Hearing and vision rehabilitation for people with dementia in five European countries (SENSE-Cog): a randomised controlled trial.

BACKGROUND: The effect of hearing and vision difficulties on the risk of developing dementia and worsening outcomes in people already living with dementia is well established. We evaluated the clinical impact of a hearing and vision rehabilitation and support programme on quality of life in people with mild-to-moderate dementia and concurrent sensory difficulties. METHODS: We conducted a parallel-group, multicentre, observer-blind, superiority randomised controlled trial in seven older adult clinics in five European countries (Cyprus, France, Greece, Ireland, and the UK). People with mild-to-moderate dementia with adult-acquired hearing difficulties, vision difficulties, or both were randomly assigned (1:1) along with their care partner to an 18-week home-basedsensory support intervention (SSI) of tailored hearing and vision rehabilitation and support, or to care as usual. Randomisation was blocked (block size of four, six, or eight) and stratified by country, with allocation assigned via a remote web-based system. The SSI included: full hearing assessment, vision assessment, or both; fitting of hearing aids, glasses, or other sensory aids; and home-based support from a sensory support therapist to assist adherence and uptake of sensory aids, foster social networking, and optimise the home sensory environment. Care as usual involved no additional intervention beyond services normally available to people with dementia at the respective sites. The primary outcome was health-related quality of life (Dementia Quality of Life Instrument [DEMQoL]) score at 36 weeks, reported as an adjusted mean difference. Analyses were done according to the intention-to-treat principle. This trial is registered with the ISRCTN Registry, ISRCTN17056211. FINDINGS: Between May 4, 2018, and May 6, 2021, 252 people with mild-to-moderate dementia were randomly assigned, of whom 251 (n=126 in the SSI group and n=125 in the care as usual group) were included in the analysis. The mean age of participants was 79·6 years (SD 5·8), and 132 (53%) were women. After a median follow-up time of 37·7 weeks (IQR 36·2-39·0), the mean DEMQoL score was 92·8 (SD 15·2) in the SSI group and 92·8 (14·0) in the care as usual group (adjusted difference 0·18, 95% CI -2·13 to 2·30, p=0·87). Among 114 adverse events reported for 56 (44%) participants in the SSI group, ten events in nine participants were related or possibly related to the intervention (medical device pain or discomfort n=6, ear pain n=1, scratch to the ear n=1, sore eye n=1, redness n=1; all of grade 1). Serious adverse events were reported for 25 (20%) participants in the SSI group and 16 (13%) in the care as usual group. Six (5%) participants in the SSI group and five (4%) in the care as usual group died. None of the serious adverse events or deaths were related to the study intervention or procedures. INTERPRETATION: This study showed no improvement in quality in life in participants who received the intervention in the longer term. Sensory difficulties are common in people with dementia and interventions aimed at improving sensory-cognitive health should be explored further. FUNDING: EU Horizon 2020.

Current distribution and trends in the location pattern of pediatricians, family physicians, and general practitioners between 1976 and 1979.

The literature suggests that pediatricians in the United States are concentrated in the more densely populated regions and states, whereas family physicians and general practitioners are more likely to settle in rural areas. The rapidly increasing supply of all child health physicians had led many to hypothesize that the traditional geographic preferences of pediatricians would expand to include smaller communities. Data for 1976 to 1979 confirm the urban concentration of pediatricians and the more even distribution of family physicians and general practitioners. These data also demonstrate a marked imbalance of pediatricians within county groups, resulting in some areas of shortage even within highly metropolitan communities. Evidence of a trend toward increased dispersion of pediatricians into urban shortage areas is presented, but there is no indication that enough pediatricians will settle in rural areas to meet the needs of children in those small communities.

Full and limited medicaid participation among pediatricians.

Participation in Medicaid by pediatricians is an important element in the access of low income children to health care. Factors that influence whether participating pediatricians choose to participate fully in the program or to limit their acceptance of Medicaid patients are identified and analyzed. Data were derived from interviews conducted with 814 pediatricians in 13 states. A multivariate analysis examining physician, practice, service area, and Medicaid policy characteristics indicates that policy factors are most influential in the physician's decision whether to participate fully in medicaid programs. Factors found to foster the willingness of pediatricians to participate fully in state Medicaid programs included more competitive levels of reimbursement, minimal delays in reimbursement, and eligibility and benefit policies that minimize interference with the exercise of medical judgment.

The extent of physician participation in Medicaid: a comparison of physician estimates and aggregated patient records.

This article compares two measures of the extent of physician participation in Medicaid programs. The first, which has been used in most research to date on the subject, is based on physician estimates of the proportion of their patients who are Medicaid patients. The second derives from encounter forms for a sample of visits to the interviewed physicians. The comparison shows that physicians in the sample tended to overestimate by 40 percent the extent of their Medicaid participation. Because the two measures are highly correlated, the analysis of the determinants of Medicaid participation was not affected by the measure used. However, since physicians tended to overstate the proportion of Medicaid patients in their practices, interview data should not be used to measure the amount of physician participation or to calculate elasticities for the effects of policy changes on the extent of participation.

Comparison of the pharmacokinetics and phototoxicity of protoporphyrin IX metabolized from 5-aminolevulinic acid and two derivatives in human skin in vivo.

Our novel approach was to compare the pharmacokinetics of 5-aminolevulinic acid (ALA), ALA-n-butyl and ALA-n-hexylester induced protoporphyrin IX (PpIX), together with the phototoxicity after photodynamic therapy (PDT) in human skin in vivo, using iontophoresis as a dose-control system. A series of four increasing doses of each compound was iontophoresed into healthy skin of 10 volunteers. The kinetics of PpIX metabolism (n = 4) and the response to PDT (n = 6) performed 5 h after iontophoresis, were assessed by surface PpIX fluorescence and post-irradiation erythema. Whilst ALA-induced PpIX peaked at 7.5 h, highest PpIX fluorescence induced by ALA-n-hexylester was observed at 3-6 h and no clear peak was seen with ALA-n-butylester. With ALA-n-hexylester, more PpIX was formed after 3 (P < 0.05) and 4.5 h, than with ALA or ALA-n-butylester. All compounds showed a linear correlation between logarithm of dose and PpIX fluorescence/phototoxicity at 5 h, with R-values ranging from 0.87 to 1. In addition, the ALA-n-hexylester showed the tendency to cause greater erythema than ALA and ALA-n-butylester. Fluorescence microscopy (n = 2) showed similar PpIX distributions and penetration depths for the three drugs, although both ALA esters led to a more homogeneous PpIX localization. Hence, ALA-n-hexylester appears to have slightly more favorable characteristics for PDT than ALA or ALA-n-butylester.

Monitor lyophilization with mass spectrometer gas analysis.

This paper presents a brief review of the basic issues of lyophilization and the fundamentals of quadrupole mass spectrometry. The emphasis of the paper is on the application of a quadrupole mass spectrometer as a process monitor. The details of sampling and data collection are discussed. Data taken while monitoring lyophilization is presented in conjunction with cycle optimization, end point detection and contaminant detection.

Femtosecond transient absorption study of carotenoid to chlorophyll energy transfer in the light-harvesting complex II of photosystem II.

Singlet energy transfer between the carotenoids (Cars) and chlorophylls (Chls) in the light-harvesting complex II (LHC II) from higher plants has been studied using ultrafast transient absorption spectroscopy by exciting the Cars directly in the 475-515 nm wavelength range. LHC II trimers from Arabidopsis thaliana with well-defined Car compositions have been used. From HPLC, the wild type (WT) monomer contains two luteins (Ls), one neoxanthin (N), and a trace of violaxanthin (V) per 12 Chls. The ABA-3 mutant contains 1.4 Ls and 0.6 zeaxanthin (Z) per monomer. Though exploitation of the difference in Car constitution and exciting the WT at 475 and 490 nm, and the ABA-3 mutant at 490 and 515 nm, the different Car contributions to energy transfer have been probed. Evidence for energy transfer mainly from the Car to Chl b is observed in the WT. In the mutant, additional transfer from Car to Chl a correlates with the presence of Z. The results imply predominant energy transfer from the central Ls to Chl b which requires a modification of the currently accepted arrangement of Chl pigments in LHC II.

Nonphysician health care providers in pediatrics.

This paper has identified nurse practitioners, physician's assistants and, potentially, nurse-midwives, as nonphysician health care providers who might have a significant impact on physician manpower requirements in pediatrics in the United States. These providers are capable of providing well child care, as well as care for minor illnesses. Patient acceptance and the quality of care rendered by these providers appear to be high. Physician acceptance is also high, especially when the physician has actually employed a nonphysician provider. State legislation and reimbursement procedures may interfere with the full utilization of nonphysician providers, but when nurse practitioners and physician assistants are employed in pediatric care, they deliver a wide range of services efficiently and economically. There are estimated to be a total of approximately 5,500 nonphysician providers specializing in pediatric care, but other nonphysician providers who may also care for children are discussed. The total number of these providers for 1980 is estimated at 7,232 and for 1990, at 15,512.