A comparison of health expectancies over 10 years: implications for elderly service needs in Hong Kong.

OBJECTIVES: We aimed to estimate health expectancies at age 65 based on physical and cognitive function in 2001-2002 and 2011-2012 and project future needs for carers from 2021 to 2041. METHODS: Data from the Elderly Health Centres (EHCs) of the Department of Health of the Government of Hong Kong comprising of people aged 65 years or older who enrolled between 2001 and 2002 (EHC 2001-2002) and between 2011 and 2012 (EHC 2011-2012) provided proportion estimates for physical impairment (assessed by independence in activities of daily living) and cognitive impairment (assessed by Abbreviated Mental Test/Mini-Mental Status Examination and self-reported doctor diagnosis of dementia). Health expectancies (years lived with/without physical and/or cognitive impairment) were calculated by Sullivan's method. The proportions of physical and/or cognitive impairment were used to project future needs for carers. RESULTS: Between 2001-2002 and 2011-2012, years lived without physical/cognitive impairment decreased for men but increased for women, both of which were less than the increases in total life expectancy. Men assessed in 2011-2012 (classified as EHC 2011-2012) lived more years with physical and/or cognitive impairment than those assessed in 2001-2002 (classified as EHC 2001-2002), and women in EHC 2011-2012 lived more years with physical impairment, but fewer years with cognitive impairment than those in EHC 2001-2002, and women enrolled in EHC 2011-2012 lived more years with physical impairment, but fewer years with cognitive impairment than those in EHC 2001-2002. As populations age, the number of carers needed is expected to increase from 344,000 in 2021 to 629,000 by 2041, or an increase of 82.9%. Sensitivity analyses excluding the participants who had been assessed in 2011-2012 from EHC 2001-2002 gave similar estimations. CONCLUSIONS: Increased life expectancy was not accompanied by an increase in years lived without physical/cognitive impairment. These findings suggest that people will live longer but could be more dependent, which would have considerable implications for elderly service needs in Hong Kong.

Trajectories of frailty among Chinese older people in Hong Kong between 2001 and 2012: an age-period-cohort analysis.

Background: there is little evidence to suggest that older people today are living in better health than their predecessors did at the same age. Only a few studies have evaluated whether there are birth cohort effects on frailty, an indicator of health in older people, encompassing physical, functional and mental health dimensions. Objectives: this study examined longitudinal trajectories of frailty among Chinese older people in Hong Kong. Methods: this study utilised data from the 18 Elderly Health Centres of the Department of Health comprising a total of 417,949 observations from 94,550 community-dwelling Chinese people aged ≥65 years in one early birth cohort (1901-23) and four later birth cohorts (1924-29, 1930-35, 1936-41, 1942-47) collected between 2001 and 2012, to examine trajectories of the frailty index and how birth cohorts may have contributed to the trends using an age-period-cohort analysis. Results: more recent cohorts had higher levels of frailty than did earlier cohorts at the same age, controlling for period, gender, marital status, educational levels, socioeconomic status, lifestyle and social factors. Older age, being female, widowhood, lower education and smoking were associated with higher levels of frailty. Conclusion: more recent cohorts had higher levels of frailty than did earlier cohorts. Frailty interventions, coupled with early detection, should be developed to combat the increasing rates of frailty in Hong Kong Chinese.

Trends in activities of daily living disability in a large sample of community-dwelling Chinese older adults in Hong Kong: an age-period-cohort analysis.

BACKGROUND: To examine the trends in activities of daily living (ADL) disability in older Chinese adults in Hong Kong between 2001 and 2012. METHODS: Using data from the Elderly Health Centres (EHCs) of the Department of Health comprising a total of 54 808 community-dwelling Chinese adults aged ≥65 years in 1 early cohort (1904-1917) and 10 3-year birth cohorts (1918-1920, 1921-1923, 1924-1926, 1927-1929, 1930-1932, 1933-1935, 1936-1938, 1939-1941, 1942-1944, 1945-1947), we examined trends in ADL disability by using age-period-cohort (APC) models. ADL disability was defined as being unable to perform at least 1 of 7 ADL activities (bathing, dressing, toileting, transferring, feeding, grooming, walking) independently. Cross-classified random-effects logistic regressions were performed for each of the APC trends with adjustment for age, period, cohort, sociodemographic, lifestyle, comorbidity and self-rated health. RESULTS: The mean age of the cohort was 70.9±4.7 (range 65-99) years. The prevalence rate of ADL disability was 1.6%. ADL disability increased with age (p<0.001) and the gradient of the increase was steeper in the older age groups. At the same age, women (1.7%) were more likely to report ADL disability than men (1.4%, p=0.001). For both genders, there was an increase in ADL disability between 2003 and 2012; adjustment for age, cohort and other covariates has diminished the trends observed among men. There was no cohort effect in ADL disability. CONCLUSIONS: ADL disability in older adults has increased over the last decade. Further study is required to identify possible causes behind the disability trends.

Use of nutritional health supplements and associated factors among parents with children at kindergartens in Hong Kong.

OBJECTIVES. To estimate the prevalence of so-called nutritional health supplement consumption among kindergarten children; secondarily to explore potential factors associated with such consumption. DESIGN. Cross-sectional, self-administered questionnaire survey. SETTING. One kindergarten each in Hong Kong island, Kowloon, and the New Territories region. SUBJECTS. Parents who had a child studying at the three sampled kindergartens in April 2010. RESULTS. Of 951 sets of parents, 730 (77%) responded. Approximately 52% (95% confidence interval, 47-58%) of the respondents gave regular health supplements to their child. The commonest type of supplement given was cod fish oil (69%). Approximately 36% of the respondents did not know the upper limit dosage of their supplement. Parents of only 66% of regular health supplements consumers, compared to 75% of non-regular users, knew that there was an inherent risk from over-consumption (P=0.018). Parental beliefs that "It is useful/important for normal child development" (adjusted odds ratio=1.93; 95% confidence interval, 1.18-3.16; P=0.009), "It is useful/important for immune function" (1.79; 1.05-3.05; P=0.032) were associated with consumption of health such supplements. CONCLUSION. There is high rate of health supplement consumption among healthy kindergarten children in Hong Kong. There are wrong beliefs from parents that health supplements are important for normal-growing children for their normal growth and body immunity. About one-third of parents has limited knowledge on potential side-effects of overdose and do not know the limit of consumption. Education on "Less (health supplement) is more (health)" is recommended.

Evaluation of a continuous quality improvement initiative for end-of-life care for older noncancer patients.

OBJECTIVES: The burden of suffering among patients with end-stage chronic diseases may be greater than those of cancer patients, as a result of longer duration of illness trajectory and high prevalence of symptoms, yet they may be less likely to receive palliative care services. To improve the quality of care of these patients, we carried out a continuous quality improvement initiative among medical and nursing staff of a convalescent facility. DESIGN: Evaluation of a quality improvement initiative. SETTING: Nonacute institution in Hong Kong SAR, China. PARTICIPANTS: The participants were patients with advanced chronic diseases not opting for active treatment. INTERVENTION: The intervention was a continuous quality improvement process carried out over a 3-month period, consisting of service reengineering, provision of guidelines and educational material, and interactive sessions to achieve culture change among staff. Evaluation before and after the intervention included patient symptoms checklist and quality-of-life measures for patients; quality-of-life and cost-of-care index for family members; quality-of-life and carer burden for staff; and use of various health care services. RESULTS: There were 80 and 89 participants in the pre- and post-intervention phase. The initiative resulted in shorter duration of stay, fewer investigations, fewer transfers back to the affiliated acute care hospital, and more follow-up by the outreach team, with no significant difference in mortality after adjusting for age and comorbidity. Symptoms of pain and cough were reduced, while there was a trend toward more constipation but less dizziness. Family members' satisfaction improved. CONCLUSIONS: It is possible to improve quality-of-life care for elderly patients with end-stage chronic diseases by staff education, and culture and system change, not only without additional resources, but likely savings were achieved in terms of reduced use of health care resources.

Psychosocial condition of family caregivers of patients with chronic obstructive pulmonary disease in Hong Kong.

OBJECTIVES. Chronic obstructive pulmonary disease is associated with physical and psychological burdens. Although there is research about health-related quality of life (HRQOL) of such patients, less is known about the psychosocial condition of their family caregivers. The objectives of this study were to examine the HRQOL and the burden of chronic obstructive pulmonary disease patient caregivers, and to identify associated relevant factors. METHODS. A total of 81 eligible caregivers completed a caregiver survey on HRQOL (Short Form-36 Questionnaire), caregiving burden (Cumulative Illness Rating Scale, CIRS) and other biopsychosocial factors. Descriptive statistics, correlations, and multiple linear regression models were used to analyse data. RESULTS. The caregiver's Mental Component Summary measure of the Short Form-36 was associated with each caregiver's total CIRS scores, the anxiety subscale of the Hospital Anxiety and Depression Scale, and the Lubben Social Network Scale. The caregiver's Physical Component Summary measure was associated with the patient's disability allowance, the caregiver's total CIRS score, and the Barthel Index score. Caregivers' Caregiving Burden Scale scores were associated with their Geriatric Depression Scale total score and the need to take care of other family members. CONCLUSIONS. This study demonstrates that depressive and anxiety symptoms are associated with caregivers' burden and HRQOL. Further studies on evaluating interventions on caregivers' HRQOL and burden should take mood symptoms into consideration.

A pilot study to examine the feasibility and acceptability of a community model for exercise prescription for patients with chronic disease.

1. A model of community care for chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) that incorporates exercise prescription is lacking, although the benefits of exercise for these diseases are established. 2. Group programmes incorporating exercise, disease education, and social support consisting of weekly sessions for 12 weeks were designed for COPD and CHF patients, in groups of 8 to 10. A home exercise programme was also prescribed. 3. This model was feasible, enjoyed good compliance, improved symptoms and measures of psychosocial outcome for both disease and improved exercise tolerance in the CHF group. 4. This model could be further developed as an integral part of community management for patients with chronic diseases.

Examining item bias in the anxiety subscale of the Hospital Anxiety and Depression Scale in patients with chronic obstructive pulmonary disease.

The Hospital Anxiety and Depression Scale (HADS) is a widely used screening instrument for depression and anxiety in medically compromised patients. The purpose of this study was to examine the differential item functioning (DIF) of the anxiety subscale of the HADA (HADS-A). A research assistant administered the HADS-A to 166 Chinese patients with chronic obstructive pulmonary disease (COPD) who were consecutively admitted to a rehabilitation hospital. Although the HADS-A was overall uni-dimensional, there were one mute item and two items with borderline misfit. Only one item had a DIF for arterial oxygen saturation. No item had DIF for other indicators of the severity of COPD. In conclusion, this study found that for one item the HADS-A has significant item bias for the severity of disease in patients with COPD.

Drug non-adherence and associated risk factors among Chinese geriatric patients in Hong Kong.

OBJECTIVES: To study the prevalence of drug non-adherence among Chinese elderly people and its associated risk factors. DESIGN: Cross-sectional survey. SETTING: Medical and Geriatrics specialist out-patient clinic in a regional hospital. PATIENTS: Elderly patients (> or =65 years) with chronic diseases requiring regular medications were selected by systematic sampling. MAIN OUTCOME MEASURES: Drug non-adherence; potential risk factors studied include patients' factors, availability of assistance, and prescription factors. RESULTS: Two hundred and nine elders participated with 84% response rate. Estimated mean prevalence rate of drug non-adherence was 37% (standard deviation, 7%). The risk factors for drug non-adherence were: (1) self-perceived adverse drug effects (odds ratio=2.5; 95% confidence interval, 1.2-5.2; P=0.017); (2) use of respiratory drugs (2.7; 1.0-7.5; P=0.048); (3) complicated drug regimens (7.4; 3.2-16.9; P<0.001); and (4) necessity to cut tablets (4.8; 2.1-10.7; P<0.001). Presence of caregiver/community nursing services assistance to pack medication (odds ratio=0.2; 95% confidence interval, 0.1-0.5; P=0.001), and the use of medication boxes (0.5; 0.3-1.0; P=0.050) were found to be the protective factors against drug non-adherence. CONCLUSION: Drug non-adherence is an important concern in patient management. Medication regimen should be simplified as far as possible, in particular to avoid cutting pills or use of different dosage at different timing. Patients receiving drugs for respiratory diseases should be the first target group for intervention. Patients should be encouraged to voice out their perceived adverse drug effects.

Prevalence and correlates of depression in Chinese elderly patients with pneumoconiosis.

Recent literature suggests that patients with pneumoconiosis may be at higher risk of developing psychiatric problems, particularly depressive illness. There are no published data on depressive disorders in elderly patients with pneumoconiosis. The aim of this study was to evaluate the prevalence and correlates of depressive disorders in a community sample of elderly Chinese patients with pneumoconiosis in Hong Kong. Two hundred and one patients with pneumoconiosis were randomly selected from the case register of the Pneumoconiosis Compensation Fund Board of Hong Kong. A psychiatrist conducted a structured clinical interview to diagnose depressive disorders according to the Diagnostic Statistical Manual for Mental Disorders, Version IV criteria. Nineteen (9.5%) patients had depressive illness. Univariate logistic regression revealed that the number of comorbid conditions, and the scores on the Lubben Social Network Scale (LSNS) and Instrumental Activities of Daily Living (IADL) were significant predictors of depressive disorders. Multivariate logistic regression analysis found that IADL and LSNS scores were the only independent predictors of depressive disorders. In conclusion, depressive disorders were common and associated with poorer functional ability and social support in patients with pneumoconiosis.

Health-related quality of life in community-dwelling men with pneumoconiosis.

BACKGROUND: There have been few data on the health-related quality of life (HRQOL) in patients with pneumoconiosis. HRQOL is an important aspect of daily living in patients with industrial diseases. OBJECTIVES: To investigate the HRQOL and factors that contribute to the impairment of HRQOL in patients with pneumoconiosis. METHODS: 297 patients with pneumoconiosis were recruited from a community-based case registry. The HRQOL was measured with the St. George's Respiratory Questionnaire (SGRQ). Pulmonary function, comorbidity and psychosocial variables were also assessed. Patients' mood state was evaluated with the Geriatric Depression Scale (GDS). RESULTS: The mean SGRQ symptom, activity, impact and total scores were 38.0 +/- 19.3, 44.5 +/- 21.9, 34.2 +/- 17.9 and 39.4 +/- 17.4, respectively. These figures were lower than those reported in patients with chronic obstructive pulmonary disease who attended chest clinics. The GDS score (r = 0.38), forced expiratory volume in 1 s predicted (FEV(1)% predicted;r = -0.33) and comorbidity (r = 0.21) were the most important predictors of the HRQOL. CONCLUSIONS: Besides lung functions, chest clinicians should consider the impact of mood symptoms and comorbidity on the HRQOL in the management of patients with pneumoconiosis.

The Geriatric Depression Scale should be shortened: results of Rasch analysis.

BACKGROUND: The purpose of this study was to examine the unidimensionality, item fit, redundancy and differential item functioning (DIF) of the 15-item version of the Geriatric Depression Scale (GDS) in a community sample of 300 Hong Kong Chinese patients with pneumoconiosis. METHODS: Participants were randomly selected from the case register of the Pneumoconiosis Compensation Fund Board of Hong Kong. A trained research assistant administered the GDS to all participants. A psychiatrist, who was blind to the GDS scores, conducted a structured clinical interview to diagnose depressive disorders according to the Diagnostic and Statistical Manual for Mental Disorders, Version IV (DSM-IV) criteria. RESULTS: Of the 300 participants, 37 (12.3%) had a DSM-IV diagnosis of depressive disorders. Eleven out of 15 items (73.3%) had INFIT/OUTFIT statistics between 0.7-1.3. Abbreviated versions were created by removal of misfit and redundant items resulting in similar overall performance as the original 15-item GDS. None of the items had significant DIF for age, level of education and cognitive impairment. CONCLUSIONS: Although the GDS was overall unidimensional, there was evidence of item redundancy indicating that a shortened version would be as adequate as the original version.

Alcohol consumption, lung function, and quality of life in pneumoconiosis.

BACKGROUND: To our knowledge, there are no previous data on drinking problems in patients with pneumoconiosis. The aim of this study was to examine drinking patterns and the impact of drinking on lung function and health-related quality of life (HRQOL) in Chinese patients with pneumoconiosis. METHODS: Three hundred patients with pneumoconiosis were recruited from a community-based case registry. The HRQOL was measured with the St. George's Respiratory Questionnaire (SGRQ). Pulmonary function, comorbidity, and psychosocial variables were also assessed. The alcohol use of the patients was evaluated with the Alcohol Use Disorders Identification questionnaire. RESULTS: Of the 300 patients, 72.3% (217) reported that they had not consumed any alcohol during the past year, whereas 83 patients (27.7%) did report drinking alcohol. In the drinking group, 88.0% (73) consumed <7 standard drinks per week, and none of them exceeded the safety limit of 21 standard drinks per week. The drinking group (n = 83) was younger, had less concurrent medical diseases, and lower (i.e., better) unadjusted SGRQ symptom, activity, impact, and total scores than the nondrinking group (n = 217). The SGRQ scores, which were adjusted for age, duration of occupation, concurrent medical diseases, smoking status, and forced expiratory volume in 1 sec predicted tests (FEV1%), remained significantly lower for the drinking group. Although the drinking group had a higher unadjusted FEV1% predicted, the difference between the FEV1% of the two groups, after adjustment for covariates, was of borderline significance only. CONCLUSIONS: Most Chinese patients with pneumoconiosis in this study did not consume alcohol, and among those who did, the level of alcohol consumption was low. This low level of alcohol consumption was associated with a better HRQOL and possibly with better lung function.

Total daily energy expenditure in wasted chronic obstructive pulmonary disease patients.

OBJECTIVES: To investigate total daily energy expenditure in chronic obstructive pulmonary disease (COPD) patients during a rehabilitation programme. DESIGN: Observational study involving a case and a control group. SUBJECTS: Ten COPD patients (six with body mass index (BMI) <18.5 kg/m(2) and four with BMI >18.5 kg/m(2)) were evaluated for their energy expenditure profile. Four additional healthy age-matched volunteers were also included for methodology evaluation. INTERVENTIONS: Measurements of total daily energy expenditure (TEE), resting energy expenditure (REE) and diet-induced thermogenesis (DIT) and energy intake were undertaken by indirect calorimetry and bicarbonate-urea methods and dietary records. RESULTS: REE in COPD patients was not significantly different from that predicted by the Harris-Benedict equation. Before the exercise day the mean TEE was 1508 kcal/day and physical activity level (PAL as calculated by TEE/REE) was 1.52. On the exercise day the TEE increased to 1568 kcal/day and PAL was 1.60, but neither of these changes were significant. The energy cost of increased physical activity during rehabilitation exercise was estimated to be 191 kcal/day. No significant change was found in DIT between the two patient groups. However, overall energy balances were found to be negative (-363 kcal/day). CONCLUSION: The rehabilitation programme did not cause a significant energy demand in COPD patients. TEE in COPD patients was not greater than in free-living healthy subjects. Patients, who were underweight, did not have a higher TEE than patients with normal weight. This suggested that malnutrition in COPD patients was not due to an increased energy expenditure. On the other hand, a significant negative energy balance due to insufficient energy intake was found in seven out of 10 patients.

Factors predicting stroke disability at discharge: a study of 793 Chinese.

OBJECTIVE: To identify factors predicting stroke disability at discharge in a Chinese population. DESIGN: Retrospective analysis of data collected from stroke patients. SETTING: A 25-bed stroke rehabilitation unit in Hong Kong. PARTICIPANTS: A total of 793 Chinese patients with acute stroke consecutively admitted for inpatient rehabilitation. INTERVENTIONS: All patients received traditional rehabilitation therapies including physical, occupational, and speech therapies when appropriate. MAIN OUTCOME MEASURES: Disability was measured with the Barthel index (BI), and mild disability at discharge was defined as a BI score of > or =15. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed. RESULTS: Logistic regression analysis revealed that a BI score of > or = 15 points at admission strongly predicted that the patient's BI at discharge would be > or =15. For those whose BI score at admission was less than 15, these factors correlated negatively with a discharge BI of 15: BI at admission of <5 (OR .08, CI .04-.17); National Institutes of Health stroke scale at admission of >7 (OR .23, CI .12-.43); urinary incontinence at admission (OR .35, CI .21-.60); age > or =65 years (OR .44, CI .25-.77); and abbreviated mental test at admission of <7 (OR .56, CI .33-.94). CONCLUSIONS: For Chinese stroke patients, the disability at admission is the most important predictor for disability at discharge. Patients with very severe disability, severe neurologic impairment, urinary incontinence, old age, and impaired cognition at admission are less likely to recover to mild disability at discharge. Although hemorrhagic stroke is more common among Chinese populations, it is not an independent predictor for disability at discharge.

Sleep-related injury in the elderly--an epidemiological study in Hong Kong.

OBJECTIVES: Sleep-related injury is a serious but under-recognized condition. We examined the occurrence of sleep-related injuries and REM sleep behavior disorder (RSBD) in a community sample of elderly in Hong Kong. DESIGN: A representative sample of elderly aged 70 years or above were interviewed with a screening question on the presence of sleep-related injuries. Those who answered affirmatively as well as a subsample of negative responders were interviewed by clinicians. Patients with suspected sleep disorders underwent physical and psychiatric assessment as well as sleep studies. SETTING: NA. PATIENTS OR PARTICIPANTS: NA. INTERVENTIONS: NA. RESULTS: In total, 1034 elderly were surveyed and 0.8% reported history of sleep-related injury. Four subjects were confirmed to have RSBD, giving an estimated prevalence of RSBD of 0.38% (95% CI=0.01 to 0.76%). One subject had suspected RSBD but refused investigations while 1 had history suggestive of transient RSBD but could not be confirmed by the sleep studies. The course of RSBD in these subjects was that of a waxing and waning course instead of a progressive deterioration as described in previous literature. Two patients had been hospitalized for sleep-related injury before but their sleep disorder was not recognized. CONCLUSIONS: We found that sleep-related injury and RSBD were not rare in the elderly but were frequently under-recognized. Our study calls for greater attention to elderly who had sustained injury during sleep.

Prevalence of dementia in Chinese elderly in Hong Kong.

This study examines the prevalence of dementia in elderly Chinese aged 70 years and older in Hong Kong using a two-phase design. In phase 1, 1,034 elderly were interviewed with the Cantonese version of the Mini-Mental State Examination. Those who scored below the cutoff points and a subsample of those with scores in the normal range were interviewed in phase 2 to identify those with dementia. The overall weighted prevalence of dementia in our subjects was 6.1 +/- 0.7%, which is at the lower end of the range of rates reported in whites. Alzheimer's disease (AD) accounted for 64.6% and vascular dementia, 29.3%. Our results, together with previous studies in Chinese populations, suggest that the rates of AD in Chinese are low compared with those in whites. Substantial differences are possible in the epidemiology of dementia across cultures related to interactions of genetic and environmental factors.

Outcome after stroke rehabilitation in Hong Kong.

OBJECTIVE: To determine the outcome of patients discharged to the community after stroke rehabilitation. METHODS: One hundred and eighty-five consecutive patients discharged after stroke rehabilitation were enrolled for follow-up 12 months after discharge from a hospital in Hong Kong. A telephone interview to determine disability and place of residence was conducted. Disability was assessed by the Barthel Index and ratings of activities of daily living and mobility on a 4-point scale. RESULTS: One hundred and thirty-one patients or their carers were contacted (70.1%). This comprised 19 patients (10.3%) who died and 112 patients or their carers (60.5%) who were interviewed. Fifty-four patients (29.2%) were lost to follow-up. Comparison of the patients contacted and those lost to follow-up did not detect membership bias. Median Barthel Index of the surviving patients who were contacted rose from 90.0 (interquartile range 78.75-100.0) at discharge to 100.0 (interquartile range 85.0-100.0) at 12 months. Ratings of activities of daily living and mobility were maintained, with significant improvement in toileting. After rehabilitation 77.3% of the patients were discharged home and there was no significant change in residence at 12 months. Elderly patients (> or = 70 years old) had higher rates of institutionalization after hospital discharge and more disability although they achieved similar gains in Barthel Index and had similar lengths of hospital stay compared to younger patients. CONCLUSIONS: These results suggest that stroke patients were able to maintain their gains achieved during inpatient rehabilitation up to one year after discharge from hospital.

High affinity saturable uptake of oxidized low density lipoprotein by macrophages from mice lacking the scavenger receptor class A type I/II.

Oxidation of low density lipoproteins (LDL) has been implicated as a causal factor in the pathogenesis of atherosclerosis. Oxidized LDL has been found to exhibit numerous potentially atherogenic properties in vitro, including receptor-mediated uptake by macrophages. Oxidized LDL is a ligand for the class A scavenger receptor type I/II (SR-AI/II), but cross-competition studies with cultured macrophages suggested that there is an additional receptor(s) that is specific for oxidized LDL and that does not interact with acetyl LDL or other chemically modified LDL. A number of macrophage membrane proteins, including CD36, FcgammaRII-B2, scavenger receptor BI, and macrosialin/CD68, have been found to bind to oxidized LDL in vitro and have been proposed as candidate oxidized LDL receptors. However, because of overlapping ligand specificity with the SR-AI/II, it has been difficult to evaluate the relative importance of these proteins in the uptake of oxidized LDL by macrophages. In the present report, we have studied the uptake and degradation of oxidized LDL by macrophages from mice in which the SR-AI/II gene had been disrupted. The uptake of acetyl LDL was reduced by more than 80% in macrophages from scavenger receptor knockout mice, confirming that most of the uptake of acetyl LDL by macrophages can be attributed to this receptor. In contrast, the uptake of extensively oxidized LDL was reduced by only 30% and showed high affinity, saturable uptake with apparent Km of about 5 microg/ml, similar to that of the SR-AI/II. This indicates that about 70% of the uptake of oxidized LDL in macrophages is attributable to an alternate oxidized LDL receptor(s). In contrast to findings reported with CD36, mildly oxidized LDL was internalized much more slowly than extensively oxidized LDL. Unlabeled oxidized LDL, polyinosinic acid, phosphatidylserine-rich liposomes, and LDL or bovine albumin modified by fatty acid oxidation products were effective competitors for the uptake of radioiodinated oxidized LDL by macrophages from knockout mice, whereas acetyl LDL and malondialdehyde-modified LDL were relatively poor competitors. This ligand specificity differs from that of CD36-related (class B) scavenger receptors but is similar to the reported specificity of macrosialin/CD68 in ligand blots. However, the rate of uptake of oxidized LDL by knockout macrophages was not increased by phorbol ester or in thioglycollate-elicited macrophages, both of which are expected to increase the amount of macrosialin on the cell surface. In macrophages from SR-AI/II knockout mice, ligand blots of membrane proteins with iodinated, oxidized, or acetylated LDL revealed several bands, with apparent molecular size on SDS-polyacrylamide gel electrophoresis of 60, 94, 124, and 210 kDa, but none of the bands were specific for oxidized LDL. These results provide direct evidence that a receptor other than SR-AI/II is responsible for most of the uptake of oxidized LDL in murine macrophages, but further studies are needed to identify the receptor(s) involved.

Outcomes of elderly stroke patients. Day hospital versus conventional medical management.

BACKGROUND AND PURPOSE: Much controversy exists over the value of geriatric day hospitals in the rehabilitation of elderly patients, and cerebrovascular accident is a particularly common diagnosis among patients referred to these day hospitals. We carried out a prospective, randomized study to compare the outcomes of elderly stroke patients managed by a geriatric team using a day hospital facility versus conventional medical management. METHODS: One hundred twenty elderly patients with acute stroke were randomized to inpatient care on a stroke ward under the care of either a neurologist or a geriatric team. Those under the care of neurologists were hospitalized until the attending physician felt that the patients had reached full rehabilitation potential. Patients under the care of the geriatric team were discharged home as soon as the team felt they were able to cope and given follow-up rehabilitation at the day hospital. Family or community support was arranged when necessary for both treatment groups. On recruitment, patient demographics, medical history, clinical features related to stroke, and functional ability as measured by the Barthel Index were noted. Subjects were reviewed at 3 and 6 months to assess functional level, hospital and outpatient services received, general well-being, mood, and level of satisfaction. Costs of treatment of the two groups were also compared. RESULTS: Functional improvement (Barthel Index score) was greater in the group managed by the geriatricians with a day hospital facility compared with the conventional group at 3 months (P = .03). There were also fewer outpatient visits among the day hospital patients at 6 months (P = .03). No significant difference was found in costs between the two treatment groups. CONCLUSIONS: Compared with conventional medical management, care in the geriatric day hospital hastened functional recovery and reduced outpatient visits in elderly stroke patients without additional cost.