treatment completion compared with treatment in specialist TB services (secondary care). METHODS: The CATAPuLT trial (Completion and Acceptability of Treatment Across Primary Care and the community for Latent Tuberculosis) randomised 34 general practices in London, England, to evaluate the efficacy and safety of treatment for LBTI in recent migrants within primary care. GP practices were randomised to either provide management for LTBI entirely within primary care (GPs and community pharmacists) or to refer patients to secondary care. The target recruitment number for individuals is 576. The primary outcome is treatment completion (defined as taking at least 90% of antibiotic doses). The secondary outcomes assess adherence, acceptance of treatment, the incidence of adverse effects including drug-induced liver injury, the rates of active TB, patient satisfaction and cost-effectiveness of LTBI treatment. This protocol adheres to the SPIRIT Checklist. DISCUSSION: The CATAPuLT trial seeks to provide implementation research evidence for a patient-centred intervention to improve treatment completion for LTBI amongst recent migrants to the UK. TRIAL REGISTRATION: NCT03069807, March 2017, registered retrospectively.

Tuberculosis and latent tuberculous infection screening of migrants in Europe: comparative analysis of policies, surveillance systems and results.

Migration patterns into and within Europe have changed over the last decade. In 2015, European Union (EU) countries received over 1.2 million asylum requests, more than double the number registered in the previous year. This review compares the published literature on policies for tuberculosis (TB) and latent tuberculous infection (LTBI) screening in EU and European Free Trade Association (EFTA) countries with the existing TB/LTBI screening programmes for migrants in 11 EU/EFTA countries based on a survey of policy and surveillance systems. In addition, we provide a systematic review of the literature on the yield of screening migrants for active TB and LTBI in Europe. Published studies provide limited information about screening coverage and the yield of screening evaluations in EU/EFTA countries. Furthermore, countries use different screening strategies and settings, and different definitions for coverage and yield of screening for active TB and LTBI. We recommend harmonising case definitions, reporting standards and policies for TB/LTBI screening. To achieve TB elimination targets, a European platform for multi-country data collection and analysis, sharing of countries' policies and practices, and harmonisation of migrant screening strategies is needed.

Body mass index, Mini Nutritional Assessment, and their association with five-year mortality in very old people.

OBJECTIVES: to investigate the prevalence of malnutrition and the association between Body Mass Index (BMI), Mini Nutritional Assessment (MNA) and five-year mortality in a representative population of very old (>85 years) people. DESIGN: A prospective cohort study. SETTING: A population-based study of very old people in northern Sweden and western Finland, living in institutional care or in the community. PARTICIPANTS: Out of 1195 potential participants, 832 were included (mean age 90.2±4.6 years). MEASUREMENTS: Nutritional status was assessed using BMI and MNA and the association of those two variables with five-year mortality was analyzed. RESULTS: The mean BMI value for the whole population was 25.1±4.5 kg/m2, with no difference between genders (P=0.938). The mean MNA score was 22.5±4.6 for the whole sample, and it was lower for women than for men (P<0.001). Thirteen percent were malnourished (MNA<17) and 40.3% at risk of malnutrition (MNA 17-23.5) according to MNA. Also, 34.8% of those with a MNA score <17 still had a BMI value ≥22.2 kg/m2. A BMI value <22.2 kg/m2 and a MNA score<17 were associated with lower survival. The association with mortality seemed to be J-shaped for BMI, and linear for MNA. CONCLUSIONS: Malnutrition according to MNA was common, but a substantial portion of those with a low MNA score still had a high BMI value, and vice versa. The association with mortality appeared to be J-shaped for BMI, and linear for MNA. The MNA seems to be a good measurement of malnutrition in very old people, and BMI might be misleading and could underestimate the prevalence of malnutrition, especially in women.

Severe orthostatic hypotension in a diabetic patient may not be due to diabetic autonomic neuropathy.

This lesson describes an unusual case of a man who was recently diagnosed with type 1 diabetes and who presented with severe orthostatic hypotension. As his diabetes was recent in onset, well controlled, and he had no other signs of microvascular disease, other causes of orthostatic hypotension were sought. His serum and cerebrospinal fluid were strongly positive for Borrelia burgdorferi IgG, suggesting a diagnosis of Lyme neuroborreliosis. Autonomic instability in Lyme, while rare, has been previously reported.

Factors governing single-trial contextual fear conditioning in the weanling rat.

Although contextual fear conditioning emerges later in development than explicit-cue fear conditioning, little is known about the stimulus parameters and biological substrates required at early ages. The authors adapted methods for investigating hippocampus function in adult rodents to identify determinants of contextual fear conditioning in developing rats. Experiment 1 examined the duration of exposure required by weanling rats at postnatal day (PND) 23 to demonstrate contextual fear conditioning. This experiment demonstrated that 30 s of context exposure is sufficient to support conditioning. Furthermore, preexposure enhanced conditioning to an immediate footshock, the context preexposure facilitation effect (CPFE), but had no effect on contextual conditioning to a delayed shock. Experiment 2 demonstrated that N-methyl-D-aspartate (NMDA) receptor inactivation during preexposure impairs contextual learning at PND 23. Thus, the conjuctive representations underlying the CPFE are NMDA-dependent as early as PND23 in the rat.

Marginalization of girl mothers during reintegration from armed groups in Sierra Leone.

BACKGROUND: Although the widespread presence of girls who participate in fighting forces is increasingly recognized, they remain a highly marginalized group globally, receiving little attention either during or after armed conflict. This is especially true for "girl mothers," girls who return to communities with children born while members of fighting forces. AIM: The concept of marginalization (Hall et al. 1994) is used to examine what happens to girl soldiers, especially girl mothers, in the aftermath of armed conflict when they seek to reintegrate back into their communities. METHODS: This analysis, as part of a larger study of reintegration of girl mothers, is based on field work with girls who were in fighting forces in northwest Sierra Leone, especially those who returned with children. FINDINGS: The type and level of marginalization these girls experience is consistent with the conceptualization of marginalization; however, they lack voice and experience shame and vulnerability. Moreover, economics were fundamentally related to their marginalization. The girls' access to resources was significantly constrained because the area was heavily impacted by the war and because of widespread poverty throughout Sierra Leone. DISCUSSION: The findings raise important questions about marginalization of girls affected by war. Girls and girl mothers experience an extremely high level of marginalization; however, some aspects are not consistent with the original conceptualization of marginalization. Theory development in nursing needs to incorporate multiple voices, especially those of the very marginalized and be done in such a manner that benefits and empowers.

Binge drinking among female Veterans Affairs patients: prevalence and associated risks.

This study evaluated the prevalence and associated risks of binge drinking, defined as having > or = 4 drinks on an occasion in the past year, in a female patient population. Of 1,259 female Veterans Affairs patients surveyed, 780 reported drinking alcohol in the past year, and 305 (24% of respondents, 39% of drinkers) reported binge drinking in the past year; 84 (11% of drinkers) had done so monthly or more often. Age-adjusted logistic regression analyses indicated that women who reported past-year binge drinking monthly or more often reported significantly increased odds of morning drinking (odds ratio [OR] = 40.3), others worrying about their drinking (OR = 38.6), arguments after drinking (OR = 13.5), hepatitis or cirrhosis (OR = 3.1), frequent injuries (OR = 2.6), smoking (OR = 3.7), drug use (OR = 22.2), and multiple sexual partners (OR = 4.6).

Family caregiver expectations and management of the stroke trajectory.

Less than 20% of stroke survivors enter rehabilitation or long-term care facilities after their stroke. Stroke recovery is extremely variable and the resulting uncertainty places a heavy burden on the survivors' family caregivers. According to the trajectory framework, chronic conditions have a defined course that can be shaped and managed. This grounded theory study, part of a larger research project, explored the expectations of family caregivers of the stroke trajectory and their management strategies. Thirteen family caregivers of stroke patients in a sparsely populated area participated in semi-structured interviews. The caregivers were without ideas about what the recovery of their loved ones would be like and had difficulty making projections about the trajectory. They used several strategies, however, in attempts to manage the stroke trajectory. They constructed a positive recovery, reconstituted family life, maintained family routines, created a safety net, and redoubled self-reliance. The findings have implications for how nurses support family caregivers of stroke survivors.

Suppression of human inflammatory cell function by subtype-selective PDE4 inhibitors correlates with inhibition of PDE4A and PDE4B.

1. Of the four major phosphodiesterase 4 (PDE4) subtypes, PDE4A, PDE4B and PDE4D are widely expressed in human inflammatory cells, including monocytes and T lymphocytes. We explored the functional role of these subtypes using ten subtype-selective PDE4 inhibitors, each belonging to one of two classes: (i) dual PDE4A/PDE4B inhibitors or (ii) PDE4D inhibitors. 2. These compounds were evaluated for their ability to inhibit antigen-stimulated T-cell proliferation and bacterial lipopolysaccharide (LPS)-stimulated tumour necrosis factor alpha (TNFalpha) release from peripheral blood monocytes. 3. All compounds inhibited T-cell proliferation in a concentration-dependent manner; with IC50 values distributed over an approximately 50 fold range. These compounds also inhibited TNFalpha release concentration-dependently, with a wider ( approximately 1000 fold) range of IC50 values. 4. In both sets of experiments, mean IC50 values were significantly correlated with compound potency against the catalytic activity of recombinant human PDE4A or PDE4B when analysed by either linear regression of log IC50 values or by Spearman's rank-order correlation. The correlation between inhibition of inflammatory cell function and inhibition of recombinant PDE4D catalytic activity was not significant in either analysis. 5. These results suggest that PDE4A and/or PDE4B may play the major role in regulating these two inflammatory cell functions but do not rule out PDE4D as an important mediator of other activities in mononuclear leukocytes and other immune and inflammatory cells. Much more work is needed to establish the functional roles of the PDE4 subtypes across a broader range of cellular functions and cell types.

Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization.

BACKGROUND: Despite the mortality benefits of breast cancer screening, not all women receive regular mammography. Such factors as age, socioeconomic status, and physician recommendation have been associated with greater use of screening. However, we do not know whether having an abnormal mammogram affects future screening. OBJECTIVE: To examine the effect of a false-positive mammogram on adherence to the next recommended screening mammogram. DESIGN: Prospective cohort study. SETTING: The breast cancer screening program at Group Health Cooperative, a health maintenance organization in Washington state. PATIENTS: 5059 women 40 years of age or older with no history of breast cancer or breast surgery who had false-positive (n = 813) or true-negative (n = 4246) index screening mammograms between 1 August 1990 and 31 July 1992. MEASUREMENTS: Screening rates and odds ratios for recommended interval screening up to 42 months after the index mammogram. RESULTS: After adjustment for differences in age; previous use of mammography; family history of breast cancer; exogenous hormone use; and age at menarche, first childbirth, and menopause, women with false-positive index mammograms were more likely than those with true-negative index mammograms to obtain their next recommended screening mammogram (odds ratio, 1.21 [95% CI, 1.01 to 1.45]). The relation between a false-positive mammogram and the likelihood of adherence to screening in the next recommended interval was strongest among women who had not previously undergone mammography (odds ratio, 1.66 [CI, 1.26 to 2.17]). CONCLUSIONS: Having a false-positive mammogram did not adversely affect screening behavior in the next recommended interval. Women with false-positive mammograms, especially those without previous mammography, were more likely to return for the next scheduled screening.

A qualitative study of self-transcendence in caregivers of terminally ill patients.

Despite changes in social and cultural structure, the family has remained a consistent provider of in-home care needs for the chronically and terminally ill. The experience of a terminal illness is not limited to the individual patient and creates a myriad of challenges for the family, including the struggle to adjust and respond to the demands of the situation. The purpose of this study was to assess the caregivers' sense of emotional well being and their ability to transcend and find meaning in the caregiving experience. The participants in this study were all caregivers of a family member who had died six to 12 months prior to the interview. They were able to find meaning as a result of their caregiving experience within the context of supportive networks, caregiving actions, grief and loss, fatigue, financial burdens and multiple challenges. Finding meaning involved "being with" or "doing for" their loved one as death approached. Finding meaning had positive consequences for the caregivers. They described a new life view and were able to reach out to help others as a result of their caregiving.

Alcohol screening questionnaires in women: a critical review.

OBJECTIVE: To describe the performance of alcohol screening questionnaires in female patients. DATA SOURCES: We searched MEDLINE from 1966 to July 1997 for alcoholism or alcohol-drinking and for CAGE, AUDIT, BMAST, TWEAK, T-ACE, MAST, SMAST, or SAAST; Citations Indexes for newer screening questionnaires and those without acronyms; and MEDLINE from 1996 to July 1997 for alcoholism or alcohol-drinking and screening. STUDY SELECTION AND DATA EXTRACTION: Reviewed studies presented data for women comparing brief alcohol screening questionnaires with valid criterion standards for heavy drinking (> or =2 drinks per day) or alcohol abuse or dependence in US general clinical populations. Sensitivities, specificities, and areas under receiver operating characteristic curves (AUROCs) were extracted. DATA SYNTHESIS: Thirteen articles (9 studies) were reviewed. The CAGE questionnaire had AUROCs of 0.84 to 0.92 for alcohol abuse and dependence in predominantly black populations of women, but using the traditional cut point of 2 or more resulted in low sensitivities (38%-50%) in predominantly white female populations. The TWEAK and Alcohol Use Disorders Identification Test (AUDIT) questionnaires had high AUROCs (0.87-0.93) for past-year alcohol abuse or dependence in black or white women, but had sensitivities less than 80% at traditional cut points. For detecting heavy drinking, the AUDIT questionnaire had AUROCs of at least 0.87 in female primary care patients. The TWEAK and T-ACE questionnaires had higher AUROCs (0.84-0.87) than the CAGE questionnaire (0.76-0.78) for detecting heavy drinking before pregnancy was recognized in black obstetric patients. CONCLUSIONS: The CAGE questionnaire was relatively insensitive in predominantly white female populations. The TWEAK and AUDIT questionnaires have performed adequately in black or white women, using lower cut points than usual.

Benefits and barriers to well-child care: perceptions of mothers in a rural state.

Though preventive health care can be beneficial, many children do not receive regular well-child care. To gain insight into the reasons for the underuse of well-child care, this qualitative study elicited consumers' views by examining how mothers in a rural state perceive well-child care, its benefits, and barriers to obtaining it. Twenty-one women in two Wyoming counties were interviewed about their knowledge and beliefs about well-child care and the care their children had received. Five categories of responses for the definition of well-child care, 10 categories of benefits, and seven categories of barriers were identified. Most of the informants valued well-child as providing maternal reassurance, information, identification of problems, developmental testing, preventive care, and health maintenance, and would obtain the recommended care if the barriers they perceived, such as financial limitations and inconvenience, were removed or reduced. Primary care providers can promote the use of well-child care in numerous ways, including educating consumers on the purposes, benefits, and schedule for preventive care, providing services that consumers value, providing high quality care, and providing cues-to-action to promote consumers to make and keep appointments.

1,4-Cyclohexanecarboxylates: potent and selective inhibitors of phosophodiesterase 4 for the treatment of asthma.

Evaluation of a variety of PDE4 inhibitors in a series of cellular and in vivo assays suggested a strategy to improve the therapeutic index of PDE4 inhibitors by increasing their selectivity for the ability to inhibit PDE4 catalytic activity versus the ability to compete for high affinity [3H]rolipram-binding sites in the central nervous system. Use of this strategy led ultimately to the identification of cis-4-cyano-4-[3-(cyclopentyloxy)-4-methoxyphenyl]cyclohexane-1-carboxyl ic acid (1, SB 207499, Ariflo), a potent second-generation inhibitor of PDE4 with a decreased potential for side effects versus the archetypic first generation inhibitor, (R)-rolipram.

Concerns of rural men and women experiencing cancer.

PURPOSE/OBJECTIVES: To examine the interpersonal relationships, self-image, healthcare interactions, and occupational concerns of rural men and women experiencing cancer directly or as a caregiver of a person with cancer. DESIGN: A descriptive design employing a mail survey as part of a larger, longitudinal study. SETTING: Rural areas in the northern Rocky Mountain region of the United States. SAMPLE: 294 people with cancer and 294 family caregivers in Montana responded to mail questionnaires. Fifty-two percent were women, and almost all were Caucasian. METHODS: Investigator-developed Cancer Concerns Inventory mailed to participants. MAIN RESEARCH VARIABLES: Interpersonal relationships, self-image, healthcare interactions, occupational concerns, gender, and type of experience with cancer. FINDINGS: In general, women were more likely than men to report relationship problems, lack of support, and feelings that were not understood. People with cancer, as compared with caregivers, were more likely to report feeling alone and that other people avoided them and were afraid to talk to them. Men with cancer were more likely than women with cancer and caregivers to feel that their job security was threatened. However, only a small percentage of all participants felt discriminated against at work. In general, a higher percentage of women with cancer and men caregivers reported concerns about healthcare interactions than men with cancer and women caregivers. CONCLUSIONS: Men and women caregivers and people with cancer have different concerns regarding cancer. IMPLICATIONS FOR NURSING PRACTICE: Nurses working in rural areas must help families work through relationship difficulties, maximize healthcare interactions, and be an advocate for people with cancer.

Rural dwellers' cancer fears and perceptions of cancer treatment.

The purpose of this study was to explore differences in cancer fears and perceptions of cancer treatment among four rural groups: men with cancer, men caregivers, women with cancer, and women caregivers (N = 590). The four groups differed in their cancer fears. About half or less feared pain, nausea, body disfigurement, and sexual problems from cancer. Over two-thirds were worried about finances and decreases in quality of life. More worried about separation from loved ones than worried about death. The four groups differed only slightly in perceptions of treatment. The majority thought chemotherapy, surgery, and radiation were important treatments. A larger percentage saw nutritional interventions and biologicals as unimportant in cancer prevention or treatment. Nurses need to address fears and perceptions of cancer treatment with persons experiencing cancer and their families. In addition, these persons and their families need support for decisions regarding cancer treatment.

Informational needs of caregivers of terminal patients in a rural state.

Home care of a terminally ill family member is stressful, especially in rural areas. This qualitative study sought to determine informational needs of rural caregivers and how that information is obtained. Although most caregivers stated satisfaction with available information, mostly obtained from physicians and nurses, their behavior belied their satisfaction. Assertive and self-reliant, they used informal communications rather than written information to meet most of their needs. Approaches home care nurses can use to help caregivers obtain important information are presented.