Geriatric assessment and medical preoperative screening (GrAMPS) program for older hernia patients.

PURPOSE: The incidence of older adults undergoing inguinal and ventral hernia repairs is increasing. Older adults are disproportionately affected by age-related risk factors, which are often under-recognized and may adversely affect surgical outcomes. These age-related risk factors often termed "geriatric syndromes," include multimorbidity, frailty, cognitive impairment, depression, obesity, functional impairment, polypharmacy, and poor subjective health. The aim of this study was to identify the prevalence of age-related risk factors in older patients undergoing elective hernia repair. METHODS: Patients aged 60 years or older with a planned elective surgical repair of a ventral or inguinal hernia were prospectively enrolled in a clinic. Subjects completed several validated screening tools for geriatric syndromes. RESULTS: Seventy patients completed preoperative assessments (mean age: 68.5 years). In total, 24 (34.3%) screened positive for previously unrecognized objective cognitive impairment (Mini-Cog) and 33 (47.1%) for a subjective memory concern. Sixty patients (85.7%) met criteria for polypharmacy. Additionally, 48 (68.6%) screened positive for either pre-frailty (37, 52.9%) or frailty (11, 15.7%), and 66 (94.3%) had multimorbidity. Twenty-five (35.7%) patients self-rated their health as "poor" or "fair," and 18 (25.7%) patients endorsed some functional impairment. CONCLUSIONS: There is a high prevalence of age-related risk factors in older patients undergoing elective hernia repair. Further, these factors are often unrecognized and underappreciated despite their potential to significantly impact informed consent and shared decision making. Additional study is required to define the impact of these age-related risk factors on surgical outcomes, which will inform preoperative risk assessment and optimization through modifiable risk reduction.

Randomized control trial evaluating the use of a shared decision-making aid for older ventral hernia patients in the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) Program.

PURPOSE: Shared decision making (SDM) is ideally suited to abdominal wall surgery in older adults given the breadth of decision making required by the hernia surgeon and the impact on quality of life (QOL) by various treatment options. Given the paucity of literature surrounding SDM in hernia patients, the feasibility of a novel, formalized SDM aid/tool was evaluated in a pilot randomized trial. METHODS: Patients 60 years or older with a diagnosed ventral hernia were prospectively randomized at an academic hernia center. In the experimental arm, a novel SDM tool, based on the SHARE Approach, guided the consultation. Previously validated SDM assessments and patient's hernia knowledge retention was measured. RESULTS: Eighteen (18) patients were randomized (9 control and 9 experimental). Cohorts were well matched in age (p = 0.51), comorbidities (Charlson Comorbidity Score: p = 0.43) and frailty (mFI-11: p = 0.19; Risk Analysis Index: p = 0.33). Consultation time was 11 min longer in the experimental cohort (p < 0.01). There was a trend towards better Decisional Conflict Scores in the experimental group (p = 0.25) and the experimental cohort had improved post-visit retained hernia knowledge (p < 0.01). All patients in the experimental arm (100%) enjoyed working through the SDM aid/tool and felt it was a worthwhile exercise. CONCLUSION: Incorporating a formalized SDM tool into a busy hernia surgical practice is feasible and well received by patients. In addition, early results suggest it improves retention of basic hernia knowledge and may reduce patient's decisional conflict. Next steps include condensing the SDM tool to enhance efficiency within the clinic and beginning a large, randomized control trial.

Feeding obese dogs during weight loss is on average cost-neutral.

OBJECTIVES: The cost of feeding a purpose-formulated weight loss diet may deter owners of obese dogs from proceeding with a weight loss programme. The current study aimed to compare average food costs during weight loss with those before weight loss. MATERIALS AND METHODS: Average daily food costs, for before and during weight loss, were calculated in 22 obese dogs that had successfully completed weight management. RESULTS: The median food cost before weight loss was £0 · 52/day (£0 · 24-3 · 31/day), for main meal only, and £0 · 64/day (£0 · 26-3 · 31/day) for main meal and additional food (table scraps and treats). The median food cost during weight loss was £0 · 90/day (£0 · 26-1 · 36/day), and no additional food was given. The average daily feeding costs during weight loss did not differ from pre-weight-loss costs, either with (P = 0 · 425) or without (P = 0 · 222) the additional food included. CLINICAL SIGNIFICANCE: Knowledge that average diet costs do not significantly differ from food costs prior to weight loss may help veterinarians to persuade owners to enrol obese dogs in a weight management programme.

How many people inject insulin? UK estimates from 1991 to 2010.

AIMS: We set out to estimate the prevalence rate of insulin use in the UK population, the total number of people in the UK who use insulin, the proportion of users with type 1 and type 2 diabetes and changes between 1991 and 2010. METHODS: Patients receiving prescriptions for insulin were identified in the Clinical Practice Research Datalink and attributed a diagnosis of type 1 or type 2 diabetes. The annual prevalence of insulin use was calculated and applied to population data. RESULTS: The crude prevalence rate of insulin use increased from 2.43 (95% CI 2.38-2.49) per 1000 population in 1991 to 6.71 (6.64-6.77) per 1000 in 2010. The largest change was an increase in the prevalence of insulin users with a diagnosis of type 2 diabetes from 0.67 (0.64-0.70) to 4.34 (4.29-4.39) per 1000 population. The absolute number using insulin increased from 137 000 people (121 000-155 000) in 1991 to 421 000 (400 000-444 000) in 2010. The proportion taking insulin alone (as against combination with oral agents) decreased from 97% in the first decade to 37% in the second. CONCLUSION: The number of people using insulin trebled between 1991 and 2010, largely due to a considerable increase in the number of people with type 2 diabetes using insulin.

Assessment of the biological and pharmacological effects of the alpha nu beta3 and alpha nu beta5 integrin receptor antagonist, cilengitide (EMD 121974), in patients with advanced solid tumors.

BACKGROUND: Cilengitide, an antiangiogenic agent that inhibits the binding of integrins alpha(nu)beta(3) and alpha(nu)beta(5) to the extracellular matrix, was studied at two dose levels in cancer patients to determine the optimal biological dose. PATIENTS AND METHODS: The doses of cilengitide were 600 or 1200 mg/m(2) as a 1-h infusion twice weekly every 28 days. A novel dose escalation scheme was utilized that relied upon the biological activity rate. RESULTS: Twenty patients received 50 courses of cilengitide with no dose-limiting toxic effects. The pharmacokinetic (PK) profile revealed a short elimination half-life of 4 h, supporting twice weekly dosing. Of the six soluble angiogenic molecules assessed, only E-selectin increased significantly from baseline. Analysis of tumor microvessel density and gene expression was not informative due to intrapatient tumor heterogeneity. Although several patients with evaluable tumor biopsy pairs did reveal posttreatment increases in tumor and endothelial cell apoptosis, these results did not reach statistical significance due to the aforementioned heterogeneity. CONCLUSIONS: Cilengitide is a well-tolerated antiangiogenic agent. The biomarkers chosen in this study underscore the difficulty in assessing the biological activity of antiangiogenic agents in the absence of validated biological assays.

The effectiveness of community-based animal health workers, for the poor, for communities and for public safety.

The development of community animal health (CAH) is an invaluable tool for addressing a series of challenges, particularly for the policy-maker, whose prime concern is public welfare. This paper examines three of the major challenges which confront governments, particularly the governments of less-developed countries, namely, the collapse of government services, the crucial issue of poverty reduction and the misuse of animal drugs. Although CAH is a potentially powerful tool for approaching all of these problems, the authors argue that CAH can only be fully exploited on a macroscopic level by developing strong institutions to support and regulate such community initiatives. In some countries, developing such institutions depends upon accepting the more fundamental and controversial principle of legalising non-professional animal health service providers who work within the private sector. In Section 1, the authors outline the three principal challenges which face governments, particularly in developing countries, and to which CAH offers a potential solution. Sections 2 to 4 investigate the evidence relating to each of these challenges in turn. Section 5 briefly draws on the lessons that have been generated by field experiences over the years, to propose how governments may develop CAH systems to their best advantage.

Contribution behavior of 401(k) plan participants.

This Issue Brief examines the 1999 contribution behavior of 1.7 million 401(k) plan participants drawn from the EBRI/ICI Participant-Directed Retirement Plan Data Collection Project. The findings in this paper build on previous academic research examining the contribution activity of 401(k) participants, by using a large sample of participants in a wide range of plan sizes and by examining in detail the factors that influence contribution activity. Eighty-five percent of participants in the sample only made before-tax contributions to their plans, and 97 percent of all dollars contributed by employees were contributed on a before-tax basis. On average, participants contributed 6.8 percent of their salaries on a before-tax basis. Before-tax contribution activity varied among participants. About 61 percent of participants contributed more than 5 percent of their salaries on a before-tax basis and about 21 percent set aside more than 10 percent of their salaries on a before-tax basis. Eleven percent of participants analyzed in this study earning more than $40,000 a year contributed at the $10,000 before-tax IRC limit in 1999. Thirteen percent of participants with salaries between $70,000 and $80,000 contributed at the cap, and 18 percent of those with salaries between $80,000 and $90,000 were at the limit. However, it appears that among participants not contributing at the IRC limit, 52 percent could not have done so because of formal plan-imposed contribution limits below the IRC limit. Older participants tended to contribute a higher percentage of their salaries to plans than did younger participants, even after factoring out differences in salary and job tenure. Participants tended to increase the share of their salary (and amounts) contributed to their 401(k) plan as their salaries rose until salaries reached $80,000. For individuals with salaries above $80,000, before-tax contribution rates (though not the amounts contributed) tended to fall as salaries rose because IRC, and possibly plan sponsor, contribution limits became binding for some participants. Giving employees the option of borrowing from their 401(k) accounts increased participant contribution rates. On average, a participant in a plan offering loans appeared to contribute 0.6 percentage point more of his or her salary to the plan than a participant in a plan with no loan provision. Total contributions--the sum of employee and employer contributions--were higher for participants who received an employer contribution as part of their 401(k) plan than for those who did not. The average total contribution rate was 10 percent of salary for employees in plans offering an employer contribution, compared with 7.4 percent for those in plans not offering an employer contribution.

401(k) plan asset allocation, account balances, and loan activity in 1998.

The Employee Benefit Research Institute (EBRI) and the Investment Company Institute (ICI) have been collaborating for the past three years to collect data on participants in 401(k) plans. This effort, known as the EBRI/ICI Participant-Directed Retirement Plan Data Collection Project, has obtained data for 401(k) plan participants from certain of EBRI and ICI members serving as plan record keepers and administrators. The report includes 1998 information on 7.9 million active participants in 30,102 plans holding nearly $372 billion in assets. The data include demographic information, annual contributions, plan balances, asset allocation, and loans, and are broadly representative of the universe of 401(k) plans. The database also includes three years of longitudinal information on approximately 3.3 million participants. Key findings include: For all 401(k) participants in the 1998 EBRI/ICI database, almost three-quarters of plan balances are invested directly or indirectly in equity securities. Specifically, 49.8 percent of total plan balances are invested in equity funds, 17.7 percent in company stock, 11.4 percent in guaranteed investment contracts (GICs), 8.4 percent in balanced funds, 6.1 percent in bond funds, 4.7 percent in money funds, and 0.3 percent in other stable value funds. Participant asset allocation varies considerably with age. Younger participants tend to favor equity funds, while older participants are more disposed to invest in GICs and bond funds. On average, participants in their 20s have 62.1 percent of their account balances invested in equity funds, in contrast to 39.8 percent for those in their 60s. Participants in their 20s invest 4.7 percent of their assets in GICs, while those in their 60s invest 20.6 percent. Bond funds, which represent 4.7 percent of the assets of participants in their 20s, amount to 9.0 percent of the assets of participants in their 60s. Investment options offered by 401(k) plans appear to influence asset allocation. For example, the addition of company stock substantially reduces the allocation to equity funds and the addition of GICs lowers allocations to bond and money funds. The average account balance (net of plan loans) for all participants was $47,004 at year-end 1998, which is 26 percent higher than the average account balance at year-end 1996. The median account balance was $13,038 at year-end 1998. The balances, however, represent only amounts with current employers and do not include amounts remaining in the plans of prior employers. The average balances of older workers with long tenure indicate that a mature 401(k) plan program will produce substantial account balances. For example, individuals in their 60s with at least 30 years of tenure have average account balances in excess of $185,000. The ratio of account balance to 1998 salary varies with salary, increasing slightly as earnings rise from $20,001 to $80,000, and falling a bit for salaries greater than $80,000. The increase in ratio likely reflects a greater propensity of higher-income participants to save, whereas the decline after $80,000 results from contribution and nondiscrimination rule constraints.

The April 8, 1998 tornado: assessment of the trauma system response and the resulting injuries.

BACKGROUND: On April 8, 1998, an F5 tornado touched down in two counties of Alabama producing a wide path of destruction. The presence of a regional trauma system in this area presents an opportunity to evaluate the effectiveness of the system in responding to the victims of this natural disaster. METHODS: Emergency room logs and the regional trauma system database were searched for all patients treated for injuries sustained from the tornado, and medical records were reviewed for demographic information, mode of transportation to hospital, injuries, treatment, and outcome. Fatalities were identified by means of the coroner's office. RESULTS: A total of 224 patients were evaluated at nine area hospitals, of whom 63 (28%) required admission. There were 32 deaths: 30 persons were dead at the scene, and 2 patients subsequently died at Level I trauma centers. Among patients with nonfatal injuries, 39% were managed at Level I facilities, 46% at Level III facilities, and 15% at nontrauma facilities. Forty patients (55%) seen at Level I facilities required admission compared with 15 patients (17%) at Level III facilities and 8 patients (29%) at nontrauma facilities; Level I facilities also had the highest Injury Severity Score. Of patients requiring admission, 83% were transported by emergency medical services; these patients also had the highest Injury Severity Score. CONCLUSION: The regional trauma system facilitated appropriate and efficient triage to system hospitals, routing the most severely injured patients to the Level I centers without overwhelming them with the more numerous, less severely injured patients.

The economics of the delivery of veterinary services.

Low livestock productivity in many developing countries is commonly considered to reflect, among other factors, the inadequate supply of services to control disease. Veterinary services have traditionally been provided by the state, but public finance constraints have limited the availability and effectiveness of public services. The author explains how economic theory can be used to identify alternative delivery systems (beyond the state) for providing animal health care and proposes new roles for the state and private sector in service delivery. The author highlights a number of barriers that currently limit the potential contribution of the private sector to service delivery, and describes a variety of approaches that have been used by the state to create an enabling environment for the private sector.

Reducing age at first calving in N'Dama heifers using groundnut cake as a supplement to grazed natural pasture in The Gambia.

N'Dama heifers, initially weighing 129 kg at approximately 30 months of age, were supplemented with 250, 500 or 1000 g/head/day groundnut cake for 3 or 6 months during the dry or dry and wet seasons. Highly significant improvements in rates of liveweight gain and reproductive performance were obtained. Supplementation during the dry season only, approximately trebled the proportion of animals calving within 2 years of the beginning of the trial (6 vs 20%, P < 0.05), while this increase was around eight-fold in the animals that continued to receive supplement during the wet season (6 vs 50%, P < 0.05). Conceptions occurred at an overall mean liveweight of 185 kg, and a "target" liveweight of 200 kg for the first conception of N'Dama heifers is proposed as the basis for husbandry recommendations concerning these animals. It is concluded that such intervention can reduce the usually observed age at first calving of village based N'Dama heifers by 12 months, in a fashion that is both practicable and financially advantageous.

Subcellular distribution of various boron compounds and implications for their efficacy in boron neutron capture therapy by Monte Carlo simulations.

Neutron capture therapy has a promising role in cancer treatment since it can achieve selectivity at the cellular level. The effect of this therapy depends on the subcellular localization of boron atoms in the target cell. Five boron compounds were investigated in this study: the monomeric and dimeric sulfhydryl boranes (BSH and BSSB), a boronated phenylalanine (BPA), and two porphyrin complexes (BOPP and VCDP). The study shows that when exponentially growing rat 9L gliosarcoma cells are exposed to an isoeffective concentration of each of the five compounds for 1 h, BOPP produces a much higher intracellular level of boron than the other four compounds; BSSB produces the second highest level, while exposure to BSH, VCDP, and BPA resulted in lower intracellular boron levels. Subcellular fractionation studies showed that most of the boron localized in the cytoplasm of the cells with all five compounds. A significantly higher boron concentration was found in the lysosomes of the cells, but the nuclei contained only minimal concentrations of boron. Computer simulations of neutron capture reactions with boron using a Monte Carlo simulation code indicated that BOPP would yield the highest potential effectiveness, followed by BSSB, BSH, VCDP, and BPA, in that order.