Community-Dwelling People Screened Positive for Dementia in Primary Care: A Comprehensive, Multivariate Descriptive Analysis Using Data from the DelpHi-Study.

BACKGROUND: Efficient help and care for people with dementia (PWD) is dependent on knowledge about PWD in primary care. OBJECTIVE: This analysis comprehensively describes community-dwelling PWD in primary care with respect to various dementia care specific variables. METHODS: The analyses are based on baseline data of the ongoing general practitioner-based, randomized, controlled intervention trial DelpHi-MV (Dementia: life- and person-centered help). 6,838 patients were screened for dementia in 136 GP practices; 17.1% were screened positive, 54.4% of those agreed to participate and data could be assessed in n = 516 subjects. We assessed age, sex, living situation, cognitive status, functional status, level of impairment, comorbidities, formal diagnosis of dementia, depression, neuropsychiatric symptoms, quality of life, utilization of medical support, and pharmacological therapy. RESULTS: Concerning clinical-, dementia-, and health-related variables, the sample under examination was on average mildly cognitively and functionally impaired (MMSE, m = 22.2; BADL, m = 3.7). A level of care was assigned in 38.0%. Depression was identified in 15.4% and other frequent comorbidities were high blood pressure (83.3%), coronary heart diseases (37.1%), cerebrovascular diseases (22.3%), among others. In 48.6%, neuropsychiatric symptoms were present in a clinically relevant severity. Pharmacological treatment with antidementia medication was received by 25.8% and antidepressant medication by 14.0%. Utilization of services was generally low. CONCLUSION: The comprehensive description of people screened positive for dementia in primary care reveals a complex and unique population of patients. They are considerably underdiagnosed and in their majority mildly to moderately affected. More in-depth analyses are needed to study relations, associations and interactions between different variables.

The effect of intermittent intraabdominal pressure elevations and low cardiac output on the femoral to carotid arterial blood pressure difference in piglets.

BACKGROUND: Our previous work in a laparoscopic setting in piglets revealed that the systolic femoral artery pressure was approximately 5 % higher than its carotid counterpart, whereas the mean and diastolic values showed no significant difference. This remained idem when the intraabdominal pressure (IAP) was gradually increased. In this study, we aimed to investigate the effect of (1) intermittent IAP elevations and (2) a low cardiac output (CO) on the blood pressure (BP) difference cranially (carotid artery) and caudally (femoral artery) of a capnoperitoneum (ΔP = P a fem-P a carot). METHODS: A total of twenty-two piglets (mean body weight 11.0 kg; range 8.9-13.3 kg) were studied. Of these, 14 underwent intermittent IAP elevations at 8 and 16 mmHg, and ΔP was measured. In another 8 piglets, a model of reduced CO was created by introducing an air embolism (2 ml/kg over 30 s) in the inferior caval vein (VCI) at 12 mmHg IAP to further assess the influence of this variable on ΔP. RESULTS: Systolic ΔP remained at a mean of 5.6 mmHg and was not significantly affected by insufflation or exsufflation up to an IAP of 16 mmHg. Diastolic and mean values showed no differences between P a carot and P a fem. P a fem, systol remained higher than its carotid counterpart as long as the cardiac index (CI) was above 1.5 l/min/m2, but fell significantly below P a carot, systol at a low CI. There was no CO-dependent effect on diastolic and mean ΔP. Repeated IAP elevations do not significantly influence ΔP. CONCLUSIONS: Intermittent IAP elevations do not significantly influence ΔP. Despite of a CO-dependent inversion of systolic ΔP, mean BP measurements at the leg during laparoscopy remain representative even at low CO values.

Air in the insufflation tube may cause fatal embolizations in laparoscopic surgery: an animal study.

BACKGROUND: The aim of this study was to evaluate the risk of an air embolization with the volume of the insufflation tube during induction of laparoscopy. A further objective was to determine the LD50 of air in young piglets. METHODS: End-tidal carbon dioxide pressure ([Formula: see text]), pulmonary arterial pressure (P pa), heart rate (f c), and mean arterial pressure (P a carot) were measured in 17 piglets divided into three groups: group 1 (n = 6), bolus application (CO2 embolization, followed by air embolization, 2 mL/kg each), group 2 (n = 7), continuous air embolization (30 min, 0.2 mL/kg/min), and group 3 (n = 4), continuous CO2 embolization (30 min, 0.4 mL/kg/min). RESULTS: All animals survived CO2 embolism. Air embolization as a bolus (2 mL/kg) or with an accumulated volume of 3.1 mL/kg led to death. Decreases in [Formula: see text] indicated air or massive CO2 embolization only. There was a good correlation between [Formula: see text] and P pa in case of air embolization (r = -0.80, p < 0.0001). In contrast, no dependency was recognized during CO2 embolism (r = -0.17, p = 0.2). CONCLUSIONS: In order to minimize the lethal risk of gas embolization, the insufflation system has to be completely filled with CO2 before connecting to the patient.

Embolism risk analysis--helium versus carbon dioxide.

BACKGROUND: Helium is used as an insufflation gas to avoid the negative properties of carbon dioxide (CO(2)), such as CO(2) accumulation, acidosis, and tachycardia, particularly in the case of insufficient respiratory function, seen also in infancy. Any laparoscopic procedure carries the risk of a gas embolism. MATERIALS AND METHODS: Seven anesthetized piglets (weighing 9.9-12.8 kg), randomized into three groups, served as models for pre-teenage children. Three piglets received a CO(2) embolism, followed by a helium embolism of 2 mL/kg, respectively. Helium was administered to three piglets, whereas both gases were repeatedly administered alternately to one piglet. The embolisms were administered for 30 seconds via a central venous line. Cardiac output was measured using the thermodilution method. The observation period for each embolism was 60 minutes in Groups 1 and 2 and 15 minutes in Group 3. RESULTS: All animals survived CO(2) embolisms. Four of the six piglets died after helium embolisms. Following helium embolisms there was a prompt initial decrease in the end-tidal CO(2) pressure and an initial increase in the pulmonary arterial pressure. A further decrease in arterial blood pressure was prevented by a compensatory increase in the heart rate and appeared just before death. After only 5 minutes cardiac output showed a 25% decline from the initial value. Helium embolisms led to a severe increase in the pulmonary dead space. CONCLUSIONS: Embolisms with the smallest amounts of helium administered via direct venous puncture have an immediate lethal impact. Extended perioperative monitoring and trocar placement under vision should be performed.

Evaluation of severely displaced radial neck fractures in children treated with elastic stable intramedullary nailing.

BACKGROUND: We performed a retrospective case study of 28 consecutive severely displaced radial neck fractures (Judet types III and IV) in children treated with elastic stable intramedullary nailing using the Metaizeau technique. METHODS: We reviewed all preoperative radiographs and classified the injuries according to Judet. All patients were asked to return for later assessment. They underwent physical examination; radiographs were taken; and they were asked for subjective assessment. An evaluation of clinical results was performed using the Mayo Elbow Performance Score (MEPS). RESULTS: According to Judet classification there were 13 type III and 15 type IV fractures. Using the MEPS, excellent results were achieved in 23 cases (82%) and good results in 5 cases (18%). The average MEPS was 97 points. Five patients complained of mild pain. Three malunions were observed. CONCLUSIONS: Elastic stable intramedullary nailing is a minimally invasive technique, allowing stable fixation and providing excellent to good outcomes with a low complication rate. LEVEL OF EVIDENCE: We performed a retrospective level 4 study of case series.

Inhibition of cortisol production by metyrapone enhances trace, but not delay, eyeblink conditioning.

RATIONALE: Hypercortisolism [ corrected] impairs trace classical conditioning of the eyeblink response to an air puff but does not affect delay conditioning. OBJECTIVES: The opposite neurohormonal condition, hypocortisolism, may facilitate trace classical conditioning, which might be informative in understanding the role of classical conditioning in stress-sensitive syndromes such as fibromyalgia. MATERIALS AND METHODS: Volunteers (n = 82) were randomized to receive either an inhibitor of cortisol production (metyrapone, 1500 mg) or placebo and to complete a delay or a trace eyeblink conditioning protocol (unconditioned stimulus: corneal air puff, 10 psi, 50 ms; conditioned stimulus: binaural pure tone, 75 dB, 1000 Hz, 400 ms; empty interval in trace conditioning: 600 ms), where conditioned eyeblink response probability was assessed electromyographically. RESULTS: Metyrapone induced hypocortisolism, reflected by a 30% decrease of salivary cortisol levels (p < 0.01), and facilitated trace eyeblink conditioning (p < 0.001), while delay eyeblink conditioning remained unaffected. Moreover, extinction of delay-conditioned eyeblink responses was impaired (p = 0.023), but extinction of trace-conditioned responses remained unaffected. CONCLUSIONS: We conclude that acute mild metyrapone-induced hypocortisolism facilitates hippocampus-mediated classical trace eyeblink conditioning but suppresses the extinction of cerebellum-based delay-conditioned responses. Both results may be of theoretical and clinical significance for the generation and persistence of psychosomatic symptoms in patient groups characterized by relative hypocortisolism (e.g., fibromyalgia and chronic fatigue).

A randomized clinical multicentre trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part III: patient factors and treatment outcome.

OBJECTIVE: Evaluation of effects of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects. MATERIAL AND METHODS: Fifty-one patients were recruited. In the intention-to-treat population 21 patients were allocated into the sequence left treatment with enamel matrix protein derivative (EMD) and right guided tissue regeneration (GTR) and 27 in the sequence left GTR and right EMD. Evaluated patient factors were: smoking, age, gender, hypertension and oral hygiene status. Outcome parameters included change of: (a) horizontal depth of the defect at the deepest point (b) distance from the fornix of the furcation to bone crest of the defect, (c) distance from stent to the bottom of the defect, (d) pocket depth and (e) attachment level at the middle of the furcation. RESULTS: In patients 54 years of age and older, in males, in non-smokers and in patients with "poor" hygiene EMD-treated sites showed a significant higher mean reduction of the parameters d (age), b (gender, hygiene) a (smoking, hygiene) when compared with sites treated with GTR. CONCLUSIONS: These data provided an indication of a possible effect of patient factors on the outcome of regenerative treatment of buccal mandibular class II furcation defects.

A randomized clinical trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part II: secondary outcomes.

BACKGROUND: This multicenter, randomized trial compared enamel matrix derivative (EMD) with barrier membranes for the treatment of Class II mandibular furcations with regard to secondary outcomes. The influence of furcation morphology on the effectiveness of either treatment was also evaluated. METHODS: Forty-eight patients (age range 28 to 73 years; 22 females, 26 males) with buccal Class II furcation involvements in both contralateral lower first or second molars were included. After initial periodontal treatment, defects were randomized to either EMD or bioabsorbable guided tissue regeneration (GTR) barrier. Study design and the results for the primary parameter were previously described. Results of the following secondary outcome variables are reported here: changes of the hard tissue boundaries describing the anatomical situation of the furcation defect and changes in the following clinical parameters between baseline and 14 months: plaque, level of gingival margin, probing depth, bleeding on probing, attachment level, and bone sounding at five sites/tooth at the buccal side. Descriptive statistics were applied for changes in clinical parameters and measurements of hard tissue boundaries. The differences observed under treatment with EMD or membrane were analyzed by means of the Wilcoxon two-sample test. The difference between the effect of the EMD and membrane treatment was estimated by means of the Hodges-Lehmann estimator. RESULTS: Overall, similar healing results were observed for both treatments. However, there was slightly more recession in the mid-furcation site following membrane treatment (P = 0.04). Additionally, different treatment effects could be detected for the distances from the stent or cemento-enamel junction (CEJ) to the buccal bone crest, mid-distal root (Pstent = 0.01; PCEJ = 0.07) and for the distance from the stent or CEJ to the buccal bone crest, mid-mesial root (Pstent = 0.01; PCEJ = 0.01). There was no measurable bone resorption in EMD sites, whereas a slight resorption occurred with membrane treatment. Furcation morphology at the time of surgery was not associated with clinical outcome, irrespective of the treatment. CONCLUSION: With regard to secondary outcome parameters, enamel matrix derivative treatment led to a similar regenerative result as the membrane procedure.

A randomized clinical trial comparing enamel matrix derivative and membrane treatment of buccal Class II furcation involvement in mandibular molars. Part I: Study design and results for primary outcomes.

BACKGROUND: The objective of this multicenter, randomized trial was to compare enamel matrix derivative (EMD; test) with barrier membranes (control) for the treatment of mandibular buccal Class II furcation defects. METHODS: Forty-five patients with 90 comparable defects on contralateral molars were included. Defects were randomly assigned to EMD or bioabsorbable barrier membrane; the contralateral defect received the alternative treatment. Assessments at baseline and 8 and 14 months included gingival margin levels, probing depths, bleeding on probing, vertical attachment levels, and vertical bone sounding from a stent at five buccal sites/ tooth. Defect dimensions were recorded at surgery and during reentry at 14 months. Change of open horizontal furcation depth was the primary outcome variable. Adverse reactions and patient perceptions were also noted. RESULTS: Both treatment modalities led to significant clinical improvements. The median reduction of open horizontal furcation depth was 2.8 mm with the corresponding interquartile interval (1.5 mm, 3.5 mm) at test sites compared with 1.8 mm (1.0 mm, 2.8 mm) at control sites. The Hodges-Lehmann estimator of the advantage (reduction test versus control) was 0.75 mm (95% confidence interval [CI]: 0.125 mm, 1.375 mm, P = 0.033, Wilcoxon). The frequency of complete furcation closure was 8/45 (test) and 3/45 (control); partial closure, 27/45 in both groups; no change, 9/45 and 11/45, respectively; and deterioration, 1/45 and 4/45, respectively. The frequency of no pain or no swelling at 1 week post-surgery was 62% and 44%, respectively, at the test sites and 12% and 6% at the control sites. CONCLUSION: There was a significantly greater reduction in horizontal furcation depth and a comparatively lower incidence of postoperative pain/swelling following enamel matrix derivative compared to membrane therapy.