Delírios e alucinações no idoso: demência com corpos de Lewy / Delusions and hallucinations in the elderly: dementia with Lewy bodies

Manifestações psicóticas, tais como delírios e alucinações, säo comuns na velhice, podendo chegar a 6 por cento do total de idosos na comunidade, seja no decurso de estados paranóides tardios ou como sintomas de comportamento nas demências. Entretanto, a definiçäo desses sintomas näo tem seguido a devida diferenciaçäo descrita pela psicopatologia clássica, permitindo assim que confabulações, idéias prevalentes e pseudoðalucinações näo sejam reconhecidas. Esse fato traz como conseqüência dificuldades para o entendimento da história natural desses sintomas durante o curso da doença e problemas na conduta clínica a ser prescrita. Respostas a tratamentos medicamentosos säo esperados para sintomas psicóticos primários, quando em verdade podeðse estar diante de manifestações psicologicamente compreensíveis ou explicáveis por transtornos de consciência e/ou memória. A demência com corpos de Lewy tem dentre os sintomas axiais para o diagnóstico clínico a presença de delírios estruturados e alucinações visuais complexas. No entanto, estas cursam de modo flutuante e o paciente tem alguma crítica, cabendo entäo discussäo quanto à estrutura primária desse vivência. Esta revisäo tem como objetivo apresentar as principais características das alucinações e delírios no idoso, em especial na demência com corpos de Lewy e discutir a psicopatologia e suas implicações para o diagnóstico e tratamento desses sintomas

Impact of recombinant human growth hormone (RH-GH) treatment on psychiatric, neuropsychological and clinical profiles of GH deficient adults. A placebo-controlled trial.

BACKGROUND: Untreated GH-deficient adults have a diversity of dysfunctions (e.g. reduced muscle strength, emotional instability during stress, depressive symptoms) that may cause deleterious effects on quality of life, and may be positively influenced by recombinant human growth hormone (rh-GH) therapy. AIM: To evaluate the impact of a clinical intervention with rh-GH therapy on GH- deficient adults. METHOD: The physical, psychiatric and neuropsychological status of 9 GH-deficient adults was determined before and after the administration of rh-GH (0.250 IU/Kg/week) in a double blind placebo-controlled trial for six months. Patients then received rh-GH for a further period of 6 months and their status was re-evaluated. RESULTS: Rh-GH was significant better than placebo at 6th month (p < 0.05), producing increased serum Insulin like growth factor-I (IGF-I) levels, reduced body mass index (BMI) and body fat, increased lean body mass and water, reduced waist/hip ratio and increased energy expenditure. The rh-GH therapy was also significantly better than placebo on depressive features as measured by the Hamilton Depression Scale (17-items) (p = 0.0431) and the Beck Depression Inventory (p = 0.0431). Neuropsychological evaluations showed significant improvements in measures of Attention: Digit Backward (p = 0.035), Verbal Fluency (FAS) (p = 0.02) and Cognitive Efficiency (WAIS-R tests): Vocabulary (p = 0.027), Picture Arrangements (p = 0.017), and Comprehension (p = 0.01) following rh-GH therapy. CONCLUSION: The clinical, psychiatric, and neuropsychological impairments of untreated GH-deficient adults can be decreased by rh-GH therapy.

Revascularization of an ischemic limb by use of a muscle pedicle flap: a rabbit model.

A rabbit model of hind limb ischemia was designed to demonstrate that new, hemodynamically significant arterial connections will develop between ischemic skeletal muscle and an independently perfused muscle pedicle flap. The right common iliac artery was divided in 15 rabbits. In eight rabbits a muscle flap based on the left deep inferior epigastric artery was transposed to the right thigh (flap group). In seven rabbits a sham operation was performed where the flap was sutured to the abdominal wall (sham group). After 7 days angiography demonstrated arterial connections between the flap and the native limb circulation in all of the flap group animals. The flap increased muscle perfusion in the ischemic limb (2.99 ml/100 gm muscle/minute in the flap group, vs 2.06 ml/100 gm muscle/minute in the sham group, p less than 0.005). Hemodynamically significant vascular connections will develop between a well-perfused muscle flap and an ischemic limb. The augmentation in perfusion provided by these connections can be quantified.

Obstetric care among family physicians in Pennsylvania. Trends, association with residency training, and policy implications.

A study was designed to investigate the status of obstetric practice by Pennsylvania family physicians and its relationship to family practice residency training. A 50% probability sample of all family and general physicians and of all graduates of Pennsylvania family practice residency programs was surveyed by mail. Ten percent of Pennsylvania family physicians and general practitioners reported currently practicing obstetrics, 44% of whom said they planned to stop within 3 years. Telephone survey information from nonresponders suggests that even fewer (5%) of the state's family physicians may actually be practicing obstetrics. Family practice residency training, postresidency obstetric training, and small community size were the best predictors of current obstetric practice. Family physicians in the smallest communities, however, were also those most likely to be planning to stop, and graduates of residency programs were increasingly choosing not to practice obstetrics. Cost of liability insurance and fear of lawsuits were primary reasons cited for stopping obstetrics. Family physicians have been major providers of obstetric care in the nation's rural areas. Now, increasingly firm evidence that fewer family physicians are practicing obstetrics signals increasing shortages in obstetric care for women in rural communities. Changes in the practice climate and obstetric training programs for family physicians seem essential to help reverse these trends.

Secular decline in death rates due to ischemic heart disease in Mexican Americans and non-Hispanic whites in Texas, 1970-1980.

Although the decline in ischemic heart disease mortality is now entering its third decade, there has been no definitive information on the experience of Mexican Americans, the nation's second largest minority group. Earlier studies carried out in the 1970s were hampered by the unavailability of satisfactory population data beyond 1970. In the present study we have used 1970 and 1980 census data to compute death rates in Mexican Americans and non-Hispanic whites from Texas for the periods 1969-1971 and 1979-1981. All four sex-ethnic groups showed statistically significant declines in death rates due to all causes, due to total ischemic heart disease, and due to acute myocardial infarction between 1969-1971 and 1979-1981. Declines in the latter two causes of death were least marked in Mexican American men. This sex-ethnic group was also the only one that failed to show a decline in death rates due to chronic ischemic heart diseases. The fact that Mexican Americans have been shown to be less well informed about and less likely to adopt lifestyle changes aimed at reducing heart disease risk than non-Hispanic whites may account for the less striking mortality decline observed in Mexican American men, but is harder to reconcile with the apparent equal decline in Mexican American women compared with non-Hispanic whites.

The role of behavioral variables and fat patterning in explaining ethnic differences in serum lipids and lipoproteins.

Mexican Americans have been previously reported to have greater adiposity, higher triglyceride levels, and lower high density lipoprotein (HDL) cholesterol levels than Anglos. This study investigated the relationship between behavioral variables (caloric balance, cigarette and alcohol consumption, exercise, postmenopausal estrogen or oral contraceptive use) and fat patterning (central vs. peripheral distribution of adiposity) in the San Antonio Heart Study (1979-1982) (n = 2,102) to explain the ethnic difference in lipids and lipoproteins. Adjustment for caloric balance (as reflected by body mass index) narrowed the ethnic difference in triglyceride and HDL levels for both sexes, while adjustment for smoking widened the ethnic difference. For females, the ethnic difference was also decreased by adjustment for alcohol and estrogen use. However, adjustment for these behavioral variables did not completely eliminate the ethnic difference in lipids and lipoproteins in either sex. Increased central adiposity, more characteristic of Mexican Americans than Anglos, was positively associated with triglycerides and negatively associated with HDL levels, especially in females. Fat patterning made a more important contribution to the prediction of triglyceride and HDL levels than did the other behavioral variables (except for caloric balance) and, in general, eliminated ethnic differences in lipids and lipoproteins. Epidemiologists should consider the use of a centrality index to distinguish different types of adiposity since it is easy and inexpensive to measure.

Employment status and women's protection against coronary heart disease. Findings from the San Antonio Heart Study.

This study examined whether currently employed women are at increased risk of coronary heart disease relative to full-time homemakers. Subjects were 1,041 Mexican-American and non-Hispanic white women aged 25-64 years, residing in households randomly selected from three socioculturally distinct neighborhoods in San Antonio, Texas. No statistically significant differences between employed women and homemakers were found for obesity, total serum cholesterol, low density lipoprotein cholesterol, systolic and diastolic blood pressures, or cigarette smoking. Highly significant differences favoring employed women over homemakers were found for both Mexican Americans and non-Hispanic whites in high density lipoprotein (HDL) cholesterol, ratio of HDL cholesterol to total cholesterol, and triglycerides. These differences were not explained by obesity, exercise, cigarette smoking, alcohol consumption, use of exogenous estrogens, and use of oral contraceptives, or by the healthy worker effect, and were observed at all occupational levels. Employed women ate a less atherogenic diet than full-time homemakers, but it is not clear that this nutritional factor could explain the differences in HDL cholesterol and triglycerides found in this study. The magnitude of the employment status difference in HDL cholesterol for both ethnic groups was in a range (3-4 mg/100 ml) associated with protection against coronary heart disease.

Role of obesity and fat distribution in non-insulin-dependent diabetes mellitus in Mexican Americans and non-Hispanic whites.

Recent data have suggested that central obesity is related positively to the prevalence of non-insulin-dependent diabetes mellitus (NIDDM). We examined whether central obesity (measured by the ratio of subscapular to triceps skinfold) was predictive of NIDDM prevalence independently of overall obesity (measured by body mass index, BMI) in 1231 Mexican Americans and 939 non-Hispanic whites who participated in the San Antonio Heart Study, a population-based survey of diabetes and cardiovascular risk factors. Mexican Americans are characterized by higher rates of NIDDM, greater overall obesity, and more central body fat distribution than age-matched non-Hispanic whites. Using multiple logistic regression with age, ethnicity, BMI, and central obesity as covariates, overall obesity was positively associated with NIDDM prevalence in both sexes (P less than 0.001) but central obesity was related to NIDDM prevalence only in women. Our data suggest that the effect of centrality decreases at higher levels of centrality. While both BMI and centrality narrow the ethnic difference in NIDDM prevalence, Mexican Americans still have an increased risk of NIDDM (odds ratio = 2.33 in men and 1.80 in women), suggesting that other factors, possibly genetic, may also be important determinants of the ethnic differences in NIDDM prevalence.

Relationship of prevalence of non-insulin-dependent diabetes mellitus to Amerindian admixture in the Mexican Americans of San Antonio, Texas.

A genetic and epidemiological survey of non-insulin-dependent diabetes mellitus (NIDDM) was conducted among the Mexican Americans residing in three socioeconomically distinct areas of San Antonio, Texas: a low socioeconomic (SES) traditional area (barrio), a middle SES, ethnically balanced area (transitional), and a high SES, predominantly Anglo area (suburb). Seventeen polymorphic markers were used to relate the prevalences of NIDDM with the extent of Amerindian ancestry of 1,237 Mexican Americans of these three residential areas. While only the RH and haptoglobin loci showed evidence of association with NIDDM, an admixture analysis of the combined allele frequency data revealed a pattern of decreasing NIDDM prevalence with increasing socioeconomic status (as approximated by neighborhood of residence) and a parallel decrease in Amerindian ancestry. The rank-order correlation between NIDDM prevalence and Amerindian admixture is 0.943 (P less than .001) for the crude prevalence rate and 0.829 (P less than .02) for the age-adjusted rate. Nested gene diversity analysis revealed that the heterogeneity of allele frequencies is more pronounced when individuals were classified by their NIDDM disease status as compared to the classification by neighborhood. Estimation of Amerindian ancestry of each individual did not reveal any significant change in the shape of the distributions of individual admixture proportions in diabetics as compared to the controls. Nevertheless, the results suggest that genetic factors partially explain the differences in NIDDM prevalence observed between the Mexican American and Anglo populations in the southwestern United States.

A comparison of three indicators for identifying Mexican Americans in epidemiologic research. Methodological findings from the San Antonio Heart Study.

Because the issue of how to empirically identify Mexican Americans in health-related research is still unresolved, the authors compared the performance of three indicators for identifying Mexican Americans across five distinct population subgroups: men and women in two age strata, and residents in low, middle, and high socioeconomic neighborhoods. Individual surname had the lowest sensitivity, specificity, and predictive values in the pooled population sample and varied the most widely on these parameters across population subgroups. Parental surnames, which are available on vital statistics and could easily be added to other health records used in secondary analyses, offered a significant improvement over individual surname in classifying persons as Mexican American. The San Antonio Heart Study (SAHS) algorithm, a nine-item indicator which uses parental surnames, birthplace of both parents, self-declared ethnic identity, and ethnic background of grandparents, had the highest sensitivity, specificity, and predictive values and varied the least on these parameters across different sex, age, and socioeconomic status population subgroups. The performance of all indicators was lower at the higher socioeconomic status levels. The findings suggest that it may be useful to use parental surnames as an indicator for Mexican-American ethnicity in research involving vital statistics and to add parental surnames to other health records frequently used in secondary analyses. Since the SAHS algorithm can be adapted for use with non-Mexican origin Hispanic subgroups, it may be a useful indicator for Mexican-American (or other Hispanic) ethnicity in survey research.

Coffee consumption, diet, and lipids.

Recent reports suggest that coffee consumption is associated with increased serum cholesterol and triglyceride concentrations. The authors examined the association between serum lipids and coffee consumption and other caffeinated beverages as part of a population-based study of 1,228 women and 923 men, aged 25-64 years, in San Antonio, Texas, studied between October 1979 and November 1982. The study confirmed a positive relationship between coffee consumption and both total and low density lipoprotein cholesterol in both sexes which persisted after adjustment for age, ethnicity, obesity, cigarette smoking, and alcohol consumption. Neither tea nor cola consumption was associated with changes in serum lipids, suggesting that caffeine alone does not exert a direct effect on lipid levels. The possibility was examined that the coffee-cholesterol relationship might be due to a more atherogenic diet consumed by heavy coffee drinkers. In men, per cent calories from both total and saturated fat and dietary cholesterol intake increased with increased coffee consumption. Similar trends were not observed in women, however. The positive relationship between coffee and cholesterol may therefore be due to confounding effects of other aspects of the diet.

Prevalence, detection, and control of hypertension in a biethnic community. The San Antonio Heart Study.

A survey was carried out on a random sample of 1,288 Mexican Americans and 929 Anglos living in three socially distinct neighborhoods in San Antonio, Texas. Hypertension was defined as diastolic blood pressure greater than or equal to 95 mmHg or currently taking antihypertensive medication. Overall age-adjusted prevalence rates of hypertension were similar for Mexican-American and Anglo men (10.0 and 9.8%, respectively); for women, the Mexican-American rate was slightly lower than that for Anglos (7.8 and 9.7%, respectively). After adjustment for obesity differences, Mexican Americans have a tendency toward lower hypertension rates than Anglos of the same socioeconomic level. Only among women was a decline in the prevalence of hypertension with increasing socioeconomic status observed. Mexican Americans have a higher proportion of newly diagnosed hypertension, and, among previously diagnosed cases, a lower proportion are on antihypertensive medication than Anglos. The rates of hypertension control found in this survey are among the highest reported in the United States at the community level. Despite this, Mexican Americans still lag somewhat behind Anglos of the same socioeconomic level in awareness, treatment, and degree of hypertension control, suggesting the possibility of sociocultural barriers to adequate medical care.

Socioeconomic status and the prevalence of clinical gallbladder disease.

The prevalence of clinical gallbladder disease was determined in a cross-sectional survey of Mexican Americans and non-Hispanic whites. The study population was randomly selected from three urban neighborhoods representing different socioeconomic strata. Gallbladder disease was defined as a history of cholecystectomy, or of stones on cholecystography. Mexican American women had an age-standardized prevalence of 16.9%, vs 8.7% for non-Hispanic whites (p less than 0.0001). Prevalences in men were 4.2 and 3.4%, respectively. The ethnic differences in women persisted after stratification by age, parity, and body mass index. Gallbladder disease prevalence was inversely related to four measures of socioeconomic status. After controlling for age, obesity, parity, and ethnicity, the prevalence in women was inversely related to levels of education, income, occupational status, and neighborhood. These socioeconomic differences, if not the result of detection bias, suggest that environmental factors may play a role in gallstone pathogenesis. Identification of such factors may lead to the development of preventive strategies.

Evidence of bimodality of two hour plasma glucose concentrations in Mexican Americans: results from the San Antonio Heart study.

Evidence for bimodality in the distribution of two hour post oral glucose challenge plasma glucose concentrations has come previously primarily from native American and Pacific Island populations having high non-insulin dependent diabetes mellitus (NIDDM) prevalence. Because the National Diabetes Data Group (NDDG) criteria for diagnosing NIDDM rely in part upon the assumption of bimodality, it is important to determine the generality of this phenomenon. We looked for bimodality among Mexican Americans in San Antonio, a population having greater than 50% Caucasian admixture. By fitting both a single normal distribution model and a mixture model of two normal distributions, for each age decade, we found that the mixture model was preferred to the single normal model (p less than 0.001) and that this model fit the data well. The proportion in the upper component (hyperglycemics) increased with each successive age decade. The minimum misclassification cutpoints decreased with age, but all were higher than the 200 mg/dl cutpoint recommended by the NDDG. Use of the NDDG cutpoint, however, improved sensitivity with only a minimal deterioration of specificity. Our findings further generalize the bimodality phenomenon and support the NDDG criteria.

Sex difference in the effects of sociocultural status on diabetes and cardiovascular risk factors in Mexican Americans. The San Antonio Heart Study.

The authors postulated that as Mexican Americans became more affluent and/or acculturated to "mainstream" United States life-style they would progressively lose their "obesity-related" pattern of cardiovascular risk factors which were defined as: obesity, diabetes, hypertriglyceridemia and low levels of high density lipoprotein cholesterol. This hypothesis was tested in 1979-1982 in the San Antonio Heart Study, a population-based study on 1,288 Mexican Americans and 929 Anglos living in three San Antonio neighborhoods: a low-income barrio, a middle-income transitional neighborhood, and a high-income suburb. The study population comprised 25-65-year-old men and nonpregnant women. In Mexican American women, all of the "obesity-related" risk factors fell sharply with rising socioeconomic status. In Mexican American men, by contrast, diabetes was the only "obesity-related" risk factor which fell with rising socioeconomic status. Moreover, it fell less steeply, there being an approximately twofold difference in diabetes prevalence between the barrio and the suburbs in men compared to a fourfold difference in women. Also, total and low density lipoprotein cholesterol rose with rising socioeconomic status in Mexican American men, but not in Mexican American women. "Obesity-related" risk factors were generally higher in Mexican Americans of both sexes than in their Anglo neighbors who were of similar socioeconomic status. These results suggest that cultural factors exert a stronger influence on diabetes and cardiovascular risk factors in Mexican Americans than do purely socioeconomic factors.

Evaluation of three potential screening tests for diabetes mellitus in a biethnic population.

We tested the ability of three potential screening tests for diabetes (fasting plasma glucose value greater than or equal to 140 mg/dl, 1-h postglucose (PG) load value greater than or equal to 200 mg/dl, and 2-h PG value greater than or equal to 200 mg/dl) to detect non-insulin-dependent diabetes in 130 diabetic Mexican Americans (MAs) and 50 diabetic Anglo Americans (AA) using the National Diabetes Data Group criteria as the standard. The sensitivity of the fasting plasma glucose (FPG) cutpoint in detecting diabetes was low in both AAs (36.0%) and MAs (59.3%) and was related to the age-adjusted prevalence rates of diabetes in the two ethnic groups (AAs, 4.9%; MAs, 10.9%). The 2-h PG load cutpoint had good sensitivity (greater than 93%) and specificity (greater than 99%) in both ethnic groups. The ethnic difference in the sensitivity of the FPG cutpoint appeared to be related to the greater hyperglycemia of diabetic MAs compared with diabetic AAs. Nearly 30% of diabetic MAs had FPG values greater than or equal to 200 mg/dl as contrasted with only 10% of diabetic AAs. The difference in severity of hyperglycemia between the ethnic groups appears to be unrelated to ethnic differences in adiposity, pharmacologic treatment, or delay in diagnosis, although longer disease duration in MAs may explain part of the difference.