Are migraine and non-migrainous headache risk factors for stroke in the elderly? Findings from a 12-year cohort follow-up.

BACKGROUND AND PURPOSE: There is evidence that migraine is a risk factor for stroke but little is known about this association in elderly people. Furthermore, non-migrainous headache (NMH) has received little attention despite being the most frequently reported type of headache. Late-life migraine and NMH were examined as candidate risk factors for stroke in a community-dwelling elderly sample over a 12-year follow-up. METHODS: One thousand nine hundred and nineteen non-institutionalized subjects aged 65+, without dementia (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM-IV criteria) and with no stroke history at baseline, were drawn from the Three-City Montpellier cohort (recruitment 1999-2001) for longitudinal analysis. Ischaemic and haemorrhagic stroke was reported at baseline and at each of the five follow-ups, with cases validated by a panel of experts, according to ICD-10 criteria (International Classification of Diseases, 10th revision). Migraine and NMH were determined at baseline during a neurological interview and examination using 1988 International Headache Society criteria. RESULTS: A total of 110 (5.4%) cases of migraine and 179 (8.9%) cases of NMH were identified at baseline. During the median 8.8-year follow-up, incident stroke was observed in 1.9% of baseline migrainers, 6.2% of NMH and 3.6% of those with no lifetime history of headache. Cox proportional hazard models indicated that migraine was not a risk factor for stroke; however, NMH sufferers were twice as likely to have a stroke (hazard ratio 2.00, 95% confidence interval 1.00-3.93, P = 0.049). CONCLUSIONS: This study is one of the first to suggest that late-life NMH rather than migraine could be an independent risk factor for stroke and a warning sign. The incidence of stroke in elderly migrainers, seldom reported, is particularly low.

The impact of septoplasty on health-related quality of life in paediatric patients.

OBJECTIVES: To assess the impact that septoplasty had on health-related quality of life (HRQoL) in paediatric patients and to determine whether there were patient characteristics that predicted better outcomes. DESIGN: Retrospective cohort study. SETTING: Academic paediatric otolaryngology practice. PARTICIPANTS: All paediatric patients who underwent septoplasty during the study period. MAIN OUTCOME MEASURES: The current HRQoL was assessed using the Paediatric Quality of Life Inventory (PedsQL). The Glasgow Children's Benefit Inventory (GCBI) was used to evaluate the perceived change in HRQoL following septoplasty. RESULTS: A total of 29 patients (16 boys, mean age 13 years) and their caregivers responded (response rate of 72.5%). There was a statistically significant improvement in HRQoL following septoplasty, as demonstrated by the positive mean GCBI subscores and the total GCBI score (35.1, sd = 28.4). The total mean PedsQL score for child self-report was 95.2 (sd = 6.9) and for parent-proxy report was 91.8 (sd = 8.6), which indicated good current HRQoL. The enhancement in HRQoL post-septoplasty was moderately correlated with self-reported degree of nasal obstruction pre-septoplasty (r = 0.621 for total GCBI). Also, there were differences in GCBI scores between the groups of children who wanted to have the surgery versus those who did not want to have the surgery. CONCLUSIONS: There was a significant positive change in HRQoL following paediatric septoplasty in our study population. Children who reported more severe nasal obstruction and those who wanted to have the surgery were more likely to experience enhancement of HRQoL following their surgery.

Developmental determinants in non-communicable chronic diseases and ageing.

Prenatal and peri-natal events play a fundamental role in health, development of diseases and ageing (Developmental Origins of Health and Disease (DOHaD)). Research on the determinants of active and healthy ageing is a priority to: (i) inform strategies for reducing societal and individual costs of an ageing population and (ii) develop effective novel prevention strategies. It is important to compare the trajectories of respiratory diseases with those of other chronic diseases.

Impact of a premature menopause on cognitive function in later life.

OBJECTIVE: To determine whether premature menopause (≤40 years) can have long-lasting effects on later-life cognition and investigate whether this association varies depending on the type of menopause and use of hormone treatment (HT). DESIGN: Population-based cohort study. SETTING: The French Three-City Study. POPULATION: Four thousand eight hundred and sixty-eight women aged at least 65 years. METHODS: Multivariable-adjusted logistic regression models were used to determine the association between age at menopause, type of menopause (surgical, natural), and the use of menopausal HT and later-life cognitive function. MAIN OUTCOME MEASURES: Performance on a cognitive test battery (at baseline and over 7 years) and clinical dementia diagnosis. RESULTS: Menopause at or before the age of 40 years, both premature bilateral ovariectomy and premature ovarian failure (non-surgical loss of ovarian function), was associated with worse verbal fluency (OR 1.56, 95%CI 1.12-1.87, P=0.004) and visual memory (OR 1.39, 95%CI 1.09-1.77, P=0.007) in later life. HT at the time of premature menopause appeared beneficial for later-life visual memory but increased the risk of poor verbal fluency. Type of menopause was not significantly associated with cognitive function. Premature menopause was associated with a 30% increased risk of decline in psychomotor speed and global cognitive function over 7 years. CONCLUSION: Both premature surgical menopause and premature ovarian failure were associated with long-term negative effects on cognitive function, which are not entirely offset by menopausal HT. In terms of surgical menopause, these results suggest that the potential long-term effects on cognitive function should form part of the risk/benefit ratio when considering ovariectomy in younger women.

The association between caffeine and cognitive decline: examining alternative causal hypotheses.

BACKGROUND: Numerous studies suggest that higher coffee consumption may reduce the rate of aging-related cognitive decline in women. It is thus potentially a cheap and widely available candidate for prevention programs provided its mechanism may be adequately understood. The assumed effect is that of reduced amyloid deposition, however, alternative pathways notably by reducing depression and diabetes type 2 risk have not been considered. METHODS: A population study of 1,193 elderly persons examining depressive symptomatology, caffeine consumption, fasting glucose levels, type 2 diabetes onset, serum amyloid, and factors known to affect cognitive performance was used to explore alternative causal models. RESULTS: Higher caffeine consumption was found to be associated with decreased risk of incident diabetes in men (HR = 0.64; 95% CI 0.42-0.97) and increased risk in women (HR = 1.51; 95% CI 1.08-2.11). No association was found with incident depression. While in the total sample lower ratio Aß42/Aß40 levels (OR = 1.36, 95% CI 1.05-1.77, p = 0.02) were found in high caffeine consumers, this failed to reach significance when the analyses were stratified by gender. CONCLUSIONS: We found no evidence that reduced risk of cognitive decline in women with high caffeine consumption is moderated or confounded by diabetes or depression. The evidence of an association with plasma beta amyloid could not be clearly demonstrated. Insufficient proof of causal mechanisms currently precludes the recommendation of coffee consumption as a public health measure. Further research should focus on the high estrogen content of coffee as a plausible alternative explanation.

The APPLE Tree programme: Active Prevention in People at risk of dementia through Lifestyle, bEhaviour change and Technology to build REsiliEnce-randomised controlled trial.

BACKGROUND: Large-scale trials of multidomain interventions show that modifying lifestyle and psychological risk factors can slow cognitive decline. We aim to determine if a lower intensity, personally tailored secondary dementia prevention programme for older people with subjective or mild objective memory decline, informed by behaviour change theory, reduces cognitive decline over 2 years. METHODS: A multi-site, single-blind randomised controlled trial recruiting 704 older adults at high dementia risk due to mild cognitive impairment (MCI) or subjective cognitive decline (SCD). Participants are randomised using 1:1 allocation ratio to the APPLE Tree intervention versus control arm (dementia prevention information), stratified by site. The intervention explores and implements strategies to promote healthy lifestyle, increase pleasurable activities and social connections and improve long-term condition self-management. Two facilitators trained and supervised by a clinical psychologist deliver ten, 1-h group video call sessions over 6 months (approximately every fortnight), video-call 'tea breaks' (less structured, facilitated social sessions) in intervening weeks and individual goal-setting phone calls every 2 weeks. From 6 to 12 months, participants meet monthly for 'tea breaks', with those not attending receiving monthly goal-setting phone calls. Participants receive a food delivery, pedometer and website access to cognitive training and information about lifestyle modification. Follow-ups for all outcome measures are at 12 and 24 months. The primary outcome is cognition (Neuropsychological Test Battery (NTB) score) at 24 months. Secondary outcomes are quality of life, cost per quality-adjusted life year (QALY) and wellbeing and lifestyle factors the intervention targets (diet, vascular risk, body weight, activity, sleep, anxiety, depression, social networks and loneliness, alcohol intake and smoking). Participants from purposively selected sites participate in qualitative process evaluation interviews, which will be analysed using thematic analytic methods. DISCUSSION: If effective, the intervention design, involving remote delivery and non-clinical facilitators, would facilitate intervention roll-out to older people with memory concerns. TRIAL REGISTRATION: ISRCTN17325135 . Registration date 27 November 2019.

Resting heart rate, mortality and future coronary heart disease in the elderly: the 3C Study.

OBJECTIVES: To investigate the association between resting heart rate (RHR) and mortality and incident coronary heart disease (CHD) in the elderly. METHODS: Data derived from the Three-City Study, a French multicentre prospective study including 9294 community-dwelling elderly subjects aged ≥65 years at baseline examination between 1999 and 2001. The study population comprised 7147 participants (61% women) who were free of a pacemaker or any cardiac arrhythmias at baseline. RHR was measured twice at baseline in a seated position using an electronic tensiometer. Participants were then followed up bi-annually for vascular morbidity and mortality over 6 years. CHD events and cardiovascular death were adjudicated by an independent expert committee. RESULTS: After 6 years of follow-up, 615 subjects died including 17.9% from cardiovascular causes. Subjects from the top quintile of RHR (>79 bpm) had respectively a 74% (95% CI, 1.3-2.3), a 87% (95% CI: 0.98-3.6, p = 0.06) and a 72% (95% CI, 1.3-2.3) increased risk of total, cardiovascular and non-cardiovascular mortality compared to those from the lowest quintile (<62 bpm), after adjustment for cardiovascular risk factors and beta-blocker (BB) use in a Cox regression analysis. Associations with total mortality were consistent according to age, gender, BB use, diabetes and hypertension status (all p values for interaction >0.10). Conversely, RHR was not predictive of incident CHD (n = 228 events; top vs lowest quintile: HR: 1.0; 95% CI: 0.6-1.5). CONCLUSIONS: RHR is an independent risk marker of mortality but not of incident CHD events in community-dwelling elderly. Its routine measurement may help identify those who are at increased risk of mortality in the short term.

A prospective study of diurnal cortisol and cognitive function in community-dwelling elderly people.

BACKGROUND: Elevated cortisol levels due to hypothalamic-pituitary-adrenal (HPA) axis stress response have been associated with cognitive impairment. However, the causal relationship between stress and subsequent cognitive impairment remains unclear, notably because of the small number of gender-stratified prospective studies. METHOD: Salivary cortisol secretion was evaluated in 197 non-depressed community-dwelling elderly people at three time points on the day of hospital attendance for a clinical examination and again on the following day at home, in a distinct environmental context. Cognitive performance was evaluated at baseline and at 2- and 4-year follow-up. RESULTS: Cross-sectional logistic analyses adjusted for age and education indicated that men with high morning cortisol at the hospital had higher risk of low cognitive performance in verbal fluency [odds ratio (OR) 3.0, p=0.05] and visuospatial performance (OR 5.1, p=0.03). Impairment in verbal fluency was observed in women with moderate high morning cortisol (OR 3.6, p=0.05) or moderate slow diurnal rhythm (OR 3.7, p=0.04). In longitudinal analyses, slow diurnal rhythm (flatter slope) was associated with decline over 4 years in visuospatial performance (OR 7.7, p=0.03) and visual memory (OR 4.1, p=0.03) in men, and in verbal fluency (OR 6.0, p=0.01) in women. High morning cortisol was associated with decline in visual memory in women (OR 5.1, p=0.06). CONCLUSIONS: HPA axis dysregulation seems to be associated with low cognitive performance in the elderly. Slower cortisol elimination rates could predict cognitive decline affecting principally non-verbal functioning in men and verbal functioning in women. The effects are independent of environmental context, apolipoprotein E (ApoE) genotype or psychopathology. Interventions blocking this pathway may provide new therapeutic options to prevent cognitive decline.

Associations of Later-Life Education, the BDNF Val66Met Polymorphism and Cognitive Change in Older Adults.

In 358 participants of the Tasmanian Healthy Brain Project, we quantified the cognitive consequences of engaging in varying loads of university-level education in later life, and investigated whether or not BDNF Val66Met affected outcomes. Assessment of neuropsychological, health, and psychosocial function was undertaken at baseline, 12-month, and 24-month follow-up. Education load was positively associated with change in language processing performance, but this effect did not reach statistical significance (P = 0.064). The BDNF Val66Met polymorphism significantly moderated the extent to which education load was associated with improved language processing (P = 0.026), with education load having a significant positive relationship with cognitive change in BDNF Met carriers but not in BDNF Val homozygotes. In older adults who carry BDNF Met, engaging in university-level education improves language processing performance in a load-dependent manner.

Modelling complex pathways between late-life depression and disability: evidence for mediating and moderating factors.

Previous research has consistently shown an association between depression and disability in the elderly but little is known about the mechanisms linking the two. Recent longitudinal population studies have shown considerable inconsistency in the criteria used to establish causality and terms such as mediation and effect modification have been frequently applied incorrectly in terms of the inferences drawn. We underline the necessity to adopt more stringent theoretical criteria for the establishment of intermediary effects in the relationship between depression and disability to better identify cross-validated potential intervention points for reducing the risk of disablement and depression.

Protein denaturation in intact hepatocytes and isolated cellular organelles during heat shock.

There is circumstantial evidence that protein denaturation occurs in cells during heat shock at hyperthermic temperatures and that denatured or damaged protein is the primary inducer of the heat shock response. However, there is no direct evidence regarding the extent of denaturation of normal cellular proteins during heat shock. Differential scanning calorimetry (DSC) is the most direct method of monitoring protein denaturation or unfolding. Due to the fundamental parameter measured, heat flow, DSC can be used to detect and quantitate endothermic transitions in complex structures such as isolated organelles and even intact cells. DSC profiles with common features are obtained for isolated rat hepatocytes, liver homogenate, and Chinese hamster lung V79 fibroblasts. Five main transitions (A-E), several of which are resolvable into subcomponents, are observed with transition temperatures (Tm) of 45-98 degrees C. The onset temperature is approximately 40 degrees C, but some transitions may extend as low as 37-38 degrees C. In addition to acting as the primary signal for heat shock protein synthesis, the inactivation of critical proteins may lead to cell death. Critical target analysis implies that the rate limiting step of cell killing for V79 cells is the inactivation of a protein with Tm = 46 degrees C within the A transition. Isolated microsomal membranes, mitochondria, nuclei, and a cytosolic fraction from rat liver have distinct DSC profiles that contribute to different peaks in the profile for intact hepatocytes. Thus, the DSC profiles for intact cells appears to be the sum of the profiles of all subcellular organelles and components. The presence of endothermic transitions in the isolated organelles is strong evidence that they are due to protein denaturation. Each isolated organelle has an onset for denaturation near 40 degrees C and contains thermolabile proteins denaturing at the predicted Tm (46 degrees C) for the critical target. The extent of denaturation at any temperature can be approximately by the fractional calorimetric enthalpy. After scanning to 45 degrees C at 1 degree C/min and immediately cooling, a relatively mild heat shock, an estimated fraction denaturation of 4-7% is found in hepatocytes, V79 cells, and the isolated organelles other than nuclei, which undergo only 1% denaturation because of the high thermostability of chromatin. Thus, thermolabile proteins appear to be present in all cellular organelles and components, and protein denaturation is widespread and extensive after even mild heat shock.

[Severe depression : environmental factors of severe depression : depression in parents]. / Les facteurs environnementaux de la dépression sévère : dépression chez les parents.

Depression in parents is a significant risk factor for depression in the offspring at all ages, and also modulates depression severity. Depression severity increases with the number of parents affected, but the presence of grandparents without depression may be protective. Most studies have focused on the transmission of maternal depression, however, the few studies examining paternal depression observe that it impacts more on behavioral than emotional disorders. The genetic component of inter-generational transmission increases with the severity of depression. The interaction between parental depression, environment and onset of depression in children is complex due to the secondary effects of depression which range from in utero disturbances of cortisol secretion via the placenta, to poor parenting skills and high rates of family conflict and co-morbidity. While pharmaceutical treatment of depression in parents reduces the risk in children, it is also necessary to modify secondary factors as these may persist in the face of treatment and continue to increase risk. A number of questions remain to be explored ; the effect of the age of the child when the parent becomes depressed, the differential impact according to the child's sex, and the effect of duration of exposure.

[Schizophrenic patients' length of stay: clinical factors of variability and consequences]. / Durées d'hospitalisation des patients souffrant de schizophrénie : facteurs cliniques de variations et leurs conséquences.

BACKGROUND: Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect and sense of self. The clinical picture is further complicated by the multiple secondary consequences of the disorder; notably disrupted education, unemployment, impoverished social relationships, isolation, legal difficulties, family stress and substance abuse. Not surprisingly, the disorder is also associated with suicidal behaviour. The management of schizophrenia is thus extremely difficult with high rates of relapse, treatment refusal and poor treatment outcome. In Europe and the United States there has been a general trend towards decreasing the former long duration of hospital care in favour of short-term pharmacological stabilization in the hospital setting, followed by longer multidisciplinary follow-up within the community. This change reflects, on the one hand, the evolution in aetiological conceptions towards a predominantly neurobiological model of the disorder, with complex social consequences and also social and economic constraints. The clinical consequences of these changes were not, however, evaluated prior to the implementation of these changes. LITERATURE FINDINGS: Several studies have shown a clear relationship between reductions in duration of stay and increases in readmission rates and suggest that the development of community services may not in fact significantly improve clinical outcome, and may also possibly increase relapse rates due to the instability of the clinical condition at first discharge. There has been some unsettling evidence to suggest that shortening hospital stays may not be a general panacea. Authors reported in 1999 that deinstitutionalization policies in Denmark had led to premature discharge and subsequently a 100% increase in suicide, a doubling of the rates of criminal acts committed by psychotic patients, and increases of 80 to 100% in acute admission rates. A large follow-up study of psychotic patients in the USA found that hospital stays of less than 14 days were significantly associated with increased suicide risk; on the other hand, shortening hospital stays appears to be linked to higher rates of care satisfaction. CONCLUSION: Indeed, studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapy and lower mortality rates. The essential question of whether shortened hospital care may lead to premature discharge or, on the other hand, decreased patient dependency and social deviance, has not been adequately addressed.

[Schizophrenic patients' length of stay: mental health care implication and medicoeconomic consequences]. / Durées d'hospitalisation des patients souffrant de schizophrénie: implication des systèmes de soin et conséquences médicoéconomiques.

A striking reduction in hospital beds can be seen as the defining characteristic of mental health services in many western countries during the last 30 years. The politic of shortening hospital stays for persons with psychosis has been questioned by a number of authors. Studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapies and lower mortality rates. An interesting comparison between three contrasting mental care systems in Holland, Italy and Australia concluded not surprisingly that hospital stays are shortest where community care is more developed, although long term hospitalization will always be required for a small number of very severe patients. The general conclusion was that shorter stays work best if and only if there is high quality community care which comes into play immediately on discharge. The central issue appears to be that the beneficial effects of short stays are modulated by conditions of discharge. That is, in the absence of a planned discharge policy, patients appear to be better off staying longer, in order that a structured rehabilitation plan may be put in place. The process of deinstitutionalisation has been driven by a variety of forces. One is to reduce costs, since hospital inpatient costs are very high. Generally, between one- and two-thirds of the total health care cost of schizophrenia is for hospitalization, even in countries that have already substantially reduced their inpatient provision. Recent years have seen a trend toward mental health services provided from community-based settings for defined catchment areas. The development of these services has a heavy cost, with the opening of replacement accommodation and other community facilities and large teams. While few patients or clinicians would contest today that a return to normal community life is preferable to institutionalization, the adoption of shorter hospital stays was not an evidence-based policy and no adequate evaluation study was ever put in place to predict the social, clinical and economic consequences of this widespread practice.

[Prevalence of psychiatric disorders in French general practice using the patient health questionnaire: comparison with GP case-recognition and psychotropic medication prescription]. / Prévalence des troubles psychiatriques en médecine générale selon le patient health questionnaire: adéquation avec la détection par le médecin et le traitement prescrit.

INTRODUCTION: Psychiatric disorders, mainly depression and anxiety, are frequently encountered in primary care and are a major cause of distress and disability. Nearly half of cases go unnoticed and among those that are recognised, many do not receive adequate treatment. In France, there is limited research concerning the prevalence, detection and management of these conditions in primary care. OBJECTIVES: To estimate the prevalence of psychiatric disorders, overall and for the main psychiatric diagnostic categories, encountered in primary care; to describe general practitioners' (GPs') case identification rate; to examine psychotropic medication prescription according to diagnosis, in a regionally representative sample of GP attenders. METHODS: GP practicing standard general practice in an urban area of the city of Montpellier and a nearby semi-rural region were recruited to participate. The response rate was 32.8% (n=41). Five additional GP almost exclusively offering homeopathy and acupuncture were recruited nonrandomly for convenience purposes. In each GP surgery, consecutive patients entering the waiting room were invited by a research assistant to participate until 25 patients per GP were recruited. Each participant completed self-report questionnaires in the waiting time, including the patient health questionnaire (PHQ), which yields provisional DSM-IV diagnoses. The GP completed a brief questionnaire during the consultation, giving his/her rating of the severity of any psychiatric disorder present and action taken. RESULTS: The patient response rate was 89.8%. In all, 14.9% of patients reached DSM-IV criteria for major depression or anxiety disorder on the PHQ (9.1% for major depression, 7.5% for panic disorder; 6% for other anxiety disorders). For the subthreshold categories, 7.4% met criteria for other depressive disorders, 11.8% for somatoform disorders and 10.9% for probable alcohol abuse or dependence. 66.3% of patients with DSM-IV diagnoses of major depression or anxiety disorder were identified by the GP as having a psychiatric disorder. The identification rate was 51% for all depressive disorders, anxiety and somatoform disorders. Of patients receiving a prescription for anxiolytic or antidepressant medication on the survey day, 80% were classified as cases of psychiatric disorder by the GP. Only 48.8% met criteria for major depression or anxiety disorder on the PHQ. CONCLUSION: This study highlights the frequency of psychiatric disorders in a regional study of French general practice. Overall, prevalence rates were similar to those found elsewhere, except for probable alcohol abuse and dependence, which was considerably higher than in the USA PHQ validation study. As in other countries, GP identified roughly half of psychiatric cases. Furthermore, half of patients treated by anxiolytic or antidepressant medication did not meet the diagnostic criteria on the survey day for which these medications have mainly shown their efficacy. This confirms the French paradox of one of the highest psychotropic medication consumption rates in Europe despite many cases of depression remaining untreated. The PHQ could be a rapid and acceptable diagnostic aid tool for French general practice but first needs to be validated against the diagnosis of mental health professionals in this setting.

Risk profiles for mild cognitive impairment and progression to dementia are gender specific.

OBJECTIVE: To examine risk factors for mild cognitive impairment (MCI) and progression to dementia in a prospective community-based study of subjects aged 65 years and over. METHODS: 6892 participants who were over 65 and without dementia were recruited from a population-based cohort in three French cities. Cognitive performance, clinical diagnosis of dementia, and clinical and environmental risk factors were evaluated at baseline and 2-year and 4-year follow-ups. RESULTS: 42% of the population were classified as having MCI at baseline. After adjustment for confounding with logistic regression models, men and women classified as having MCI were more likely to have depressive symptomatology and to be taking anticholinergic drugs. Men were also more likely to have a higher body mass index, diabetes and stroke, whereas women were more likely to have poor subjective health, to be disabled, to be socially isolated, and to suffer from insomnia. The principal adjusted risk factors for men for progression from MCI to dementia in descending order were ApoE4 allele (OR = 3.2, 95% CI 1.7 to 5.7), stroke (OR = 2.8, 95% CI 1.2 to 6.9), low level of education (OR = 2.3, 95% CI 1.3 to 4.1), loss of Instrumental Activities of Daily Living (IADL) (OR = 2.2, 95% CI 1.1 to 4.5) and age (OR = 1.2, 95% CI 1.1 to 1.2). In women, progression is best predicted by IADL loss (OR = 3.5, 95% CI 2.1 to 5.9), ApoE4 allele (OR = 2.3, 95% CI 1.4 to 4.0), low level of education (OR = 2.2, 95% CI 1.3 to 3.6), subclinical depression (OR = 2.0, 95% CI 1.1 to 3.6), use of anticholinergic drugs (OR = 1.8, 95% CI 1.0 to 3.0) and age (OR = 1.1, 95% CI 1.1 to 1.2). CONCLUSIONS: Men and women have different risk profiles for both MCI and progression to dementia. Intervention programmes should focus principally on risk of stroke in men and depressive symptomatology and use of anticholinergic medication in women.

Frequent attendance and the concordance between PHQ screening and GP assessment in the detection of common mental disorders.

OBJECTIVE: Frequent Attenders (FAs) have high rates of both common mental disorders (CMD) and physical disorders, partly justifying this service use behaviour. This study examines both case and non-case concordance between CMDs as estimated by a self-report screening questionnaire and as rated by the general practitioner (GP), in FAs compared to Other Attenders (OAs). METHODS: 2275 patients of an overlapping sample of 55 GPs from 2 surveys performed 10 years apart, completed in the waiting room the Patient Health Questionnaire (PHQ) and Client Service Receipt Inventory on 6-month service use. For each patient, the GP rated mental health on a 0-4 scale, with a clear indication that scores of 2 and above referred to caseness. PHQ-CMDs included major and other depressive, anxiety, panic, and somatoform disorders, identified using the original PHQ DSM-IV criteria-based algorithms. FA was defined as the top 10% of attenders in age, sex and survey-year stratified subgroups. RESULTS: FAs had higher rates of PHQ-CMDs (42% versus 23% for OAs, p < .0001). They reported more personal and social problems, disability and had higher GP-rated physical illness. Survey-day antidepressant/anxiolytic medication prescription was higher for FAs (p < .0001), with (p = .02) but also without a CMD (p < .0001). Both GP/PHQ case and non-case concordance differed between FAs and OAs, with a non-case concordance odds ratio of 0.5 (95% CI: 0.3-0.7, p = .001) for FAs compared to OAs. CONCLUSION: Despite a greater likelihood of GPs detecting CMDs in FAs, our findings suggest a potential risk of 'over-detection' of patients not reaching CMD threshold criteria among FAs.

Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016.

BACKGROUND: While naloxone, the overdose reversal medication, has been available for decades, factors associated with its availability through pharmacies remain unclear. Studies suggest that policy and pharmacist beliefs may impact availability. Indiana passed a standing order law for naloxone in 2015 to increase access to naloxone. OBJECTIVE: To identify factors associated with community pharmacy naloxone stocking and dispensing following the enactment of a statewide naloxone standing order. METHODS: A 2016 cross-sectional census of Indiana community pharmacists was conducted following a naloxone standing order. Community, pharmacy, and pharmacist characteristics, and pharmacist attitudes about naloxone dispensing, access, and perceptions of the standing order were measured. Modified Poisson and binary logistic regression models attempted to predict naloxone stocking and dispensing, respectively. RESULTS: Over half (58.1%) of pharmacies stocked naloxone, yet 23.6% of pharmacists dispensed it. Most (72.5%) pharmacists believed the standing order would increase naloxone stocking, and 66.5% believed it would increase dispensing. Chain pharmacies were 3.2 times as likely to stock naloxone. Naloxone stocking was 1.6 times as likely in pharmacies with more than one full-time pharmacist. Pharmacies where pharmacists received naloxone continuing education in the past two years were 1.3 times as likely to stock naloxone. The attempted dispensing model yielded no improvement over the constant-only model. CONCLUSIONS: Pharmacies with larger capacity took advantage of the naloxone standing order. Predictors of pharmacist naloxone dispensing should continue to be explored to maximize naloxone access.

Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review.

Reducing the incidence of healthcare-associated infection represents a major challenge. This systematic review of the evidence base considers the clinical effectiveness of incorporating an alcohol-based hand hygiene product into procedures aimed at improving compliance with hand hygiene guidelines, and thereby reducing the incidence of healthcare-associated infections. Multi-component interventions that included alcohol-based products were as effective as those that did not, both in achieving sustained hand hygiene compliance and in reducing infection rates. However, a number of difficulties were encountered in assessing hand hygiene studies: the problem of attributing efficacy to an alcohol-based product when used in a multi-component intervention; the variability inherent in the design of such studies; and how to use data from uncontrolled, unblinded studies in the assessment.