[Cholecystolithiasis and intestinal bypass procedures]

With the increasing number of surgical interventions for obesity, the numbers of associated complications, such as gallstones after bariatric surgery are also increasing. The incidence of postbariatric symptomatic cholecystolithiasis is 5-10%; however, the numbers of severe complications due to gallstones and the probability of a necessary extraction of gallstones are low. For this reason, a simultaneous or preoperative cholecystectomy should only be carried out in symptomatic patients. Treatment with ursodeoxycholic acid reduced the risk of gallstone formation in randomized trials but not the risk of complications related to gallstones in cases of pre-existing gallstones. The most frequently used access route to bile ducts after intestinal bypass procedures is the laparoscopic approach via the stomach remnants. Other possible access routes are the enteroscopic approach as well as the endosonography-guided puncture of the stomach remnants.

Compressive and tensile strain sensing using a polymer planar Bragg grating

A polymer planar Bragg grating sensor is used for measuring both mechanical compressive and tensile strain. The planar waveguide with integrated Bragg grating is fabricated in bulk Polymethylmethacrylate in a single writing step using combined amplitude and phase mask technique. After butt coupling of a single-mode optical fiber the planar structure can be applied for measuring both mechanical tensile and compressive strain alongside the integrated waveguide without the need of further modifications. In this respect, we particularly report for the first time compressive strain measurements using a polymer Bragg grating. Furthermore, the sensitivity of the sensor against tensile and compressive strain, its reproducibility and hysteresis are investigated and discussed.

Recurrence after endoscopic mucosal resection-therapy failure?

PURPOSE

To evaluate the success and complication rates of endoscopic mucosal resections (EMR) for large flat adenomas and to identify risk factors for adenoma recurrence.

METHODS

We evaluated all consecutive patients treated with EMR at our institution between 2003 and 2005 that fulfilled the following criteria: >10-mm diameter, Paris 0-Is and 0-IIa-c, and endoscopic follow-up. We conducted univariate analysis and multivariate analysis using a non-stratified logistic regression model to identify possible influencing factors.

RESULT

In a median follow-up period of 6 years, we analyzed 177 EMR procedures, with a mean size of 21 mm. The majority of the resections were in the right colon. Recurrence occurred in 29 patients. Further treatment of patients with recurrence was endoscopic in 27 patients, whereas 1 patient was treated with transanal endoscopic microsurgery and one underwent surgery. The variables influencing the multivariate model were resection technique, immediate complication age, and histology.

CONCLUSIONS

We show that EMR can achieve a long-term clearance of large flat adenomas. A recurrence after EMR does not equal to failed therapy. The possibility of recurrence has to be considered in the clinical implementation of EMR. An important part of the stratifying factors for follow-up is the procedural assessment of the effectiveness of the resection and the resection technique.

Polymer planar Bragg grating sensor for static strain measurements

We report on a new optical strain sensor based on a polymer planar Bragg grating (PPBG). The sensor consists of commercially available bulk Polymethlymethacrylate with a UV-inscribed optical waveguide as well as a Bragg grating, both of which are fabricated simultaneously in a single writing step. Upon axial strain, the Bragg wavelength reveals a quasi-instantaneous spectral red shift that depends linearly on the mechanical load with a sensitivity of 2.95 pm/με. The relative reflected intensity of the PPBG remains constant in the investigated load region.

Planar Bragg grating in bulk polymethylmethacrylate

We report on a one-step writing process of a planar waveguide including a Bragg grating structure in bulk Polymethylmethacrylate (PMMA). A KrF excimer laser and a phase mask covered by an amplitude mask were used to locally increase the refractive index in PMMA and thereby generate simultaneously the planar waveguide and the Bragg grating. Our results show a reflected wavelength of the Bragg grating of about 1558.5 nm in accordance to the phase mask period. The reflectivity of the grating is about 80%. Initial characteristics of the Bragg grating structure towards humidity are investigated.

Selective tissue elevation by pressure for endoscopic mucosal resection of colorectal adenoma: first clinical trial

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection of large lateral spreading tumors currently are technically limited by complications such as bleeding, perforation, and disturbed large procedural sites, leading to incomplete resection and secondary surgery. Further technical improvements are necessary. The authors previously demonstrated the effectiveness of a focused water jet for elevation of the lamina submucosa in animal studies. For the first time, the clinical application of selective tissue elevation by pressure (STEP) for the treatment of colorectal adenomas as a prospective single-arm human trial is presented.

METHODS

This trial evaluated 59 patients who had primary colorectal adenomas with diameters exceeding 12 mm classified as 0-IIa or 0-IIb according to Paris classification. A submucosal cushion was created with a flexible water jet applicator using the Helix HydroJet. The adenoma was subsequently resected with a mucosal resection snare. All results were recorded. The resected specimens were assessed histologically.

RESULTS

A total of 59 patients underwent resection of 70 lesions with a maximum diameter of 80 mm (mean, 27 mm). Submucosal elevation with the water jet dissector was possible in all cases and locations from the pectinate line to the ileocecal valve. Of the 70 lesions, 64 (91%) were resected completely in one session. Histologically, the resected specimens were found to be adenocarcinomas (n = 2, 3%), adenomas with high-grade intraepithelial neoplasia (n = 24, 34%), adenomas with low-grade intraepithelial neoplasia (n = 38, 54%), and hyperplastic polyps (n = 6, 9%). Hemostasis during the resection was necessary in 24 cases (34%). No perforation required surgical intervention.

CONCLUSION

This first clinical trial to analyze STEP technique demonstrated that STEP used to elevate large mucosal lesions in any location is feasible and facilitates EMR for colorectal adenoma.

Temporary cystogastrostomy with self-expanding metallic stents for pancreatic necrosis

Conventional endoscopic drainage of symptomatic pancreatic pseudocysts has its limitations when the content of the collection is nonfluid. This leads to obstruction of placed flap stents; it requires the placement of an irrigation catheter and repeated implantation of several stents. Herein we describe the temporary use of a special self-expanding partially covered metal mesh stent, which was designed to keep the pancreaticogastrostomy open for drainage of walled-off necrosis and for further endoscopic necrosectomies. The stent has a diameter of 20-25 mm and a length of 50 mm and was placed following the first transgastric removal of necrotic masses. After a treatment period of 7-11 days involving 2-3 endoscopic procedures we achieved clinical success, defined as complete removal of necrotic masses, in all cases without major complications.

Measurement of leisure time satisfaction in family caregivers

Caregiving is known to limit participation in a variety of roles. Leisure roles are increasingly recognized as important for the well-being of older adults. Little is known, however, about the impact of caregiving on leisure activities, and existing measures are of limited utility in caregiving research. We developed the Leisure Time Satisfaction (LTS) measure to allow further study of the impact of caregiving on caregivers' leisure time satisfaction, the role of leisure in understanding the caregiving process, and whether caregiving interventions improve leisure time satisfaction. The six-item LTS measure shows excellent psychometric properties, including internal consistency, a single factor structure, and convergent validity. Psychometric features are robust across diverse groups of caregivers, including subgroups varying by race/ethnicity and relationship to the care recipient. The LTS measure appears to be a promising tool for inclusion in caregiving research.

Mortality of men versus women in comparable high-level jobs: 15-year experience in the Federal Women's Study

The authors investigated exposure to high-level occupations in relation to the well-known survival advantage of women compared with men of the same age. Women in the federal workforce in positions of General Schedule 14 and above in 1979--1993 (n = 4,727) were each matched with three men (n = 14,181) by age, General Schedule level, and supervisory role. Fifteen-year mortality rates were compared between men and women and against expected 15-year mortality from the US general population. Despite similar job demands, women experienced markedly lower 15-year mortality than did men. However, men in these positions had nearly 50% lower mortality compared with age-matched men in the general population; the comparable reduction for women was 38%. The simultaneous substantial, but unequal by gender, improvement in mortality resulted in a reduced male/female mortality ratio, from 1.67 in the general population to 1.40. The reduced male/female mortality ratio was especially prominent for cancer and was not evident for heart disease mortality. Survival was nominally higher in non-White than in White participants. In summary, high-level employment is associated with substantially reduced mortality in both men and women. The relative improvement in survival is greater in men despite a comparable reduction in risk of heart disease mortality by gender.

Cognitive test performance and presence of subclinical cardiovascular disease in the cardiovascular health study

The purpose of the present study was to investigate the relationship between performance on a comprehensive battery of neuropsychological tests and the presence of clinical, subclinical or no cardiovascular disease in an elderly community-dwelling population. The results confirm previous reports of significant associations of age, education and gender with test performance. When performance was examined controlling for these variables, significant associations of disease group were seen with five measures emphasizing speed of performance; Parts A and B of the Trail Making Test, the WAIS-R Digit Symbol and Block Design subtests and category verbal fluency. These results add to the evidence that, in addition to other health implications, cardiovascular disease is related to cognitive functioning in the elderly even at subclinical levels.

Ten-year incidence of dementia in a rural elderly US community population: the MoVIES Project

OBJECTIVE

To determine incidence rates by age, sex, and education of overall dementia and probable/ possible AD in a largely rural community.

METHODS

Ten-year prospective study of a randomly selected community sample aged 65+; biennial cognitive screening followed by standardized clinical evaluation. Incidence rates were estimated for overall dementia (Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised, criteria and Clinical Dementia Rating [CDR]) and for probable/possible AD (National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria).

RESULTS

The cohort consisted of 1,298 individuals free of dementia at study entry. Among these, 199 incident (new) cases of overall (all-cause) dementia with CDR stage > or = 0.5, including 110 with CDR > or = 1, were detected during follow-up. Among the incident cases, 153 (76.9%) had probable/ possible AD. Age-specific incidence rates are reported for all dementia and for probable/possible AD, by sex and CDR stage. Among all-cause dementias with CDR = 0.5, controlling for age and education, men had a higher incidence rate than women. In the same group, those with less than high school education had significantly higher incidence rates than those with more education. Rates did not vary significantly by sex or education for probable/possible AD or for dementia with CDR > or = 1.

CONCLUSIONS

Incidence rates of all dementias and of AD increased with age; men and those with lesser education had higher rates of possible/incipient dementia (CDR = 0.5) in this community. Potential explanations for these sex and education effects are discussed.

Resource utilization in liver transplantation: effects of patient characteristics and clinical practice. NIDDK Liver Transplantation Database Group

CONTEXT

Liver transplantation is among the most costly of medical services, yet few studies have addressed the relationship between the resources utilized for this procedure and specific patient characteristics and clinical practices.

OBJECTIVE

To assess the association of pretransplant patient characteristics and clinical practices with hospital resource utilization.

DESIGN

Prospective cohort of patients who received liver transplants between January 1991 and July 1994.

SETTING

University of California, San Francisco; Mayo Clinic, Rochester, Minn; and the University of Nebraska, Omaha.

PATIENTS

Seven hundred eleven patients who received single-organ liver transplants, were at least 16 years old, and had nonfulminant liver disease.

MAIN OUTCOME MEASURE

Standardized resource utilization derived from a database created by matching all services to a single price list.

RESULTS

Higher adjusted resource utilization was associated with donor age of 60 years or older (28% [$53813] greater mean resource utilization; P=.005); recipient age of 60 years or older (17% [$32795]; P=.01); alcoholic liver disease (26% [$49596]; P=.002); Child-Pugh class C (41% [$67 658]; P<.001); care from the intensive care unit at time of transplant (42% [$77833]; P<.001); death in the hospital (35% [$67 076]; P<.001); and having multiple liver transplants during the index hospitalization (154% increase [$474 740 vs $186 726 for 1 transplant]; P<.001). Adjusted length of stay and resource utilization also differed significantly among transplant centers.

CONCLUSIONS

Clinical, economic, and ethical dilemmas in liver transplantation are highlighted by these findings. Recipients who were older, had alcoholic liver disease, or were severely ill were the most expensive to treat; this suggests that organ allocation criteria may affect transplant costs. Clinical practices and resource utilization varied considerably among transplant centers; methods to reduce variation in practice patterns, such as clinical guidelines, might lower costs while maintaining quality of care.

Development of an activities of daily living scale to screen for dementia in an illiterate rural older population in India

OBJECTIVE

to develop a measure of activities of daily living appropriate for use in assessing the presence of dementia in illiterate rural elderly people in India.

DESIGN

identification of relevant items, pre-testing of items and refinement of administrative procedures and scoring in four successive groups of 30 subjects each, pilot testing in a group of 100 subjects comparable to those for whom the measure is intended, administration to a representative sample of 387 people aged 55 and older, and assessment of the reliability of the final measure.

SETTING AND SUBJECTS

age-stratified random sample of older men and women in rural areas of Ballabgarh, Northern India.

RESULTS

the original pool of 35 items covering mobility, instrumental and personal care activities was reduced to an 11-item unidimensional scale (to which an additional item on mobility was added) with internal consistency (Cronbach's alpha)=0.82, perfect inter- and intra-rater reliability, test-retest reliability (intraclass correlation)=0.82 (any disability) and 0.92 (unable to perform for 'mental' reasons). Women, older subjects, the totally illiterate and subjects with poorer cognitive function performed significantly more poorly (P < or = 0.02 for all). PRODUCT: a brief, reliable and valid activities of daily living measure, with norms, which is appropriate for use in assessing dementia in illiterate rural elderly people in India.

Practical issues in cognitive screening of elderly illiterate populations in developing countries. The Indo-US Cross-National Dementia Epidemiology Study

The study of the epidemiology of dementia, specifically Alzheimer's disease, in developing countries requires specialized instruments and personnel. Cultural and sub-cultural differences among populations are highly relevant to the design of such instruments. Over and above the cultural issues, it is widely recognized that low education and illiteracy pose considerable challenges to reliable and valid cognitive screening. The overall objectives of the Indo-US Cross-National Dementia Epidemiology Study were: a) to determine the prevalence and incidence of, and risk factors for, Alzheimer's and other dementias in a defined Indian community; and b) to compare these results with those found in a defined American community. To achieve these epidemiological objectives, our first task was to develop, systematically and empirically, suitable cognitive and activities assessment screening instruments for use in India, which would 1) be culturally fair, psychometrically sound, and valid for a population with little or no education; 2) be optimally sensitive and specific for dementia; and 3) allow not only the identification but also the more detailed characterization of dementia, and of normal and abnormal cognitive aging. In this paper we address the practical issues involved in the development and administration of the modified cognitive screening battery in our rural Indian context.

Prevalence of Alzheimer's disease and other dementias in rural India: the Indo-US study

OBJECTIVE

To determine the prevalence of AD and other dementias in a rural elderly Hindi-speaking population in Ballabgarh in northern India.

DESIGN

The authors performed a community survey of a cohort of 5,126 individuals aged 55 years and older, 73.3% of whom were illiterate. Hindi cognitive and functional screening instruments, developed for and validated in this population, were used to screen the cohort. A total of 536 subjects (10.5%) who met operational criteria for cognitive and functional impairment and a random sample of 270 unimpaired control subjects (5.3%) underwent standardized clinical assessment for dementia using the Diagnostic and Statistical Manual of Mental Disorders-fourth edition diagnostic criteria, the Clinical Dementia Rating Scale (CDR), and National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria for probable and possible AD.

RESULTS

We found an overall prevalence rate of 0.84% (95% CI, 0.61 to 1.13) for all dementias with a CDR score of at least 0.5 in the population aged 55 years and older, and an overall prevalence rate of 1.36% (95% CI, 0.96 to 1.88) in the population aged 65 years and older. The overall prevalence rate for AD was 0.62% (95% CI, 0.43 to 0.88) in the population aged 55+ and 1.07% (95% CI, 0.72 to 1.53) in the population aged 65+. Greater age was associated significantly with higher prevalence of both AD and all dementias, but neither gender nor literacy was associated with prevalence.

CONCLUSIONS

In this population, the prevalence of AD and other dementias was low, increased with age, and was not associated with gender or literacy. Possible explanations include low overall life expectancy, short survival with the disease, and low age-specific incidence potentially due to differences in the underlying distribution of risk and protective factors compared with populations with higher prevalence.

Effects of literacy and education on measures of word fluency

As part of a cross-national study of dementia epidemiology, two types of verbal fluency tasks were administered to three groups of subjects, varying in level of literacy and education, recruited from the rural district of Ballabgarh in northern India. Subjects were asked to list items in a given semantic category (animals; fruits) or words beginning with a given sound (the phonemes /p/ and /s/) the latter being a minor modification of the more familiar initial letter fluency task in view of the high prevalence of illiteracy in Ballabgarh. Analysis of variance revealed main effects of education and task with a task by education interaction such that education had a greater effect on initial sound fluency than on category fluency. The results are discussed in terms of their implication for the design of cross-cultural studies and the evidence that the ability to segment speech into phonemic units is dependent on literacy.

Over-the-counter medication use in an older rural community: the MoVIES Project

OBJECTIVE

To examine the self-reported use of over-the-counter (OTC) medications and the factors associated with OTC use in a rural older population.

DESIGN

A cross-sectional study of an age-stratified random community sample.

SETTING

The mid-Monongahela Valley, a rural area of Southwestern Pennsylvania.

PARTICIPANTS

A total of 1059 older individuals with a mean age of 74.5 (+/- 5.5) years, 96.9% of whom were white and 57.3% of whom were women.

MEASUREMENTS

Self-reported over-the-counter drug use and demographic information, and information about prescription drug use and recent use of health services.

RESULTS

The majority (87.0%) of the sample were taking at least one OTC medication; 5.7% reported taking five or more OTCs. Women took significantly more OTCs than did men (P < .001). Individuals with more education took significantly more OTCs than those who had less (P = .018). The OTC category used most commonly was analgesics (66.3% overall), followed by vitamin and mineral supplements (38.1%), antacids (27.9%), and laxatives (9.7%). The use of analgesics decreased significantly (P = .018) with increasing age, whereas the use of laxatives increased significantly (P < .001). Women were more likely than men to be using each of these four major OTC groups. Unlike the associations with prescription drug use we reported previously in the same population, there were no significant associations for overall OTC use with age or with the use of health services. However, although vitamin use (as an example of an OTC drug taken for "preventive" purposes) was not associated with health services use, the use of laxatives (as an example of a "curative" OTC) was significantly associated (P < or = .002) with a greater number of physician visits, emergency room visits, hospitalizations during the past 6 months, home health care service utilization, and number of prescription medications.

CONCLUSIONS

A substantial proportion of our older sample reported using a variety of over-the-counter drugs. Analgesics and vitamin/mineral supplements were the most frequently used categories. Women and those with more education were taking more OTC drugs. OTC use was not related to age, but the use of analgesics decreased with age while laxative use increased with age. Unlike prescription drug use, overall OTC drug use was not associated with health services utilization.

Association between dementia and elevated TSH: a community-based study

We report on 194 individuals (96 men and 98 women), aged 65 and over, who had dementia assessments and basal TSH measurements as part of an ongoing epidemiological study of dementing disorders in a larger population. Dementia was diagnosed according to DSM-III-R and measured by the Clinical Dementia Rating scale; CDR scores of 0, 0.5, and > or = 1, represent individuals with no dementia (n = 122), possible dementia (n = 29), and definite dementia (n = 43), respectively. The odds ratio for the association of elevated TSH with definite dementia (CDR > or = 1) was 3.8 (95% confidence interval = 1.6, 9.1) and with possible and/or definite dementia (CDR > or = 0.5) was 3.8 (95% confidence interval = 1.6, 9.2), after adjusting for the effects of age, gender, and level of education. This is the first community-based study to report an association between TSH elevation and dementia. Our findings are consistent with recent evidence that subclinical hypothyroidism is associated with cognitive impairment, and that thyroidal state may influence cerebral metabolism.

Characteristics of rural homebound older adults: a community-based study

OBJECTIVE

To determine the frequency and characteristics of homebound older adults in a rural community.

DESIGN

An epidemiological survey of an age-stratified random community sample.

SETTING

The rural mid-Monongahela Valley in Southwestern Pennsylvania.

PARTICIPANTS

A total of 878 noninstitutionalized persons aged 68 years and older, fluent in English, and with at least grade 6 education.

MEASUREMENTS

The frequency with which subjects left their homes, the Mini-Mental State Examination (MMSE) score, and additional information on demographics, self-reported health problems, health services utilization, IADLs, depression, and social support were measured.

RESULTS

10.3% of the sample was classified as homebound. In univariate analyses, being homebound was found to be associated significantly (P < .001) with being older, female, and widowed and with MMSE and IADL impairment, with more depressive symptoms and worse social supports, fair to poor self-rated general health, weight loss, and histories of stroke, angina, arthritis of the spine, and falls. In a multiple regression model, variables associated independently with homebound status were gender (odds ratio = 9.4, 95% confidence interval = 3.6 - 24.9), weight loss (OR = 3.7, CI = 1.7 - 8.2), IADL impairment (OR = 2.6, CI = 2.1 - 3.1), and depressive symptoms (OR = 2.1, CI = 1.3 - 3.2). Being homebound was also associated with recent acute hospitalization and use of home health and social services.

CONCLUSIONS

These data provide evidence that homebound older adults have a disproportionate share of morbidity and disability and suggest a sociodemographic and clinical profile to help identify those older people at risk of being or becoming homebound. They also point to the need for home-based health services for the older adults, particularly in medically underserved communities such as rural areas.

Cognitive test performance in a community-based nondemented elderly sample in rural India: the Indo-U.S. Cross-National Dementia Epidemiology Study

Interpretation of cognitive test performance among individuals from a given population requires an understanding of cognitive norms in that population. Little is known about normative test performance among elderly illiterate non-English-speaking individuals. An age-stratified random sample of men and women, aged 55 years and older, was drawn from a community-based population in the rural area of Ballabgarh in northern India. These Hindi-speaking individuals had little or no education and were largely illiterate. A battery of neuropsychological tests, specially adapted from the CERAD neuropsychological battery, which was administered to this sample, is described. Subjects also underwent a protocol diagnostic examination for dementia. Norms for test performance of 374 nondemented subjects on these tests are reported across the sample and also by age, gender, and literacy.

Influence of donor age on graft survival after liver transplantation--United Network for Organ Sharing Registry

The waiting list for liver transplantation has more than doubled between 1988 and 1992, yet the number of liver transplantations during the same period increased by only 79%. This discrepancy is due to the limited availability of donors. The modest increase in donor pool is caused entirely by donors > or = 40 years of age, a trend likely to continue. To determine the impact of increasing donor age on the outcome of liver transplantation, we analyzed 6-month graft survival in 7,988 adults who received first liver graft between October 1987 and September 1992, and were observed through the United Network for Organ Sharing Scientific Liver Transplant Registry. Graft survival was measured by death and/or retransplantation, donor age by decades. The independent effect of donor age on graft survival was estimated by Cox regression analysis controlling for the possible confounding of donor, recipient, and institutional characteristics. Between 1987 and 1992, the percentage of donors over 50 years increased from 2.1% to 17.5% resulting in change of median donor age from 23 to 31 years. For donor age > or = 50, graft failure rate was 50% higher than with donor age less than 20 years (excess for mortality was 25% and for retransplantation 94%). Adjustment for characteristics associated to donor age or outcome did not eliminate the excess risk found with increasing donor age. Despite these adversities, graft failure rate in recipients from oldest donors (27.2%) in 1992 was nearly equivalent to recipients from the youngest donors (26.9%) in 1987 to 1988. Although increasing donor age has an adverse effect on 6-month graft survival, improvement in transplantation technology and patient care over time have more than compensated for poorer graft function associated with the simultaneous rise in median donor age.

Self-care behaviors of older women with urinary incontinence

1. Despite the availability of effective treatments for urinary incontinence, many women self-manage incontinence and never have it evaluated or treated. 2. The vast majority of women in this study used one or more self-care behaviors to manage their incontinence; the most frequently used behaviors were locating or staying near bathrooms when out, voiding more frequently, and wearing some type of protective garment. 3. Most women reported that incontinence was not at all or only a little difficult to manage and were satisfied with the self-care behaviors they used to manage this problem despite the fact that most of these behaviors had little or no potential to reduce or eliminate their incontinence.

Studies of the epidemiology of dementia: comparisons between developed and developing countries

By the year 2025, 68% of the world's population aged 65 and above, nearly 277 million people, will be residing in developing countries. The less industrialized nations have been the least studied to date, and may yield significant new information about the etiology and risk factors for Alzheimer's disease (AD) and other dementias. Although it is readily apparent that cross-national and cross-cultural comparisons are desirable, these can be meaningful only if based on comparable methodology. In this work we will discuss some general conceptual and methodological issues regarding epidemiological studies of dementia in developing countries. The topics discussed include community-based screening for dementia, screening instruments and their application in cross-cultural studies, steps in standardization of new or modified neuropsychological tests, and some special considerations in studying uneducated/illiterate populations.

Liver transplantation for fulminant hepatic failure in the United States: October 1987 through December 1991

BACKGROUND

Early mortality and retransplantation rates following liver transplantation for fulminant hepatic failure (FHF) are high. We investigated possible reasons for these findings.

METHODS

Data were obtained from the liver transplantation database of the United Network for Organ Sharing (UNOS) Scientific Registry. Recipient information was limited to waiting time; diagnosis; demographic, laboratory and serologic data; and six UNOS functional status codes. Donor information included demographic characteristics, cause of death, ABO blood type, and serology test results. Comparisons between FHF and non-FHF were carried out for children and adults separately. The influence of an FHF diagnosis on 1-year patient and graft survival was examined using the Cox proportional hazard model. The same model was used to determine independent predictors of outcome following transplantation for FHF.

RESULTS

The majority of FHF recipients were on pretransplant life support, had much shorter waiting times, and were less well matched for ABO blood type (especially the children) than their non-FHF counterparts. Although 1-year survival and graft survival were significantly lower, the significance of these differences was eliminated when the initial recipient, donor and matching characteristics between the two groups were controlled in the analysis. For FHF recipients, ABO mismatch and abnormal kidney function were the strongest independent predictors of adverse outcome.

CONCLUSIONS

The results of this study provide circumstantial evidence that patients with FHF derive as much benefit from liver transplantation as patients with other diagnoses of comparable severity.

Cognitive impairment and the use of health services in an elderly rural population: the MoVIES project. Monongahela Valley Independent Elders Survey

OBJECTIVE

To describe the patterns of use of health and human services by elderly rural individuals and to determine whether cognitively impaired persons had a distinctive pattern of service utilization.

DESIGN

An epidemiological survey and cognitive screening of an age-stratified random community sample.

SETTING

The mid-Monongahela Valley, a rural community in Southwestern Pennsylvania.

PARTICIPANTS

1366 non-institutionalized persons aged 65 years and older, fluent in English, and with at least a sixth grade education.

MEASUREMENTS

We administered a battery of cognitive screening tests (the Mini-Mental State Examination; Immediate and Delayed Recall of a Story; Immediate and Delayed Recall of a Word List; CERAD modification of the Boston Naming Test; Verbal Fluency for initial letters P and S and for names of Fruits and Animals; Temporal Orientation; Praxis; Clock Drawing; and Trailmaking Tests A and B.) We also obtained basic demographic information and inquired about the use of health and human services in the previous year.

RESULTS

Approximately 10% of the sample was classified (by operational criteria) as cognitively impaired. In univariate analyses, cognitive impairment was found to be significantly associated with the use of certain health services: hospitalization in the previous 6 months (odds ratio, OR = 2.1; 95% CI = 1.3, 3.3), previous nursing home use (OR = 9.3; 95% CI = 3.8, 22.9), home health care (OR = 4.6; 95% CI = 2.7, 8.0), social services (OR = 6.5; 95% CI = 3.4, 12.4), mental health services (OR = 2.8; 95% CI = 1.2, 6.2), and the regular use of prescription medications (OR = 2.0; 95% CI = 1.3, 3.2). Visits to physicians were not significantly different between the impaired and unimpaired groups. In a multiple regression model, which included age and educational level, the use of home health care (OR = 3.4; 95% CI = 1.8, 6.4) and social services (OR = 2.3; 95% CI = 1.1, 4.9) remained significantly associated with cognitive impairment.

CONCLUSIONS

The association of cognitive impairment with the use of these health and human services underscores the general frailty of the impaired group. These findings also point to potential target groups in the community for further evaluation and services for dementia. The findings support the need for education regarding cognitive impairment and dementia to be made available to providers of these services, particularly informal social services such as those provided by church groups.

Sensitivity and specificity for dementia of population-based criteria for cognitive impairment: the MoVIES project

BACKGROUND

Few norms exist for the elderly on the cognitive tests commonly used to screen for dementia; conventional cutpoints used in clinical settings may be of limited value in population screening. A particular problem is posed by elderly populations with low educational levels, as performance on most cognitive tests is affected by education. Thus, a healthy but poorly educated population may obtain test scores in the range considered impaired in the clinical setting.

METHODS

A random sample of 1,367 subjects aged 65+ years was screened for dementia in a rural community in Southwestern Pennsylvania. Two sets of cognitive measures were used: a global cognitive scale (the MMSE) and a brief battery of tests tapping a variety of cognitive domains. Rather than using a priori cutoff scores, we examined the specificity and sensitivity for dementia of two operationally defined levels of cognitive impairment, at the 5th and 10th percentiles of the study sample on each set of measures.

RESULTS

Results suggest that the screening of multiple cognitive domains at the 10th percentile had significantly greater sensitivity but not lower specificity for definite dementia than did the use of the single global scale.

CONCLUSION

Our data support the use of population-based cutpoints over standard cutoff scores, in that the global scale at the conventional cutoff was less sensitive than the battery at the same percentile, and because adequate norms do not exist for tests such as those in the battery.

Reactivation of Epstein-Barr virus during early infection with human immunodeficiency virus

Reactivation of Epstein-Barr virus (EBV) in early human immunodeficiency virus (HIV) infection was investigated in 49 homosexual men who seroconverted to HIV (cases) as compared with 49 matched controls who remained seronegative to HIV during a longitudinal study. EBV infection was reactivated in cases 6 months, but not 12 months, prior to HIV seroconversion as compared with controls and remained reactivated during 18 months of follow-up after HIV seroconversion, as shown by increases in immunoglobulin (Ig) G antibody titers to EBV early antigen. Antibody titers to EBV viral capsid antigen did not differ between cases and controls prior to the time of seroconversion to HIV but were significantly increased among cases by the first seropositive study visit and remained elevated during the 18 months after HIV seroconversion. Total serum IgG levels were increased in cases at the visit of seroconversion, and during 18 months of follow-up, but did not correlate with enhanced IgG production specific for EBV antigens. Significant decreases in numbers of CD4+ cells and increases in numbers of CD8+ cells during this early phase of HIV infection were not associated with changes in patterns of EBV antibody responses. Reactivation of EBV beginning 6 months before HIV seroconversion may have implications regarding the role of this herpesvirus in the pathogenesis of HIV.

Effects of age, gender, and education on cognitive tests in a rural elderly community sample: norms from the Monongahela Valley Independent Elders Survey

A random sample of 1,350 persons aged 65 years and older in a rural community underwent cognitive screening as part of a survey to establish a population-based registry of dementing disorders. The screening battery included the neuropsychological tests of the assessment protocol used in the National Institute on Aging multicenter Consortium to Establish a Registry for Alzheimer's Disease (CERAD). This paper reports a large body of normative neuropsychological data from this sample with members of relatively low socioeconomic status. Age, sex, and educational level were found to have statistically significant effects on test scores. The implications of these findings for the establishment of screening cutoff scores are discussed.

Establishing criterion validity of a computer-based clinical simulation

Clinical simulations, depictions of real-life patient care situations, have been used extensively in medical education. This study determined the criterion validity of a computer-based simulation which permits natural language interface and runs interactively with videotape to be fair to good (K = .61).

Serial sevens versus world backwards: a comparison of the two measures of attention from the MMSE

This paper reports on a comparison of the two alternative tests of attention in the Mini-Mental State Examination (MMSE), a well-known cognitive screening tool. The two tests, serial subtraction by seven and backwards spelling of the word world, are often used interchangeably. In a large population-based sample, the two tests were found to be weakly associated with each other, with the former test appearing more difficult, although both were strongly associated with educational level. The authors discuss the implications of this finding in clinical and research settings, and make recommendations for more consistent use of the instrument.

Reproductive history of women dying of sudden cardiac death: a case-control study

Reproductive history events may be risk factors for sudden coronary death (SCD) among women. A retrospective case-control study of SCD among women aged 25-64 was conducted in Allegheny County, Pennsylvania. The present analysis focused on a description and analysis involving the childbearing and reproductive history of 67 ever-married female SCD cases and 73 ever-married neighbourhood controls with a mean age of 54.6 and 53.4 years respectively. Information included: age and number of years married, number of children, age at first birth, cardiovascular risk factors, obstetric and gynaecological history. Age and the risk factors, history of hypertension or diabetes, cigarette intake, death of significant other and psychiatric disease, were controlled for in the analysis. More cases than controls experienced their first birth before age 20 (14 of the SCD and 7 controls). However, after adjustment for cigarette smoking status, a strong predictor of sudden cardiac death, the effect of early childbearing did not remain significant for this population. In women less than or equal to 50 years of age, childlessness was not a risk factor for SCD (1 of 16 cases and 2 of 26 controls were childless). However in women greater than 50 years of age, childlessness was a significant predictor of SCD (OR = 6.7 (1.3-32] 12 of 51 cases were childless compared to 2 of 46 controls. After adjustment for aged and other coronary heart disease (CHD) risk factors, the relationship of nulliparity with sudden cardiac death remained in this age group. There was no difference in hysterectomy or miscarriage history or in the total years married between cases and controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatic artery thrombosis after pediatric liver transplantation--a medical or surgical event?

Hepatic artery thrombosis (HAT) is one of the most serious complications after orthotopic liver transplantation, and is associated with a high morbidity and mortality. This study retrospectively reviewed 66 liver transplants in children under the age of 10 years during a year-long period at a single institution. A total of 28 perioperative variables were analyzed to identify responsible factors of HAT. Of the 66 children, 18 (26%) developed HAT within 15 days after the transplant (HAT group); 29 (42%) had an uneventful postoperative course (control group). To avoid the possible influence of other complications 19 patients were excluded. Of the variables compared between the 2 study groups, three surgical factors (diameter of the hepatic artery--greater or less than 3 mm; type of arterial anastomosis--end-to-end versus the use of an iliac graft or aortic conduit; and number of times the anastomosis was redone--one versus more than one), were found to be significantly different (P less than .05) between HAT and control groups. Two medical factors also were significantly different: the use of intraoperative transfusion of fresh frozen plasma (FFP) and the administration of postoperative prophylactic anticoagulant treatment. A heparin and dextran-40 protocol appeared to be effective in preventing HAT (P less than .02). Moreover, after multivariate analysis, anticoagulation therapy was demonstrated to be the major independent variable influencing HAT. A better definition of factors responsible for the occurrence of HAT is required. This study should help in formulating effective methods to decrease the incidence of this dreaded complication after liver transplantation.

A histometric analysis of chronically rejected human liver allografts: insights into the mechanisms of bile duct loss: direct immunologic and ischemic factors

Conspicuous pathologic features of chronic liver allograft rejection include bile duct loss and chronic obliterative arteriopathy. A quantitative histometric analysis was performed to document the extent of bile duct loss, the size of the "vanished" ducts and the extent of chronic obliterative arteriopathy and to determine whether there was any relationship between chronic obliterative arteriopathy and bile duct loss. All failed liver allograft specimens with chronic rejection were reviewed and categorized according to the degree of chronic obliterative arteriopathy, assessed by the degree of luminal narrowing of hilar hepatic artery branches. Histometric analysis of the grafts revealed: (i) there was a loss of small portal arterioles (less than 35 microns); (ii) bile ducts which should accompany arteries less than 35, 35 to 54 or 55 to 74 microns in diameter were missing, with the greatest decrease occurring among the smallest ducts; (iii) bile duct loss was seen in the absence of significant large vessel chronic obliterative arteriopathy, and (iv) the severity of arteriole and bile duct loss, as well as the size of the vanished ducts, was directly proportional to the degree of chronic obliterative arteriopathy. Furthermore, the size of the "vanished" bile ducts in liver allografts appeared to differ from the size of ducts destroyed in primary biliary cirrhosis. These studies offer indirect, but suggestive proof that two mechanisms are operative in the bile duct loss seen in chronic rejection: direct lymphocytotoxicity and ischemic damage.

Antibody-mediated rejection of human orthotopic liver allografts. A study of liver transplantation across ABO blood group barriers

A clinicopathologic analysis of liver transplantation across major ABO blood group barriers was carried out 1) to determine if antibody-mediated (humoral) rejection was a cause of graft failure and if humoral rejection can be identified, 2) to propose criteria for establishing the diagnosis, and 3) to describe the clinical and pathological features of humoral rejection. A total of 51 (24 primary) ABO-incompatible (ABO-I) liver grafts were transplanted into 49 recipients. There was a 46% graft failure rate during the first 30 days for primary ABO-I grafts compared with an 11% graft failure rate for primary ABO compatible (ABO-C), crossmatch negative, age, sex and priority-matched control patients (P less than 0.02). A similarly high early graft failure rate (60%) was seen for nonprimary ABO-I grafts during the first 30 days. Clinically, the patients experienced a relentless rise in serum transaminases, hepatic failure, and coagulopathy during the first weeks after transplant. Pathologic examination of ABO-I grafts that failed early demonstrated widespread areas of geographic hemorrhagic necrosis with diffuse intraorgan coagulation. Prominent arterial deposition of antibody and complement components was demonstrated by immunoflourescent staining. Elution studies confirmed the presence of tissue-bound, donor-specific isoagglutinins within the grafts. No such deposition was seen in control cases. These studies confirm that antibody mediated rejection of the liver occurs and allows for the development of criteria for establishing the diagnosis.

The neurologic examination in patients with probable Alzheimer's disease

Abnormal findings on a standardized neurologic examination were compared between patients with a clinical diagnosis of probable Alzheimer's disease (AD) and healthy control subjects. Aside from mental status findings, the most useful examination findings for differentiating AD from control subjects were the presence of release signs, olfactory deficit, impaired stereognosis or graphesthesia, gait disorder, tremor, and abnormalities on cerebellar testing. These abnormalities probably reflect the different areas of the central nervous system that are affected pathologically in AD. In the clinical diagnosis of AD, particular attention should be given to these aspects of the neurologic examination.