A path analysis of patient dependence and caregiver burden in Alzheimer's disease.

BACKGROUND: The concept of dependence has been proposed as an integrative measure to assess the progression of Alzheimer's disease (AD).This study aimed to investigate the association of patient's dependence level with the caregiver burden within a general theoretical model that includes other well-established determinants. METHODS: Observational and cross-sectional multicenter study. The sample consisted of patients with AD recruited in outpatient consultation offices by a convenience sampling procedure stratified by dementia severity. Cognitive and functional status, behavioral disturbances, dependence level, medical comorbidities, and caregiver burden were assessed by using standardized instruments. A path analysis was used to test the hypothesized relationships between the caregiver burden and its determinants, including the level of dependence. RESULTS: The sample consisted of 306 patients (33.3% mild, 35.9% moderate, 30.7% severe), the mean age was 78.5 years (SD = 7.8), and 66.2% were women. The model fit was acceptable and explained 29% of the caregiver burden variance. Primary stressors were the level of dependence and the distress related to behavioral disturbances. Caregiver's age, gender, and co-residence with the patient were the contextual factors related to caregiver burden. The job status of the caregiver was a significant secondary stressor, functional disability was indirectly associated with caregiver burden via dependence, and frequency of behavioral disturbances was indirectly associated with the caregiver burden via distress. CONCLUSIONS: Dependence was, apart from behavioral disturbances, the most important primary stressor directly related to caregiver burden irrespective of the disease severity.

Mediterranean diet adherence in individuals with prediabetes and unknown diabetes: the Di@bet.es Study.

BACKGROUND AND AIMS: Mediterranean diet (MedDiet) is causally related to diabetes and is a dietary pattern recommended to individuals with diabetes. We investigated MedDiet adherence in individuals with prediabetes and unknown (PREDM/UKDM) or known diabetes (KDM) compared to those with normal glucose metabolism (NORMAL). METHODS: This was a national, population-based, cross-sectional, cluster-sampling study. MedDiet adherence was scored (MedScore, mean ± SD 24 ± 5) using a qualitative food frequency questionnaire. Logistic regression was used to examine the association between MedScore and PREDM/UKDM or KDM versus control subjects. RESULTS: We evaluated 5,076 individuals. Mean age was 50 years, 57% were female, 826 (582/244) were PREDM/UKDM, 478 were KDM and 3,772 were NORMAL. Mean age increased across MedScore tertiles (46, 51 and 56 years, p < 0.0001). Higher age-adjusted adherence to MedDiet (5-unit increment in the MedScore) was associated with lower and nondifferent odds (OR, 95% CI) of prevalent PREDM/UKDM (0.88, 0.81-0.96, p = 0.001) and KDM (0.97, 0.87-1.07, p = 0.279), respectively, compared to individuals in the NORMAL group. CONCLUSIONS: In a representative sample of the whole Spanish population, MedDiet adherence is independently associated with PREDM/UKDM. Therapeutic intervention may be, in part, responsible for the lack of differences in adherence observed between the KDM and NORMAL groups. However, reverse causation bias cannot be ruled out in cross-sectional studies.

Prevalence of diabetes mellitus and impaired glucose regulation in Spain: the Di@bet.es Study.

AIMS/HYPOTHESIS: The Di@bet.es Study is the first national study in Spain to examine the prevalence of diabetes and impaired glucose regulation. METHODS: A population-based, cross-sectional, cluster sampling study was carried out, with target population being the entire Spanish population. Five thousand and seventy-two participants in 100 clusters (health centres or the equivalent in each region) were randomly selected with a probability proportional to population size. Participation rate was 55.8%. Study variables were a clinical and demographic structured survey, lifestyle survey, physical examination (weight, height, BMI, waist and hip circumference, blood pressure) and OGTT (75 g). RESULTS: Almost 30% of the study population had some carbohydrate disturbance. The overall prevalence of diabetes mellitus adjusted for age and sex was 13.8% (95% CI 12.8, 14.7%), of which about half had unknown diabetes: 6.0% (95% CI 5.4, 6.7%). The age- and sex-adjusted prevalence rates of isolated impaired fasting glucose (IFG), isolated impaired glucose tolerance (IGT) and combined IFG-IGT were 3.4% (95% CI 2.9, 4.0%), 9.2% (95% CI 8.2, 10.2%) and 2.2% (95% CI 1.7, 2.7%), respectively. The prevalence of diabetes and impaired glucose regulation increased significantly with age (p < 0.0001), and was higher in men than in women (p < 0.001). CONCLUSIONS/INTERPRETATION: The Di@bet.es Study shows, for the first time, the prevalence rates of diabetes and impaired glucose regulation in a representative sample of the Spanish population.

Quality of life of patients with Alzheimer's disease: differential perceptions between spouse and adult child caregivers.

BACKGROUND/AIMS: Little research has been conducted into differences in the perceived quality of life of patients (QoL-p) when comparing spouse and adult child caregivers of people with Alzheimer's disease (AD). The aim of this study was to identify the differential variables in perceived QoL-p between patients and carers, distinguishing between spouse and adult child caregivers. METHOD: Cross-sectional analytic study of 251 patients and their carers (spouses: 112; adult children: 139) using the QoL-AD scale and sociodemographic and clinical data. RESULTS: The more positive perception of spouses was associated with higher educational levels of the caregiver and greater functional autonomy in the patient. The more negative perception of adult children was associated with greater caregiver burden and higher levels of depression in the patient. The perception of daughter caregivers showed the strongest association with mental health and burden. CONCLUSIONS: Spouse caregivers have a more positive perception of the patient's quality of life than adult child caregivers.

Extra- and intra-articular synovial chondromatosis and malignant transformation to chondrosarcoma.

Intra- and extra-articular primary synovial chondromatosis (SC) was observed in a five-year-old, entire male German Shepherd. Thousands of small cartilaginous nodules were removed from the stifle joint as well as from several adjacent muscles. Diagnosis of SC was established based on clinical, radiographic and biopsy results. The owner declined to have a new surgery performed for complete nodule removal and partial synovectomy. Nine months after the initial presentation, a proximal pathological intra- articular tibial fracture was observed and malignant transformation to chondrosarcoma was diagnosed after limb amputation. No metastasis was observed after 1.5 years of follow-up.

Simultaneous bilateral contracture of the infraspinatus muscle.

A case of bilateral fibrotic contracture of the infraspinatus muscles in a five-year-old Belgian Shepherd dog is described. The dog was presented with progressive forelimb lameness with postural and gait abnormalities three months after an episode of overexertion. When walking, the lower part of both forelimbs swung in a lateral arc causing a circumduction movement and in the standing position, the dog showed elbow adduction with external rotation of the distal part of both front limbs. Orthopaedic examination revealed bilateral atrophy of both infraspinatus and supraspinatus muscles and restriction in the range of motion of both shoulders, especially when attempting abduction and flexion. No specific findings were observed in the shoulder or elbow radiographs but hyperechogenic areas were evident in the ultrasonographic examination of both infraspinatus muscles. A diagnosis of fibrotic contracture of both infraspinatus muscles was established and bilateral tenectomy of the insertion tendons of the infraspinatus muscles was performed. Complete recovery of the animal was achieved after the surgery, which was confirmed in a long-term follow-up (10 months). In conclusion, physical examination and ultrasonography allowed a proper diagnosis of the condition, and tenectomy of the infraspinatus muscles resulted in a complete recovery of the patient even with bilateral involvement.

The stepped hybrid plate for carpal panarthrodesis - Part I: relationship between plate and bone surfaces.

In the 1990s, the AO (Arbeitsgemeinschaft für Osteosynthesefragen) Hand Study Group developed several anatomically bent plates (standard and short) for wrist panarthrodesis in humans. However, only straight plates have been used for carpal panarthrodesis (CP) in animals to date. The primary purpose of this study was to determine if precontoured plates are more anatomical for CP in dogs. Measurement of several of the bones that are implicated in CP, as well as the relationship between their surfaces and the surface of a straight plate, were performed in a radiographic and computed tomographic cadaveric study. Axial and transverse measurements taken at different levels of the metacarpal bones 2, 3 and 4 were also included. The second objective of this study was to develop a more anatomical CP plate according to the results obtained. The measurements and images obtained in this study show that, as in human orthopaedics, bent or stepped plates are more anatomically correct than straight plates for CP in dogs.

[Galanthamine versus donepezil in the treatment of Alzheimer's disease]. / Galantamina frente a donepecilo en el tratamiento de la enfermedad de Alzheimer.

AIM: To use comparative studies on the utilisation of the acetylcholinesterase inhibitors (AchE), galanthamine and donepezil, to evaluate the effectiveness and tolerance of the two drugs in the treatment of the symptoms of Alzheimer's disease (AD). DEVELOPMENT: A search was conducted on Medline for papers dealing with galanthamine and donepezil that had been published up to February 2007. Six comparative studies involving galanthamine and donepezil were found, although there are other studies that compare them together with other AchE inhibitors. CONCLUSIONS: Both drugs are moderately effective in the treatment of AD. Nevertheless, whereas in the case of donepezil there seems to be a positive relation between the maximum dosage and response, for galanthamine doses above 24 mg/day do not seem to offer any improvement. In general, treatment was well tolerated in all the studies. Maximum recommended doses (24 mg/day for galanthamine versus 10 mg/day for donepezil) were more often reached in patients treated with donepezil. The five most common side effects were, in order of frequency of presentation: nausea, agitation, vomiting, headache and fainting. In the long term, the most frequent side effects from anticholinesterases are, generally speaking, muscle cramps, tremors, nightmares, nausea, vomiting, fatigue, vertigo and loss of weight. The studies analysed show limitations in the design, duration, sample sizes and the titration schemes of the drugs.

[Telemedicine and dementia: a need for the 21st century]. / Telemedicina y demencia: una necesidad para el siglo XXI.

INTRODUCTION: The ongoing process of information and communication technologies in health services implies a change in the conception, organization and management of these services. Telemedicine is a working method that allows health professionals to explore and/or treat a patient from an off-site location. In this review we provide a historical background on telemedicine, the evolution of its bibliometric impact, and its application for people with dementia. DEVELOPMENT: Telemedicine's applications have been developed in order to provide greater availability and easier access to healthcare to underserved people. The bibliometric study of telemedicine literature shows an increase in the number of bibliographic references related to telemedicine since 1995. During the last few years in Spain the research and development of telemedicine programs have increased significantly and at present there are telemedicine programs in all regions of the country. Although some of the needs of the patients with dementia may be unsuitable for communication and information technologies, their application could offer an added value to health services. This technology does not attempt to replace face-to-face medical consultations but rather to prevent some difficulties this kind of patients can present and improve their quality of life. CONCLUSIONS: Dementia could be an appropriate field in order to implement some telemedicine programs that may improve patient medical care, and reduce medical and management expenses for social and healthcare services.

[Characterisation and prevalence of the psychological and behavioural symptoms in patients with dementia]. / Caracterización y prevalencia de los síntomas psicológicos y conductuales en pacientes con demencia.

AIM: To assess the prevalence of behavioural and psychological symptoms (BPS's) in patients with dementia in Spain and their dementia-specific characteristics. PATIENTS AND METHODS: A cross-sectional and retrospective study of 1025 patients from 52 specialized dementia care units using the Neuropsychiatric Inventory (NPI). Patients with a probable diagnosis of Alzheimer's disease (AD), dementia with Lewy bodies (DLB) and Parkinson's disease and dementia (PDD) were selected for BPS's characterisation. RESULTS: The global prevalence of BPS's was 66.7% (684 patients; 95% CI = 63.8-69.6%). BPS's were under-diagnosed in one third of cases. A total of 668 patients with NPI of 4 or superior and a diagnosis of AD (n = 380; 56.8%), DLB (n = 156; 23.3%) and PDD (n = 132; 19.7%) had a NPI mean of 21.1 (SD = 14.7), 25.6 (SD = 13.9) and 21.8 (SD = 14.2), respectively. Apathy, depression and anxiety were the most common BPS's. Delusions and hallucinations were significantly more prevalent in DLB. Dementia severity was correlated with the global NPI value and with all the sub-items, but anxiety and euphoria. The presence of agitation, euphoria or lability was associated with a deficient therapeutic fulfillment. CONCLUSION: A high prevalence of non-diagnosed BPS's was observed in the studied population. This has serious negative consequences for the quality of life of patients and their social environment. Therefore we propose an active search and subsequent correct treatment of BPS's in all patients with dementia.

[Clinical heterogeneity of Alzheimer's disease according to the age of onset]. / Heterogeneidad clinica de la enfermedad de Alzheimer segun la edad de inicio.

INTRODUCTION: The age of onset of Alzheimer's disease (AD) has been linked to the degree of clinical heterogeneity. Some studies have suggested that the presenile and senile forms may be different conditions. AIM: To describe the clinical and developmental characteristics of patients with AD according to the age of onset. PATIENTS AND METHODS: A clinical sample of AD patients was evaluated by means of the Cambridge Examination for Mental Disorders of the Elderly protocol together with other tests and clinical scales (Trail Making Test, Neuropsychiatric Inventory, Rapid-Disability Rating Scale-2 and Zarit Burden Interview). Patients were reassessed at 12 months. RESULTS: Of the 492 participants, 419 (85.2%) were cases of late-onset AD and 73 cases (14.8%) had early-onset AD. For this latter group, the time between onset of the first symptoms and diagnosis of the disease was higher (3.85 versus 2.5 years) and there was a higher frequency of family histories of dementia (35.6%) and personal histories of psychiatric disorders (13.7%). This group also presented better scores on the functional evaluation scales and on the neuropsychological tests, as well as more frequent and severe symptoms of depression. At 12 months no clinical differences were recorded between the two groups, except for an increase in the frequency and severity of apathy. CONCLUSIONS: From the differences found between early-onset and late-onset AD we cannot consider them to be two different conditions from the clinical and/or neuropsychological point of view.

Evaluation of bone formation in calcium phosphate scaffolds with µCT-method validation using SEM.

There is a plethora of calcium phosphate (CaP) scaffolds used as synthetic substitutes to bone grafts. The scaffold performance is often evaluated from the quantity of bone formed within or in direct contact with the scaffold. Micro-computed tomography (µCT) allows three-dimensional evaluation of bone formation inside scaffolds. However, the almost identical x-ray attenuation of CaP and bone obtrude the separation of these phases in µCT images. Commonly, segmentation of bone in µCT images is based on gray scale intensity, with manually determined global thresholds. However, image analysis methods, and methods for manual thresholding in particular, lack standardization and may consequently suffer from subjectivity. The aim of the present study was to provide a methodological framework for addressing these issues. Bone formation in two types of CaP scaffold architectures (foamed and robocast), obtained from a larger animal study (a 12 week canine animal model) was evaluated by µCT. In addition, cross-sectional scanning electron microscopy (SEM) images were acquired as references to determine thresholds and to validate the result. µCT datasets were registered to the corresponding SEM reference. Global thresholds were then determined by quantitatively correlating the different area fractions in the µCT image, towards the area fractions in the corresponding SEM image. For comparison, area fractions were also quantified using global thresholds determined manually by two different approaches. In the validation the manually determined thresholds resulted in large average errors in area fraction (up to 17%), whereas for the evaluation using SEM references, the errors were estimated to be less than 3%. Furthermore, it was found that basing the thresholds on one single SEM reference gave lower errors than determining them manually. This study provides an objective, robust and less error prone method to determine global thresholds for the evaluation of bone formation in CaP scaffolds.

Beta-tricalcium phosphate as a synthetic cancellous bone graft in veterinary orthopaedics: a retrospective study of 13 clinical cases.

The clinical use of beta-tricalcium phosphate (beta-TCP) as a synthetic cancellous bone graft in veterinary orthopaedics is herein reported. The retrospective study was based on 13 clinical cases belonging to 11 dogs and one cat. The weights of the dogs ranged from 3.4 to 48 kg. One female cat weighing 3.5 kg completed the study. The clinical cases were six arthrodeses (four carpal, two tarsal), one hypertrophic non-union (femur), one atrophic non-union (metacarpal bones) and five long-bone fractures (two femurs, one tibia, two radii) possessing subcritical-sized bone defects. The beta-TCP used in this study was presented as irregular interconnected- porous granules and was placed in the bone defects after mixing it with fresh blood. Bone healing was achieved at between eight and 12 weeks in all clinical cases except for the case of the chronic atrophic nonunion in which only one of the four metacarpal bones healed. In the 12 successful cases, the bone defect grafted with beta-TCP showed a radiological bone ingrowth of 100% (10 cases), 90% (one case) and 75% (one case). The complete lack of tissue adverse effects in our series, and the good defect healing, allows us to hypothesise that beta-TCP can be successfully used as a synthetic bone graft in bone defects with good local biological conditions and where osteoconduction is especially needed for assuring a structural scaffold for new-bone ingrowth. When, in addition to osteoconduction, osteoinduction and osteogenesis are necessary for defect healing, the fresh cancellous bone graft remains the gold standard in veterinary orthopaedics.

Myocarditis and generalised vasculitis associated with leishmaniosis in a dog.

A three-year-old, female bulldog was presented with bilateral uveitis, apathy, listlessness, generalised lymphadenopathy and perivulvar haematoma. The initial laboratory studies showed non-regenerative anaemia, polyclonal gammopathy and a high urine protein:creatinine ratio. Serology for leishmaniosis was positive and treatment with allopurinol and meglumine antimoniate was started. Despite treatment, the dog's clinical condition deteriorated. Signs included cutaneous ecchymosis, respiratory distress and finally cardiorespiratory arrest. Histopathological studies of postmortem tissue samples revealed a generalised vasculitis of several internal organs and severe myocarditis. Leishmania species organisms were identified in affected tissues using immunoperoxidase labelling and PCR techniques.

Interlocking nail treatment of long-bone fractures in cats: 33 cases (1995-2004).

A retrospective study between 1995 and 2004 of fracture repair in cats (n = 46) using interlocking nails (ILN) was made. Only the cases in which clinical and radiographic examination of bone healing were available are included. Five humeral and twenty eight femoral fractures were reviewed. Multiple-hole interlocking nails (MH-ILN) were used in 22 fractures, with the four-hole model (FH-ILN) in the remaining cases. In three of the cases, the FH-ILN was transformed to a three-hole model by cutting the nail between the two most distal holes. The average length of humeral ILN was 78.8 mm, and the femoral ILN was 97.2 mm. Static fixation was performed in 27 cases, with dynamic fixation in the remaining. The medullary canal filling was 100% in both radiographic views in 16 cases. Intra-operative complications were encountered in two cases. A total number of 76 screws were inserted, with 5.26% of them being malpositioned. Malunion, in a deformed femur, and partial unscrewing of one screw were the only radiographic complications observed at the time of follow-up. The clinical outcome, as well as fracture healing, were excellent in all of the cases. The results of this study indicate that the 4.0 and 5.0 mm MH-ILN and FH-ILN can be used to repair simple or comminuted humeral and femoral fractures in cats.

Multiple cartilaginous exostosis in a Golden Retriever cross-bred puppy. Clinical, radiographic and backscattered scanning microscopy findings.

Multiple cartilaginous exostosis was diagnosed in a six-month-old Golden Retriever cross-bred male with a history of forelimb lameness and isolated, but very painful, acute episodes. Physical examination revealed a right forelimb lameness with a firm, painful palpable mass on the cranial aspect of the forearm. The radiological examination showed the presence of bony masses at the humerus and radius as well as several masses in the ribs and spinous processes of the thoracic vertebrae. Based on the history and radiographic findings, multiple cartilaginous exostosis was diagnosed. Treatment with non-steroidal anti-inflammatory drugs was commenced for two weeks without any effect. Due to the lack of a response to the treatment as well as to the progressive physical deterioration of the animal, the owners requested euthanasia of the dog. Histology of the different exostoses demonstrated the presence of a hyaline cartilage cup surrounding a central area, formed mainly by bone and cartilage trabecullae. Signs of malignancy were not observed. Back-scattered scanning electron microscopy (BEI-SEM) study revealed well ordered and progressively calcified cartilage trabecullae present underneath the non-calcified cartilage cap. At a greater depth, those cartilage trabecullae became osteochondral trabecullae, and the innermost were formed exclusively by woven and lamellar bone. The histological and back-scattered electron scanning microscopy results conclude that it was a well-arranged normal endochondral ossification process that followed a centripetal pattern inside the bony mass, confirming the diagnoses of multiple cartilaginous exostoses.