Alzheimer and vascular neuropathological changes associated with different cognitive States in a non-demented sample.

The state between aging with no cognitive impairment and dementia has become a major focus for intervention. The neuropathological and neurobiological correlates of this intermediate state are therefore of considerable interest, particularly from population representative samples. Here we investigate the neuropathological profile associated with different cognitive ability levels measured using strata defined by Mini Mental State Examination (MMSE) scores. One hundred and fifty one individuals were stratified into three cognitive groups including: non-, mildly, and moderately impaired at death. Alzheimer's disease, atrophy, and vascular pathologies were investigated. Mild impairment was associated with an increased risk of vascular pathologies including small vessel disease and lacunes. In contrast, the moderately impaired group showed a more extensive pattern of pathology, including tangles and neuritic plaques (entorhinal/hippocampus), atrophy (cortical and hippocampal), and vascular disease (small vessel disease, lacunes, and infarcts). In a population-based sample of older people, MMSE score defined strata are associated with multiple pathologies. The profile of AD and vascular changes becomes more complex with increased cognitive impairment and these changes are likely to constitute a major substrate for age associated cognitive impairment. The results highlight the need for rigorous investigation of both neurodegenerative and vascular risks factors in old age.

Patients' descriptions of angina symptoms: a qualitative study of primary care patients.

BACKGROUND: Initial diagnosis of angina in primary care is based on the history of symptoms as described by the patient in consultation with their GP. Deciphering and categorising often complex symptom narratives, therefore, represents an ongoing challenge in the early diagnosis of angina in primary care. AIM: To explore how patients with a preexisting angina diagnosis describe their symptoms. METHOD: Semi-structured interviews were conducted with 64 males and females, identified from general practice records as having received a diagnosis of angina within the previous 5 years. RESULTS: While some patients described their angina symptoms in narratives consistent with typical anginal symptoms, others offered more complex descriptions of their angina experiences, which were less easy to classify. The latter was particularly the case for severe coronary artery disease, where some patients tended to downplay chest pain or attribute their experience to other causes. CONCLUSION: Patients with a known diagnosis of angina do not always describe their symptoms in a way that is consistent with Diamond and Forrester's diagnostic framework for typicality of angina. Early diagnosis of angina in primary care requires that GPs operate with a broad level of awareness of the various ways in which their patients describe their symptoms.

How do clinical nurse specialists influence primary care management of asthma? A qualitative study.

METHODS: We carried out a qualitative interview study alongside a randomised controlled trial which tested the effectiveness of asthma nurse specialists in east London. We carried out face-to-face interviews with five asthma nurse specialists, eight general practitioners (GPs) and six practice nurses, and also held a focus group session with six people who had attended hospital with acute asthma. RESULTS: Four factors were associated with effective specialist nurse liaison: (1) primary care practices which prioritised asthma care; (2) GPs who trusted practice nurses to manage chronic disease autonomously; (3) GPs who recognised specialist nurse expertise and acted on their advice; and (4) practices which had simple systems in place to deal with recommendations. Patients found nurse specialists approachable and informative. CONCLUSIONS: Asthma specialist nurse influence was greatest in practices that prioritised asthma care and where practice nurses had clinical autonomy. Patients valued specialist nurses but found advice from a multiplicity of clinicians confusing. Ensuring that practices prioritise chronic disease care, and improving the credibility of nurse specialists amongst GPs, may improve the effectiveness of asthma nurse specialists.

Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA).

OBJECTIVE: To determine whether asthma specialist nurses, using a liaison model of care, reduce unscheduled care in a deprived multiethnic area. DESIGN: Cluster randomised controlled trial. SETTING: 44 general practices in two boroughs in east London. PARTICIPANTS: 324 people aged 4-60 years admitted to or attending hospital or the general practitioner out of hours service with acute asthma; 164 (50%) were South Asian patients, 108 (34%) were white patients, and 52 (16%) were from other, largely African and Afro-Caribbean, ethnicities. INTERVENTION: Patient review in a nurse led clinic and liaison with general practitioners and practice nurses comprising educational outreach, promotion of guidelines for high risk asthma, and ongoing clinical support. Control practices received a visit promoting standard asthma guidelines; control patients were checked for inhaler technique. MAIN OUTCOME MEASURES: Percentage of participants receiving unscheduled care for acute asthma over one year and time to first unscheduled attendance. RESULTS: Primary outcome data were available for 319 of 324 (98%) participants. Intervention delayed time to first attendance with acute asthma (hazard ratio 0.73, 95% confidence interval 0.54 to 1.00; median 194 days for intervention and 126 days for control) and reduced the percentage of participants attending with acute asthma (58% (101/174) v 68% (99/145); odds ratio 0.62, 0.38 to 1.01). In analyses of prespecified subgroups the difference in effect on ethnic groups was not significant, but results were consistent with greater benefit for white patients than for South Asian patients or those from other ethnic groups. CONCLUSION: Asthma specialist nurses using a liaison model of care reduced unscheduled care for asthma in a deprived multiethnic health district. Ethnic groups may not benefit equally from specialist nurse intervention.