Improving the mix of institutional and community care for older people with dementia: an application of the balance of care approach in eight European countries.

OBJECTIVES: To examine whether the mix of community and institutional long-term care (ILTC) for people with dementia (PwD) in Europe could be improved; assess the economic consequences of providing alternative services for particular groups of ILTC entrants and explore the transnational application of the 'Balance of Care' (BoC) approach. METHOD: A BoC study was undertaken in Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden, and the UK as part of the RightTimePlaceCare project. Drawing on information about 2014 PwD on the margins of ILTC admission, this strategic planning framework identified people whose needs could be met in more than one setting, and compared the relative costs of the possible alternatives. RESULTS: The findings suggest a noteworthy minority of ILTC entrants could be more appropriately supported in the community if enhanced services were available. This would not necessarily require innovative services, but more standard care (including personal and day care), assuming quality was ensured. Potential cost savings were identified in all countries, but community care was not always cheaper than ILTC and the ability to release resources varied between nations. CONCLUSIONS: This is believed to be the first transnational application of the BoC approach, and demonstrates its potential to provide a consistent approach to planning across different health and social care systems. Better comparative information is needed on the number of ILTC entrants with dementia, unit costs and outcomes. Nevertheless, the findings offer important evidence on the appropriateness of current provision, and the opportunity to learn from different countries' experience.

Hierarchical tailoring of strut architecture to control permeability of additive manufactured titanium implants.

Porous titanium implants are a common choice for bone augmentation. Implants for spinal fusion and repair of non-union fractures must encourage blood flow after implantation so that there is sufficient cell migration, nutrient and growth factor transport to stimulate bone ingrowth. Additive manufacturing techniques allow a large number of pore network designs. This study investigates how the design factors offered by selective laser melting technique can be used to alter the implant architecture on multiple length scales to control and even tailor the flow. Permeability is a convenient parameter that characterises flow, correlating to structure openness (interconnectivity and pore window size), tortuosity and hence flow shear rates. Using experimentally validated computational simulations, we demonstrate how additive manufacturing can be used to tailor implant properties by controlling surface roughness at a microstructual level (microns), and by altering the strut ordering and density at a mesoscopic level (millimetre).

Hip bone geometry in HIV/HCV-co-infected men and healthy controls.

UNLABELLED: People with both HIV and hepatitis C are more likely than those with HIV alone to have wrist, hip, and spine fractures. We compared hip strength between HIV/HCV-co-infected men and healthy men and found that HIV/HCV-co-infected men had decreased hip strength due to lower lean body mass. INTRODUCTION: Hepatitis C co-infection is a risk factor for fragility fracture among HIV-infected populations. Whether bone strength is compromised in HIV/HCV-co-infected patients is unknown. METHODS: We compared dual-energy x-ray absorptiometry (DXA)-derived hip geometry, a measure of bone strength, in 88 HIV/HCV-co-infected men from the Johns Hopkins HIV Clinic to 289 men of similar age and race and without HIV or HCV from the Boston Area Community Health Survey/Bone Survey. Hip geometry was assessed at the narrow neck, intertrochanter, and shaft using hip structural analysis. Lean body mass (LBM), total fat mass (FM), and fat mass ratio (FMR) were measured by whole-body DXA. Linear regression was used to identify body composition parameters that accounted for differences in bone strength between cohorts. RESULTS: HIV/HCV-co-infected men had lower BMI, LBM, and FM and higher FMR compared to controls (all p < 0.05). At the narrow neck, significant differences were observed between HIV/HCV-co-infected men and controls in bone mineral density, cross-sectional area, section modulus, buckling ratio, and centroid position. After adjustment for race, age, smoking status, height, and weight, only buckling ratio and centroid position remained significantly different between cohorts (all p < 0.05). Substituting LBM, FM, and FMR for weight in the multivariate model revealed that differences in LBM, but not FM or FMR, accounted for differences in all narrow neck parameters between cohorts, except buckling ratio and centroid position. CONCLUSION: HIV/HCV-co-infected men have compromised hip strength at the narrow neck compared to uninfected controls, which is attributable in large part to lower lean body mass.

The development of a scanning strategy for the manufacture of porous biomaterials by selective laser melting.

Porous structures are used in orthopaedics to promote biological fixation between metal implant and host bone. In order to achieve rapid and high volumes of bone ingrowth the structures must be manufactured from a biocompatible material and possess high interconnected porosities, pore sizes between 100 and 700 microm and mechanical strengths that withstand the anticipated biomechanical loads. The challenge is to develop a manufacturing process that can cost effectively produce structures that meet these requirements. The research presented in this paper describes the development of a 'beam overlap' technique for manufacturing porous structures in commercially pure titanium using the Selective Laser Melting (SLM) rapid manufacturing technique. A candidate bone ingrowth structure (71% porosity, 440 microm mean pore diameter and 70 MPa compression strength) was produced and used to manufacture a final shape orthopaedic component. These results suggest that SLM beam overlap is a promising technique for manufacturing final shape functional bone ingrowth materials.

Reliability of needs assessments in the community care of older people: impact of the single assessment process in England.

BACKGROUND: The single assessment process (SAP) for older people, introduced in England across health and social care agencies from April 2004, aimed at improving assessment processes. We examined the impact of this policy in terms of the reliability of needs identification within statutory social services assessments. METHODS: An observational study compared the accuracy of needs identification in samples of older people before and after SAP introduction. Participants, at risk of entering care homes, were interviewed using standardized measures. Needs elicited from interviews were compared with those from statutory social services assessments to ascertain the reliability of needs identification at both times. Inter-rater reliabilities were calculated using the kappa (k) statistic. A Chi-squared statistic tested the equality of kappa values pre- and post-SAP. RESULTS: Most needs were identified more reliably after SAP introduction (range adjusted k = 0.05-0.58) than before (range adjusted k = -0.09 to 0.28), this being statistically significant for 9 out of 15 needs. Depression, and associated apathy, was an exception. CONCLUSION: Statutory social services assessments better captured need following the introduction of the SAP. However, the extent to which these findings can be attributed to SAP introduction is limited by the introduction of multiple policy initiatives throughout the study period.

Penile modification in young Thai men: risk environments, procedures and widespread implications for HIV and sexually transmitted infections.

OBJECTIVES: To determine the prevalence and types of penile modification and describe the circumstances surrounding this practice among a sample of young methamphetamine users in Thailand. METHODS: A mixed methods study was conducted in Chiang Mai, Thailand, in 2005-6. One hundred young men were surveyed for the quantitative study and in-depth interviews were administered to 9 men, 11 women and 1 transgender. RESULTS: The prevalence of penile modification was 51%, with the most common type being inlaying with muk(s) (61%). The majority of modifications were performed in prison or juvenile detention (80%) by a friend (90%). Motivations for penile modification included peer pressure and perceived enhanced female sexual pleasure. In prison, the practice was veiled in secrecy, the conditions under which modification was performed were unhygienic, sometimes leading to infection, and sharing equipment was common. Men and women reported that condom use was more difficult post modification as condoms were more likely to break or leak and less likely to fit correctly. In addition, sexual intercourse was often painful for the female partner. CONCLUSION: Penile modification is prevalent in this group of young methamphetamine users and is associated with behaviours and consequences that could facilitate the spread of HIV and other sexually transmitted infections.

Anatomical flow phantoms of the nonplanar carotid bifurcation, part I: computer-aided design and fabrication.

Doppler ultrasound is widely used in the diagnosis and monitoring of arterial disease. Current clinical measurement systems make use of continuous and pulsed ultrasound to measure blood flow velocity; however, the uncertainty associated with these measurements is great, which has serious implications for the screening of patients for treatment. Because local blood flow dynamics depend to a great extent on the geometry of the affected vessels, there is a need to develop anatomically accurate arterial flow phantoms with which to assess the accuracy of Doppler blood flow measurements made in diseased vessels. In this paper, we describe the computer-aided design and manufacturing (CAD-CAM) techniques that we used to fabricate anatomical flow phantoms based on images acquired by time-of-flight magnetic resonance imaging (TOF-MRI). Three-dimensional CAD models of the carotid bifurcation were generated from data acquired from sequential MRI slice scans, from which solid master patterns were made by means of stereolithography. Thereafter, an investment casting procedure was used to fabricate identical flow phantoms for use in parallel experiments involving both laser and Doppler ultrasound measurement techniques.

Relationship of deep white matter hyperintensities and cerebral blood flow in severe carotid artery stenosis.

Leukoaraiosis (LA) has been associated with abnormalities of both large and small blood vessels. This study attempts to clarify the pathogenesis of LA by testing the hypothesis that increased frequency of LA with occlusive extra-cranial arterial disease results directly from global reduction in cerebral blood flow (CBF). Thirty-five normal subjects and 55 patients with carotid stenosis (>70%) were studied using MR. CBF was measured using phase contrast MR angiography and LA was scored using previously validated scoring system. Patients were divided into those with evidence of previous infarction on MRI and those without. LA was more severe in patients than in normal subjects (P<0.01) and correlated with age in normal subjects but not in patients. CBF in patients with (809+/-214 ml/min) and without infarction (mean 792+/-181 ml/min) was significantly lower than in normal subjects (mean 1073+/-194 ml/min). There was no correlation between the severity of LA and measured CBF in any group. The severity of LA is greater in patients with severe carotid stenosis but is not correlated to reductions in CBF. This suggests that microvascular abnormality is the dominant pathogenetic factor in LA even in the presence of severe stenotic/occlusive large vessel disease.

Treatment response in late-onset depression: relationship to neuropsychological, neuroradiological and vascular risk factors.

BACKGROUND: Late-onset depressive disorder is associated with white matter lesions and neuropsychological deficits that in some studies are linked to a poorer outcome for depression. Some white matter lesions may be vascular in origin. This study investigated the relationship between response or non-response to antidepressant monotherapy and neuropsychological function, structural brain measures and vascular factors. METHOD: This was a case control study. Fifty patients with late-onset major depressive disorder (29 who were responders to antidepressant monotherapy and 21 who were not) were compared with 35 non-depressed control subjects. Measures included assessment of vascular risk factors, neuropsychological testing and a magnetic resonance imaging (MRI) scan. RESULTS: After adjustment for depressed mood and medication at evaluation, both patient groups had significantly more impairment compared to control subjects on verbal learning tasks involving immediate or delayed recall. Patients who did not respond to antidepressant monotherapy had significantly poorer performance than controls on tests involving visuospatial ability, language, word recognition and tests of executive function, whereas there were no differences between control subjects and responders. On two tests of executive function (verbal fluency and the Stroop test) non-responders scored significantly worse than responders. There were no significant group differences on MRI measures of atrophy or of white matter lesions apart from a higher periventricular hyperintensity score in non-responders compared to controls. There were no group differences on measures of vascular disease. CONCLUSION: The results lend support to the emerging evidence that resistance to treatment in late-onset depression may be associated with impaired executive function. Subtle cerebrovascular mechanisms may be involved.

A new version of the geriatric depression scale for nursing and residential home populations: the geriatric depression scale (residential) (GDS-12R).

The objective was to develop a new short-form Geriatric Depression Scale (GDS-12R) suitable for older people living in nursing and residential care settings, including those persons with significant cognitive impairment. A total of 308 newly admitted residents of 30 nursing and residential homes in northwest England were interviewed using the Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination, and the Affect Balance Scale (ABS). A 12-item version of the GDS was shown to have greater internal reliability than the 15-item version, because of the context-dependent nature of the deleted items. There was close agreement between the GDS-12R items and another indicator of depressed mood (a single item from the ABS). Furthermore, moderate to high levels of cognitive impairment did not affect the performance of the new version of the scale. The GDS-12R provides researchers and clinicians with a brief, easy-to-administer depression scale that is relevant to residential and nursing home populations.

Dependency in older people recently admitted to care homes.

OBJECTIVE: to investigate dependency and general health status of a cohort of older people admitted to residential or nursing homes for long-term care. METHOD: we assessed 308 people aged over 65 years within 2 weeks of admission for long-term care to one of 30 nursing or residential homes in north-west England. Dependency was assessed using the Barthel activities of daily living index and the Crichton Royal Behaviour Rating Scale. We collected information from the homes' records on diagnosed conditions and current medication. RESULTS: 50% of the cohort were in a 'low dependency' band (Barthel score 13 - 20): 31% of those in nursing homes and 71% of those in residential homes. In nursing homes, low-dependency residents were more likely to be self-funding than those with higher dependency. Of a number of broad diagnostic groupings, only a diagnosis of dementia was associated with nursing- rather than residential-home admission. Of 47 residents who scored 9 or less on the Mini-Mental State Examination (indicating severe cognitive impairment), 85% had no diagnosis of dementia, neurological disorder or other psychiatric disorder. DISCUSSION: the high proportion of new admissions of subjects with low dependency needs raises questions about the effective targeting of resources and about management of the boundary between home-based and institutional care. The existence of an important group of self-funded, low-dependency new admissions to nursing homes suggests a need to provide better assessment and placement services for those who are financially independent of local authorities. Many new admissions had conditions which might benefit from rehabilitation but there were almost no therapy staff in the studied homes. In some cases where severe cognitive impairment was evident, there was no evidence that the result of any formal pre-admission psychiatric evaluation had been communicated to nursing or care staff.

Asleep-Awake-Asleep general anesthesia for open cervical rhizotomy: case report and description of the technique.

The authors describe the technique of Asleep-Awake-Asleep anesthesia for open dorsal rhizotomy in a 78-year-old female patient, admitted to the hospital with intractable pain in the distribution of C2 dermatome following a road traffic accident. The patient was anesthetised and the rhizotomy performed using the intradural approach. Anesthesia was conducted by Total Intravenous Anesthesia using a Target Controlled Infusion system. The patient was awakened twice intraoperatively to verify success of the rhizotomy. Complete pain relief was obtained and maintained at 1 year follow-up.

Recognition of depression by staff in nursing and residential homes.

Newly admitted residents in long-term care facilities are particularly vulnerable to depression and the early recognition and treatment of depression is therefore crucial around the time of admission to a home. Staff from 30 nursing and residential homes were asked to assess newly admitted residents for depression using HoNOS 65+ and their responses were compared with residents' scores on the Geriatric Depression Scale (GDS-15). The findings indicated low levels of recognition by staff, with rates ranging from 15% to 27% of those identified as depressed, depending on the definition of depression used. There was no statistically significant difference in the rate of recognition between nursing staff and other care staff. A staff survey conducted in the 30 study homes indicated that fewer than 2% had received specific in-service training on depression in older people. The findings suggest that more needs to be done to raise staff awareness of depression in residents of nursing and residential homes, particularly in newly admitted residents.

Multiorgan autonomic dysfunction in mice lacking the beta2 and the beta4 subunits of neuronal nicotinic acetylcholine receptors.

Transcripts for the beta2 and the beta4 nicotinic acetylcholine receptor (nAChR) subunits are found throughout the CNS and the peripheral nervous system. These two beta subunits can form heteromultimeric channels with any of the alpha2, alpha3, alpha4, or alpha5 subunits in heterologous expression systems. Nonetheless, the subunit composition of native nAChRs and the role of different nAChR subtypes in vivo remain unclear. We prepared null mutations for the beta2 and the beta4 genes and bred beta2-/-beta4-/- mice by mating mice of identical beta2-/-beta4+/- or beta2+/-beta4-/- genotype. The beta2-/- and the beta4-/- single-mutant mice grow to adulthood with no visible phenotypic abnormalities. The beta2-/-beta4-/- double mutants survive to birth but have impaired growth and increased perinatal mortality. They also present enlarged bladders with dribbling urination and develop urinary infection and bladder stones. The ocular pupils are widely dilated and do not constrict in response to light. Histological studies revealed no significant abnormalities of brain or peripheral tissues except for hyperplasia in the bladder mucosa of beta4-/- and beta2-/-beta4-/- mutants. Bladder strips from beta2-/-beta4-/- mice did not respond to nicotine but contracted when stimulated with a muscarinic agonist or electric field stimulation. Bladder strips from beta4 mutants did not respond to nicotine despite the absence of major bladder dysfunction in vivo. Acetylcholine-activated whole-cell currents were absent in superior cervical ganglion neurons from beta2-/-beta4-/- mice and reduced in neurons from beta4-/- mice. Although there is apparent redundancy and a superficially normal phenotype in beta2-/- and beta4-/- mice, physiological studies indicate major deficits in the beta4-/- mice. Our previous description of a similar phenotype in alpha3-/- mice and the current data suggest that the alpha3 and the beta4 subunits are major components in autonomic nAChRs. The phenotype of the beta2-/-beta4-/- and alpha3-/- mice resembles the autosomal recessive megacystis-microcolon-hypoperistalsis syndrome in humans.

'Not knowing where I am doesn't mean I don't know what I like': cognitive impairment and quality of life responses in elderly people.

OBJECTIVE: To elucidate the extent to which elderly people with cognitive impairment are able to answer questions about their quality of life.Design and setting308 elderly residents were interviewed within 2 weeks of admission to one of 30 residential or nursing homes in north-west England. MEASURES: The Mini-Mental State Examination (MMSE), the Lancashire Quality of Life Profile (Residential) (LQOLP(R)), the Crichton Royal Behaviour Rating Scale (CRBRS) and the HONOS-65+. RESULTS: Of the 308 subjects, LQOLP(R) interviews were attempted with 213 who scored 10 or over on the MMSE. Of the 213, 77.5% were found to be 'interviewable', ie able to answer the majority of questions in the LQOLP(R) and in doing so to give answers in which the interviewer had confidence. Of the seven cognitive domains measured by the MMSE, visual construction and registration were not significantly associated with interviewability. While orientation to time and recall were significantly associated with interviewability, many interviewable respondents had poor scores in these domains. No respondents were interviewable who scored less than 2 (out of 5) for orientation to place or less than 3 (out of 8) for language or less than 2 (out of 5) for attention. CONCLUSIONS: A high proportion of elderly people can answer questions about their quality of life, even in the presence of significant cognitive deficits.

An investigation into the relative merits of pituitary adenylate cyclase-activating polypeptide (PACAP-27) and vasoactive intestinal polypeptide as vagal neuro-transmitters in exocrine pancreas of rats.

Pancreatic exocrine secretions were collected over 15 min periods and analysed in terms of weight of juice, total HCO3- and total protein in anaesthetized and pithed rats. Pituitary adenylate cyclase-activating polypeptide (PACAP) (i.v.) evoked a serous HCO3- secretion which contained relatively little protein, together with a marked vasodepressor action. The latter was still maximal at lower doses of PACAP, which evoked diminished pancreatic secretions. The effects of PACAP were similar to those evoked by the same dose of VIP and by cervical vagal stimulation, while secretion evoked a much larger secretion of fluid and HCO3-. The time courses of the PACAP-evoked secretions were significantly delayed compared with those of VIP. In the pithed rat, PACAP caused the same level of pancreatic secretions as in the anaesthetized rat, though this was now accompanied by a substantial pressor response which was blocked by phentolamine or prazosin, indicating that it was alpha 1-adrenoceptor mediated. VIP caused a depressor response in the pithed rat, as well as the same level of pancreatic secretions as in the anaesthetized rat. The putative VIP antagonist [Lys1,Pro25,Arg3,4,Tyr6]-VIP (abbreviated as VIPi) caused a selective and significant reduction in the HCO3- secretion evoked by VIP and blocked the vasodepressor response caused by VIP. By contrast, VIPi did not antagonize either the secretory or vasodepressor actions of PACAP. Unilateral electrical stimulation of the cervical vagus nerve evoked significant increases in the weight of juice, total protein and total HCO3- secreted. When preceded by injection of VIPi, vagally evoked secretions were unchanged in terms of weight of juice and total protein but had a significantly reduced HCO3- content. These results are consistent with the release of VIP, though not PACAP, as a vagal neurotransmitter in the exocrine pancreas.

Counselling carers of the elderly at home: a preliminary study.

A comparative study of two different methods of counselling for informal carers of elderly people with dementia was carried out in their own homes over an 18-week period. Carers were randomly allocated to short-term emotional support, information-provision or no-treatment control groups. Carers were assessed for mood, stress (Beck Depression Inventory and General Health Questionnaire), degree of burden and knowledge of problems of dementia. Carers receiving emotional support experienced the greatest reduction in stress, whereas those receiving information only showed an increase in knowledge, but no reduction in stress.

Cushing's syndrome, nodular adrenal hyperplasia and virilizing carcinoma.

A 48-year-old hypertensive diabetic woman rapidly became virilized. Urine 17-oxo-and oxogenic steroids and plasma testosterone, androstenedione, DHEA, DHEA-sulphate and androstenediol were greatly elevated. Plasma cortisol was constantly high and was not suppressed by dexamethasone. Circulating immunoreactive ACTH was consistently detectable at 18-24 ng/l. A 450 g carcinoma arising from a nodular hyperplastic right adrenal gland was resected. Production by the tumour of 17a-hydroxypregnenolone, 17a-hydroxyprogesterone and five C-19 steroids, but very little prenenolone, progesterone or cortisol, was shown by blood sampling, tumour culture and dramatic falls after operation. The plasma cortisol fell to half, with no diurnal variation, consistent with persistent Cushing's syndrome, and the plasma ACTH rose to 55 ng/l. She died 3 months later from a myocardial infarction. Autopsy revealed a pituitary basophil adenoma at a site where radiologically there had been an indentation in the fossa floor for at least 7 years. The left adrenal gland showed nodular hyperplasia. Therefore we conclude that mild pituitary-dependent Cushing's syndrome may have been present for many years before development of a virilizing carcinoma. This case demonstrates that adrenal carcinoma in man can sometimes develop as a consequence of nodular adrenal hyperplasia which may in turn be due to long-standing trophic hyper-stimulation.