Effects of rich cannabidiol oil on behavioral disturbances in patients with dementia: A placebo controlled randomized clinical trial.

Background: Almost 90% of patients with dementia suffer from some type of neurobehavioral symptom, and there are no approved medications to address these symptoms. Objective: To evaluate the safety and efficacy of the medical cannabis oil "Avidekel" for the reduction of behavioral disturbances among patients with dementia. Materials and methods: In this randomized, double-blind, single-cite, placebo-controlled trial conducted in Israel (ClinicalTrials.gov: NCT03328676), patients aged at least 60, with a diagnosis of major neurocognitive disorder and associated behavioral disturbances were randomized 2:1 to receive either "Avidekel," a broad-spectrum cannabis oil (30% cannabidiol and 1% tetrahydrocannabinol: 295 mg and 12.5 mg per ml, respectively; n = 40) or a placebo oil (n = 20) three times a day for 16 weeks. The primary outcome was a decrease, as compared to baseline, of four or more points on the Cohen-Mansfield Agitation Inventory score by week 16. Results: From 60 randomized patients [mean age, 79.4 years; 36 women (60.0%)], 52 (86.7%) completed the trial (all eight patients who discontinued treatment were from the investigational group). There was a statistically significant difference in the proportion of subjects who had a Cohen-Mansfield Agitation Inventory score reduction of ≥ 4 points at week 16: 24/40 (60.0%) and 6/20 (30.0%) for investigational and control groups, respectively (χ2 = 4.80, P = 0.03). There was a statistically significant difference in the proportion of subjects who had a Cohen-Mansfield Agitation Inventory score reduction of ≥ 8 points at week 16: 20/40 (50%) and 3/20 (15%), respectively (χ2 = 6.42, P = 0.011). The ANOVA repeated measures analysis demonstrated significantly more improvement in the investigational group compared to the control group at weeks 14 and 16 (F = 3.18, P = 0.02). Treatment was mostly safe, with no significant differences in the occurrence of adverse events between the two groups. Conclusion: In this randomized controlled trial, 'Avidekel' oil significantly reduced agitation over placebo in patients suffering from behavioral disturbances related to dementia, with non-serious side-effects. Further research is required with a larger sample size.

Efficacy of Fluocinonide\Bifonazole Cream for the Treatment of Trachyonychia: A Retrospective Case Series.

Background: Trachyonychia is a benign nail condition, most commonly seen in children. Trachyonychia manifests as excessive longitudinal ridging, nail roughness, and nail brittleness. Treatment is sought mainly for esthetic reasons as well as functional reasons. A number of therapeutic approaches exist, mainly based on case reports or small non-comparative case series. Aims: To report treatment outcome among patients with trachyonychia. Methods: A retrospective case-series study was conducted among patients who were treated trachyonychia between years 2017 and 2020. Patients were prescribed fluocinonide 0.05% with bifonazole 1% cream, applied with or without occlusion, and methylprednisolone 1-2 mg/nail, injected into the involved nail matrix, or oral cyclosporine 3 mg/kg. Complete response (over 90% improvement) and partial response (over 50% improvement) were assessed. Results: A total of 43 patients with trachyonychia were included [mean age 10.0 years (±5.7), 69.8% males, mean disease duration 4.7 years (±3.0)]. In 90.7% of the cases, topical fluocinonide\bifonazole cream was prescribed. Under-occlusion topical application was found to be highly effective, achieving complete response in 35.3% and partial response in an additional 52.9% of the patients. Occluded application was also found to be significantly more effective than non-occluded application. Treatment efficacy was not affected by the severity of nail roughness, trachyonychia morphology, or whether trachyonychia was idiopathic or coexisted with other dermatological conditions. Conclusion: Occluded application of fluocinonide plus bifonazole cream is efficient for the treatment of trachyonychia and should be considered a first line of treatment.

Continuous terbinafine and pulse itraconazole for the treatment of non-dermatophyte mold toenail onychomycosis.

INTRODUCTION: Although dermatophytes are considered the predominant causative organisms in onychomycosis, non-dermatophyte mold (NDM) infections may be more prevalent than originally thought and may be more difficult to treat. There are limited data of oral antifungal efficacy in treating NDM onychomycosis. METHOD: A retrospective chart review (2009-2016) was conducted in patients receiving continuous oral terbinafine or pulse itraconazole for toenail onychomycosis due to NDMs. Mycology results and percent nail affected were recorded with patient characteristics including demographics and concurrent diseases. Complete, clinical, and mycological cure were tabulated. RESULTS: Data from 176 patients were collected. Mycological and complete cure rates for terbinafine (69.8% and 17%) and itraconazole (67.5% and 22%) were not significantly different from each other. Regardless of oral treatment, age (p = .013), baseline severity (p = .016), and presence of atherosclerosis (p = .040) or hyperlipidemia (p = .033) decreased the likelihood of mycological cure, while age decreased the likelihood of complete cure (p = .001). CONCLUSION: Continuous terbinafine and pulse itraconazole were similar in efficacy for curing NDM onychomycosis. Age was the most consistent prognostic factor affecting likelihood of cure, with factors that may influence drug reaching the site of infection also decreasing likelihood of mycological cure.

Bacterial Resistance to Cephalosporin Treatment in Elderly Stable Patients Hospitalized With a Urinary Tract Infection.

BACKGROUND: It is unclear if parenteral cephalosporin treatment is appropriate in stable elderly patients hospitalized with a urinary tract infection (UTI) in settings with a high prevalence of bacterial resistant organisms. METHODS: We selected 934 consecutive stable patients aged ≥65 years with a UTI, 94.4% (n = 882) treated with a parenteral cephalosporin. Patients were divided into those with and without bacterial resistance to initial antibiotic therapy (BRIAT). Outcome measures were response to antibiotic therapy at 72 hours, prolonged hospitalization (>5 days) and mortality. RESULTS: There were 316 patients (33.8%) with BRIAT. At 72 hours, 33.9% (107/316) did not respond to initial treatment. The odds of a prolonged hospitalization was 2.1 (95% confidence interval-1.6-2.9), but no patient with BRIAT died from urosepsis (0%, 95% confidence interval-0-1.2%). CONCLUSIONS: In elderly stable patients hospitalized with a UTI, treatment with a parenteral cephalosporin might be appropriate despite a high prevalence of resistant organisms.

[ORTHOSTATIC AND POSTPRANDIAL HYPOTENSION IN THE ELDERLY IN THE GERIATRIC WING].

INTRODUCTION: We describe the incidence of orthostatic hypotension (OH) and postprandial hypotension (PPH) in a population of elderly people. METHODS: Blood pressure was measured with the subjects lying in bed and after postural change to sitting. Blood pressure was also measured before and after breakfast. We examined the association between postprandial hypotension, caloric intake and the alertness of the subjects. A total of 101 residents of the Geriatric Ward in the Laniado Hospital were included in the study. RESULTS: We found a significant change in blood pressure before and after food consumption (p≤0.001, T(65)=3.31(. Post prandial hypotension PPH was found in half of the patients. Overall, no significant postural change in blood pressure was found between lying and sitting (p>0.05) although orthostatic hypotension was found in 27% of the patients. No association was found between caloric intake, postprandial hypotension and the level of alertness. DISCUSSION: The high prevalence of OH and PPH in the elderly requires strict blood pressure surveillance with appropriate and timely adjustment of drug therapy.

Exceptionally Long-Lived Individuals (ELLI) Demonstrate Slower Aging Rate Calculated by DNA Methylation Clocks as Possible Modulators for Healthy Longevity.

Exceptionally long-lived individuals (ELLI) who are the focus of many healthy longevity studies around the globe are now being studied in Israel. The Israeli Multi-Ethnic Centenarian Study (IMECS) cohort is utilized here for assessment of various DNA methylation clocks. Thorough phenotypic characterization and whole blood samples were obtained from ELLI, offspring of ELLI, and controls aged 53-87 with no familial exceptional longevity. DNA methylation was assessed using Illumina MethylationEPIC Beadchip and applied to DNAm age online tool for age and telomere length predictions. Relative telomere length was assessed using qPCR T/S (Telomere/Single copy gene) ratios. ELLI demonstrated juvenile performance in DNAm age clocks and overall methylation measurement, with preserved cognition and relative telomere length. Our findings suggest a favorable DNA methylation profile in ELLI enabling a slower rate of aging in those individuals in comparison to controls. It is possible that DNA methylation is a key modulator of the rate of aging and thus the ELLI DNAm profile promotes healthy longevity.

Feline cognitive dysfunction as a model for Alzheimer's disease in the research of CBD as a potential treatment-a narrative review.

With the improvement in modern medicine, the world's human and feline (Felis catus, the domestic cat) population is aging. As the population grows older, there is an increase of age-related diseases, such as Alzheimer's disease in humans and feline cognitive dysfunction in felines, which shares many similarities with Alzheimer's disease. They both result in cognitive decline and lack effective treatments. In light of their pathological similarities, both occur at old age, and as domestic cats share the human environment and risk factors (cats are considered an indicator to the effect of environmental contaminants on humans as they share exposures and diseases), cats have the potential to be a spontaneous model for Alzheimer's disease. Classic animal models in many cases fail to predict the results in humans, and a natural model can lead to better prediction of results, thus being both time and cost-effective. The feline disease can be researched in trials that could be simultaneously clinical trials for cats and preclinical trials for humans, also referred to as reverse translational medicine. As both maladies lack effective medical intervention, new potential treatments are merited. Cannabidiol (CBD) is a promising agent that may improve the life of these patients, as it was shown to potentially treat several of the pathologies found in both conditions. yet there is a need for further research in order to establish the benefits and safety of CBD to both human and feline patients.

[ELDERLY HOSPITALIZED FEBRILE PATIENTS WITH A SUSPECTED URINARY TRACT INFECTION: DIAGNOSTIC AND THERAPEUTIC APPROACH].

INTRODUCTION: Since the urinary tract is thought to be one of the common sources of fever in hospitalized geriatric patients, urine analysis and urine cultures are routinely ordered in patients with and without urinary tract symptoms. The widespread lack of understanding of the uncertainties in the diagnosis and treatment of a symptomatic urinary tract infection (UTI) leads to unnecessary laboratory testing, and inappropriate antibiotic therapy. We present evidence for the following proposal that on the one hand will limit urine cultures and unnecessary antibiotic therapy without compromising patient safety and on the other hand will ensure proper antibiotic therapy. (1) Patients with extra-urinary sources for their fever should not have a urinalysis or urine culture. (2) In-and-out urinary catheterization procedures to obtain a sample should be limited (3) Patients without a positive dipstick test result do not need a urine culture in some settings. (4) A negative microscopic urinalysis after a positive dipstick test does not rule out a symptomatic UTI. (5) Febrile elderly patients without evidence of end organ damage can be followed-up carefully without antibiotic therapy. (6) Patients with septic shock require immediate antibiotic treatment with a carbapenem. It is unclear however, what to do with patients who have evidence of end organ damage variously defined. Whether these patients need immediate antibiotic treatment with or without coverage of ESBL-producing bacteria to decrease the risk for in-hospital mortality is an important question that requires randomized controlled studies.

Gastrostomy Tube Placement by Radiological Methods for Older Patients Requiring Enteral Nutrition: Not to be Forgotten.

Background: The use of gastrostomy tubes for long-term nutritional support in older patients is frequent. Percutaneous gastrostomy tube placement may be performed using various techniques, including endoscopic, surgical, and radiologically-guided methods. While percutaneous endoscopic gastrostomy (PEG) placement is the most widely used and accepted approach, experience with the use of percutaneous radiological gastrostomy (PRG) is more limited. Objective: To evaluate the safety and short-term outcomes of PRG in older patients requiring long-term enteral feeding. Method: We performed a prospective study involving all patients aged 65 years and older who underwent PRG insertion at the Laniado hospital over a period of 2 years. Adverse events related to the gastrostomy tube insertion were recorded over a period of 3 months following the procedure. Results: A total of 58 patients were included with a mean age of 78.1 years, and 48% were women. The most frequent indications for enteral feeding were stroke (47%) and dementia (41%). The technical success rate was 100% with no immediate procedure-related mortality or morbidity. One-month mortality was 3%, and overall mortality at 3-month follow-up was 16%. Complications were reported in 39 (67%) of patients, with 17 (29%) experiencing more than 1 complication. While most complications (88%) were minor, major complications occurred in 19 (33%) of the patients. Peritonitis was the cause of death in 2 patients, and tube dislodgment occurred in 17 subjects. During the follow-up period 17 (29%) of patients were re-admitted to hospital, with the cause for re-hospitalization being unrelated to the PRG in half of the cases. Neither bleeding nor deep wound infection was detected in the study group. Conclusions: PRG is relatively safe and effective for gastrostomy placement in older patients, and this technique may be of value in patients with oral infections and those receiving anti-thrombotic therapy.

No need for a urine culture in elderly hospitalized patients with a negative dipstick test result.

To determine the clinical utility/disutility of canceling urine cultures in elderly patients with a negative dipstick. The cohort included consecutive patients aged ≥ 65 years hospitalized in internal medicine departments with an admission urinalysis and urine culture (January 1, 2014 to December 31, 2016). We calculated the sensitivity of the dipstick (either a trace leukocyte esterase or a positive nitrite test result) to detect patients with bacteriuria, and the decrease in urine cultures resulting from cancelation in patients with a negative dipstick. We reviewed the charts of patients with a positive culture but negative dipstick to determine if they received appropriate antibiotic therapy and if the culture results had clinical utility, defined as changes in antibiotic therapy made according to culture results in a patient who did not respond to initial antibiotic therapy. The sensitivity of the dipstick for bacteriuria was 90.8% (95% CI, 89.6-92.0%). Of the 210 patients with a positive culture but negative dipstick, 132 (62.9%) had a diagnosis clearly outside the urinary tract. Thirty-five patients (16.7%) received inappropriate differential antibiotic therapy. Urine cultures did not have clinical utility and canceling urine cultures in those with a negative dipstick would result in a 41.5% (95% CI, 40.3-42.7%) decrease in urine cultures. We conclude that canceling orders for urine cultures in the elderly patient with a negative dipstick did not have clinical disutility and would decrease inappropriate antibiotic therapy. Extrapolation to other settings is dependent on urinalysis methodology, patient selection, and physician ordering and treatment behaviors.

Sensitivity of the dipstick in detecting bacteremic urinary tract infections in elderly hospitalized patients.

BACKGROUND: The sensitivity of the dipstick in elderly patients with a suspected urinary tract infection (UTI) is unclear because of the inclusion of patients with urine contamination or asymptomatic bacteriuria in previous studies. METHODS: We selected consecutive patients aged 65 years or older hospitalized in internal medicine departments with bacteremic UTI (same organism in blood and urine cultures) minimizing misclassifications. The false positive rate was determined in consecutive patients with negative culture results. A positive dipstick was a test result with a trace leukocyte esterase and/or nitrite positivity. Bacteriuria was the growth of at least 105 colony-forming units per milliliter of urine. RESULTS: Of 20,555 consecutive patients, 228 had a bacteremic UTI, and 4069 a negative culture result. The sensitivity of the dipstick was 96.9% (95% CI-93.7-98.6) with a false positive rate of 42.4% (95% CI, 41.0-43.8) in those with a negative culture result. CONCLUSIONS: In elderly hospitalized patients with a bacteremic UTI, the dipstick urinalysis is highly sensitive, much higher than reported previously in studies of UTIs in the elderly. It is unclear whether the observed high sensitivity of the dipstick was due to the exclusion of patients with asymptomatic bacteriuria or to spectrum bias. Studies of the clinical utility/disutility of using a negative dipstick to rule out a urinary tract infection are warranted.

The impact of geriatric consultation on the care of the elders in community clinics.

The aim of this retrospective study was to describe and evaluate the impact of a new model used in caring for the elders in the community, based on geriatrician consultation, initiated by their general physician (GP) and conducted by both in five urban primary care clinics. Five hundred and forty-two elderly patients were referred to a geriatric consultant during a 41-month period. The patients' demographic, functional, cognitive medical status, reasons for referral and recommendations were recorded. Implementation by the GP of the geriatrician's recommendations was analyzed with the number of visits during the 6-month follow up. Patients were referred mainly for affective, cognitive, medical problems, functional decline and gait disturbances in 39.7%, 30.4%, 24.4%, 18.6% and 12.7% of cases, respectively. The referrals to the geriatrician increased from 133 in 2004 to 207 in 2006 (p=0.01), while the visits to the GP decreased from 10.9 to 10.2 during 6-month period following the geriatric consultation (p<0.01). No decline was found in the other elderly patients. In most cases, the GP implemented the geriatrician's advice (p<0.01). Geriatrician consultations and recommendations in the primary care clinic were well accepted by the GP, thereby reducing the number of visits.

Factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture.

OBJECTIVE: To identify factors associated with postacute rehabilitation outcome of disabled elderly patients with proximal hip fracture. SETTING: Geriatric rehabilitation center. PARTICIPANTS: One hundred thirty-three older patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM instrument, motor FIM score, absolute functional gain on the FIM and motor FIM scores, relative functional gain on the FIM and motor FIM scores, rate of improvement on the FIM and motor FIM scores, proportion of patients discharged to home, and length of stay (LOS). RESULTS: Mean FIM score improved by 14 points (22%) with a functional gain rate of .56 point per day. No significant differences (P>.05) were found between weight-bearing and non-weight-bearing patients regarding the above outcome measures. Functionally independent and cognitively intact patients achieved significantly better score changes and rates of improvement and showed a higher ability to extract their rehabilitation potential than dependent and cognitively impaired patients. Their LOSs were significantly shorter. Patients with latency time (time delay from fracture to operation) of more than 5 days and patients with a history of stroke had significantly longer LOSs. Mini-Mental State Examination score, albumin levels on admission, and prefracture functional status were the most important parameters associated with FIM discharge scores (r=.756) and relative functional gain on the FIM (r=.583). Depression was the most important factor associated with LOS in patients with weight-bearing instructions on admission. The presence of a caregiver was the significant predictive value variable for returning home. CONCLUSIONS: Cognitive function, nutritional status, preinjury functional level, and depression were the most important prognostic factors associated with rehabilitation success of older patients with proximal hip fracture. Of these, depression and nutritional status are correctable, and early intervention may improve rehabilitation outcome.

Intraorbital and periorbital tumors in children--value of ultrasound and color Doppler imaging in the differential diagnosis.

PURPOSE: To evaluate the role of ultrasonography (US) and color Doppler imaging (CDI) in the diagnosis of orbital tumors in children. DESIGN: Retrospective nonrandomized interventional case series. METHODS: This study included 42 children with intraorbital and periorbital tumors who were evaluated in our clinic. All children underwent a complete clinical evaluation as well as orbital US and CDI. The children then underwent operation or were followed up, based on the clinical diagnosis and the findings on the imaging modalities. RESULTS: The mean age of the patients at diagnosis was 22.5 months (range 2 weeks-14 years old). Eighteen patients (12 female and 6 male) were diagnosed with hemangioma based on the findings in US and CDI; 16 patients (9 female and 7 male) were diagnosed with dermoid, 5 patients (4 female and 1 male) with lymphangioma, 2 patients with rhabdomyosarcoma, and 1 patient with a subperiostal abscess. Twenty-two patients underwent operation, and the diagnosis was confirmed on pathology. Twenty patients did not undergo operation and continued to be followed up in the clinic (mean follow-up period 38.2 months). The disease course in all patients who did not undergo operation was consistent with the working diagnosis. CONCLUSION: Both US and CDI are useful modalities in the diagnosis of intraorbital and periorbital tumors in the pediatric age group.