Demographic profile of the elderly population in Dublin accident and emergency hospital catchment areas

The Dublin metropolitan area is now divided into a number of clearly defined accident and emergency (A & E) catchment areas since the closing of the smaller inner city hospitals and the opening of newer hospitals on the periphery of the city. We examined the demographic profile of the elderly population in Dublin city and county served by each of the new catchment areas. Whilst the elderly population make up 9.9% (105,188) of the Dublin population (1996 census) they make up over 20% of the A & E attendances and up to over 40% of the A & E admissions in major Dublin hospitals. There is a wide variation in the percentage elderly population in each hospital catchment area with inner more settled city areas having a much higher percentage elderly population over those hospital catchment areas that serve newer housing areas. We also looked at the level of deprivation. Combining the two most deprived levels St James's Hospital had the largest absolute number and the highest percentage of deprived elderly 12,736 (51.1%) followed by the Mater 6,919 (32.9%), Beaumont 5371 (31.5%), James Connolly 2,983 (38.1%), Tallaght 2012 (22.3%) and St Vincent's Hospital 1987 (7.7%). Hospitals with high numbers of elderly and serving deprived catchment areas face particular resource problems in meeting the needs of the population that they serve. A significant increase in the provision of publicly funded community facilities and long stay accommodation is required to meet the needs of the large number of deprived elderly in the inner city area. Failure to respond to these demographic challenges will have a profound effect on the ability of hospital emergency services to meet the increasing pressures posed by the high volume of acutely sick economically deprived elderly presenting to hospital accident and emergency departments.

Identification of a novel stress resistance mechanism in Campylobacter jejuni

AIM

To study stress resistance mechanisms in Campylobacter spp.

METHODS AND RESULTS

Campylobacter strains were grown to the appropriate phase in Brucella broth. The cells were diluted into either cell-free spent medium (obtained by filtration of a grown culture) or a freshly prepared medium and the pH reduced to 4.5, a lethal pH value. At suitable time intervals survivors were enumerated on Campylobacter blood free selective agar base. The cell-free spent medium from mid-exponential and stationary phase had a protective effect on acid and thermal stress in Campylobacter jejuni CI 120, a natural isolate. The protective effect of the extracellular compound was not significantly inactivated by boiling, but was inactivated by proteinase.

CONCLUSIONS

The present study suggests that a protein (or proteins) accumulated by C. jejuni CI 120 during growth may play an active role in the induction of stress responses and that this protein is heat stable.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results indicate that C. jejuni CI 120, a natural isolate, has the ability to use extracellular signalling mechanisms to induce tolerance to stress factors. This is a major advancement in the understanding of the physiological basis for survival of C. jejuni in the environment.

Patients' health-related quality-of-life and health state values for motor neurone disease/amyotrophic lateral sclerosis

Motor neurone disease (MND) has a severe impact on patient quality of life, especially in later stages of the disease. This study assesses the health-related quality of life (HRQL) of MND patients, and for the first time elicits health state values from patients for their present health state. A structured interview was conducted with 77 patients. Patients completed a disease specific health status measure (ALSAQ-40), a generic health status measure (EuroQol EQ-5D), a visual analogue scale (VAS) and a standard gamble (SG) exercise. The ALSAQ-40 was sensitive to disease severity. Patients' mean VAS rating of their own health ranged from 0.74 for stage 1 (early) disease severity (n = 15), to 0.37 for stage 4 (late stage) disease severity (n = 19). Utilities elicited via SG varied from a mean of 0.79 for stage 1 disease severity to a mean of 0.45 for stage 4 disease severity. The EQ-5D derived single index ranged from a mean of 0.63 for stage 1 disease severity to a mean of -0.01 for stage 4 disease severity. This study demonstrates that it is feasible and practical to obtain health state values from MND patients and it provides evidence that patients place a high value on their HRQL, even in cases where health status is very poor.

Comparison of the effects of two intrathecal anaesthetic techniques for transurethral prostatectomy on haemodynamic and pulmonary function

BACKGROUND AND OBJECTIVE

Transurethral prostatectomy is routinely performed under spinal anaesthesia. This technique can cause hypotension, which is particularly undesirable in the elderly. The objective was to compare spinal anaesthesia for transurethral prostatectomy using hyperbaric bupivacaine 15 mg (control group) and hyperbaric bupivacaine 10 mg (limiting spread by maintaining the upright position for 15 min) and fentanyl 25 microg (fentanyl group) in terms of haemodynamic and pulmonary function.

METHODS

Thirty ASA I-III patients were randomly selected and underwent spinal anaesthesia with either hyperbaric bupivacaine 15 mg (immediately positioned supine) or hyperbaric bupivacaine 10 mg (upright for 15 min) and fentanyl 25 microg.

RESULTS

The greatest changes in mean arterial pressure (P = 0.9), ephedrine requirements (P = 0.8) and mean maximum change in forced vital capacity (P = 0.5) were similar in both groups.

CONCLUSIONS

The addition of fentanyl 25 microg to bupivacaine 10 mg and limiting the spread of the block does not improve either haemodynamic or pulmonary function compared with bupivacaine 15 mg in patients undergoing transurethral prostatectomy.

A Scandinavian adaptation of the Multi-Clinic Smell and Taste Questionnaire: evaluation of questions about olfaction

OBJECTIVE

A Scandinavian adaptation of the Multi-Clinic Smell and Taste Questionnaire (MCSTQ-Sc) was evaluated with respect to comprehension and test-retest reliability for responses to questions about olfactory dysfunction (abnormal sensitivity, parosmia and phantosmia) and related questions about medical history and consequences of olfactory dysfunction.

MATERIAL AND METHODS

Comprehension was evaluated in a first study in 20 patients with chief complaints of olfactory dysfunction by comparing questionnaire- and interview-based responses. Test-retest reliability was evaluated in a second study in 30 other patients with olfactory complaints.

RESULTS

Data from the two studies suggest that the vast majority of the questions evaluated from the MCSTQ-Sc are comprehensible and generate responses with very good reliability. Distinct exceptions were poor agreement between the questionnaire- and interview-based responses for questions about the number of cigarettes smoked and the pleasantness and typical episode length of phantosmia; the test-retest reliability regarding the nostril side of phantosmia also showed poor agreement. The results suggest the importance of probing these areas further in the clinical interview.

CONCLUSION

The findings imply that, with a few caveats, the MCSTQ-Sc is a useful tool for the clinical assessment of olfactory dysfunction and its consequences.

Patients' expectations of recovery following stroke: a qualitative study

PURPOSE

Patients and carers frequently express disappointment with the extent of recovery achieved at the point of discharge from physiotherapy. Research has suggested that high expectations of recovery may be encouraged by physiotherapists. This study examined the information exchanged between physiotherapists and patients in relation to recovery following stroke in order to explore this issue.

METHODS

The study comprised in-depth longitudinal case studies of 16 patients with a first incident stroke. Qualitative interviews were conducted with patients and their physiotherapists to explore their understandings and expectations of recovery and of physiotherapy at three time points. Patients were assessed for deficits of movement, function and mood at the same three stages and observations of out-patient sessions were also conducted. Qualitative data were analysed using thematic analysis. The assessment data were analysed using descriptive and comparative statistics.

RESULTS

Data indicated deficits of movement improved significantly between the first and third assessments. The qualitative data showed that physiotherapists did not encourage over-optimistic expectations of recovery through the verbal information they provided to patients. Nevertheless patients did maintain high expectations of recovery throughout the three-month post-stroke period.

CONCLUSION

Improved communication strategies, informed by an evidence base of recovery, should be used to encourage realistic expectations of physiotherapy without destroying the process of active participation and skill acquisition.

Clinical presentation of inhalational anthrax following bioterrorism exposure: report of 2 surviving patients

The use of anthrax as a weapon of biological terrorism has moved from theory to reality in recent weeks. Following processing of a letter containing anthrax spores that had been mailed to a US senator, 5 cases of inhalational anthrax have occurred among postal workers employed at a major postal facility in Washington, DC. This report details the clinical presentation, diagnostic workup, and initial therapy of 2 of these patients. The clinical course is in some ways different from what has been described as the classic pattern for inhalational anthrax. One patient developed low-grade fever, chills, cough, and malaise 3 days prior to admission, and then progressive dyspnea and cough productive of blood-tinged sputum on the day of admission. The other patient developed progressively worsening headache of 3 days' duration, along with nausea, chills, and night sweats, but no respiratory symptoms, on the day of admission. Both patients had abnormal findings on chest radiographs. Non-contrast-enhanced computed tomography of the chest showing mediastinal adenopathy led to a presumptive diagnosis of inhalational anthrax in both cases. The diagnoses were confirmed by blood cultures and polymerase chain reaction testing. Treatment with antibiotics, including intravenous ciprofloxacin, rifampin, and clindamycin, and supportive therapy appears to have slowed the progression of inhalational anthrax and has resulted to date in survival.

Characterization of protein C receptor expression in monocytes

Many sequelae associated with endotoxaemic-induced shock result from excessive production of the cytokine mediators, tumour necrosis factor alpha (TNF-alpha), interleukin 1 (IL-1) and IL-6 from lipopolysaccharide (LPS)-activated monocytes. Protein C (PC)/activated protein C (APC) has potent cytokine-modifying properties and is protective in animal models and human clinical trials of sepsis. The precise mechanism by which this anti-inflammatory response is achieved remains unknown; however, the recently described endothelial protein C receptor (EPCR) appears to be essential for this function. The pivotal role that monocytes play in the pathophysiology of septic shock led us to investigate the possible expression of a protein C receptor on the monocyte membrane. We used similarity algorithms to screen human sequence databases for paralogues of the EPCR but found none. However, using reverse transcription-polymerase chain reaction (RT-PCR), we detected an mRNA transcribed in primary human monocytes and THP1 cells that was identical to human EPCR mRNA. We also used immunocytochemical analysis to demonstrate the expression of a protein C receptor on the surface of monocytes encoded by the same gene as EPCR. These results confirm a new member of the protein C pathway involving primary monocytes. Further characterization will be necessary to compare and contrast its biological properties with those of EPCR.

Executive dysfunction and disability in elderly patients with major depression

The authors studied 126 elderly patients without dementia and with unipolar major depression. Impairment in instrumental activities of daily living (IADLs) was significantly associated with age (P<0.0001), gender (P<0.001), medical burden (P=0.013), severity of depression (P=0.01), initiation/perseveration (IP; P=0.035), and IP x depression (P=0.029). Depression was associated with IADL impairment mainly in patients with impaired IP. Among the cognitive impairments, IP-only contributed significantly to IADL impairment, whereas attention, construction, conceptualization, and memory did not. Attention to executive function and disability may guide clinical management and lead to development of innovative pharmacological and behavioral interventions.

Patients' health-related quality of life and utilities associated with different stages of amyotrophic lateral sclerosis

OBJECTIVES

Amyotrophic lateral sclerosis (ALS) is a devastating disease that has serious consequences in terms of impairments and disabilities, which are expected to impact on health-related quality of life (HRQL). The aim of the present study was to assess self-reported health status and HRQL, as well as patients' own valuation of their present health state in a sample of patients with different levels of severity of ALS.

METHODS

Structured interviews were conducted with 77 patients with different levels of disease severity. Patients completed a disease-specific health status measure (ALSAQ-40), a generic health status measure (EuroQol EQ-5D), visual analogue scale (VAS) rating of current health and a standard gamble (SG) exercise to provide health state utilities for their own health state.

RESULTS

The results from the ALSAQ-40 and EQ-5D descriptive system indicate that patients' HRQL decreases systematically with increasing severity of disease. Patients' mean VAS rating of their own health ranged from 0.74 for stage 1 (early) disease severity, to 0.37 for stage 4 (late stage) disease severity. Utilities elicited via SG were systematically higher than VAS scores and ranged from a mean of 0.79 for stage 1 disease severity to a mean of 0.45 for stage 4 disease severity.

Structural features of the Abeta amyloid fibril elucidated by limited proteolysis

Although the gross morphology of amyloid fibrils is fairly well understood, very little is known about how the constituent polypeptides fold within the amyloid folding motif. In the experiments reported here, we used trypsin and chymotrypsin to conduct limited proteolysis studies on synthetic amyloid fibrils composed of the Alzheimer's disease peptide Abeta(1-40). In both reactions, the extreme N-terminal proteolytic fragment is released from fibrils as rapidly as it is from the Abeta monomer, while other proteolytic fragments are generated much more slowly. Furthermore, aggregated material isolated by centrifugation of intermediate digestion time points from both proteases contains, in addition to full-length material, peptides that possess mature C-termini but truncated N-termini. These data strongly suggest that the N-terminal region of Abeta is not involved in the beta-sheet network of the amyloid fibril, while the C-terminus is essentially completely engaged in protective-presumably beta-sheet-structure. In both digests, release of the extreme N-terminal fragments of Abeta(1-40) reaches plateau values corresponding to about 80% of the total available Abeta. This suggests that there are two classes of peptides in the fibril: while the majority of Abeta molecules have an exposed N-terminus, about 20% of the peptides have an N-terminus that is protected from proteolysis within the fibril structure. The most likely cause of this heterogeneity is the lateral association of protofilaments into the fibril structure, which would be expected to generate a unique environment for those Abeta N-termini located at protofilament packing interfaces and/or in the interior core region between the packed protofilaments. This suggests that the N-terminal region of Abeta, while not directly involved in the beta-sheet network of the fibril, may contribute to fibril stability by participating in protofilament packing.

Development of a Canadian standardized protocol for subtyping methicillin-resistant Staphylococcus aureus using pulsed-field gel electrophoresis

A panel of 24 methicillin-resistant Staphylococcus aureus strains was distributed to 15 laboratories in Canada to evaluate their in-house pulsed-field gel electrophoresis (PFGE) protocols and interpretation criteria. Attempts to compare fingerprint images using computer-aided analysis were not successful due to variability in individual laboratory PFGE protocols. In addition, individual site interpretation of the fingerprint patterns was inadequate, as 7 of 13 sites (54%) made at least one error in interpreting the fingerprints from the panel. A 2-day standardized PFGE protocol (culture to gel image) was developed and distributed to all of the sites. Each site was requested to use the standardized protocol on five strains from the original panel. Thirteen sites submitted gel images for comparisons. The protocol demonstrated excellent reproducibility and allowed interlaboratory comparisons with Molecular Analyst DST software (Bio-Rad) and 1.5% band tolerance.

A short-term inpatient program for agitated demented nursing home residents

OBJECTIVE

This case series describes the various contributors of disruptive behavior in demented nursing home residents and outlines the necessary steps to identify and treat them.

DESIGN

Evaluation of overall clinical improvement and agitation at discharge from the hospital and at follow-up.

SETTING

Nursing home residents consecutively admitted to the geriatric psychiatry service of a psychiatric university hospital in the New York metropolitan area.

PATIENTS

15 elderly demented nursing home residents with agitation.

MEASURES

Overall clinical improvement was assessed with the 'global assessment of functioning scale'. Agitation was evaluated with the 'brief agitation rating scale' and the 'nursing home scale for agitation'. Medication side-effects were measured with the 'Simpson-Angus scale' and the 'abnormal involuntary movement scale'.

RESULTS

The patients showed significantly more overall clinical improvement at discharge compared with admission. Additionally, agitation scores were significantly lower at discharge and at follow-up compared with admission.

CONCLUSION

A comprehensive medical and neurological assessment, an accurate identification of comorbid psychopathology, evaluation of drug toxicity, and a thorough history of psychotropic medication trials are essential steps for a successful treatment.

Codeposition of apolipoprotein A-IV and transthyretin in senile systemic (ATTR) amyloidosis

Protein material was extracted from amyloid-rich sections of formalin-fixed and paraffin-embedded heart tissue from an individual with senile systemic amyloidosis, known to contain wild-type transthyretin as major amyloid fibril protein. Amino acid sequence analysis of tryptic peptides of this material revealed in addition to transthyretin sequences, also amino acid sequence corresponding to an N-terminal fragment of apolipoprotein A-IV. In immunohistochemistry, an antiserum to a synthetic apolipoprotein A-IV peptide labeled amyloid specifically. This peptide formed spontaneously amyloid-like fibrils in vitro and enhanced fibril formation from wild-type transthyretin. We conclude that several apolipoproteins, including apolipoprotein A-IV, may be important minor amyloid constituents, promoting fibril formation.

Glutamate is a mediator of neurotoxicity in secretions of activated HIV-1-infected macrophages

We sought to identify neurotoxin(s) secreted by HIV-1-infected mononuclear phagocytes that could contribute to the pathophysiology of HIV-1-associated dementia (HAD). Neurotoxic factors were characterized in batches of conditioned media (CM) from human monocyte-derived macrophages (MDM) infected with HIV-1(ADA) and/or activated with lipopolysaccharide (LPS). All of the neurotoxicity was: present in the <3000-Da fraction; blocked by 5 microM MK801; and not trypsin sensitive or extractable into polar organic solvents. Glutamate measured in CM accounted for all neurotoxic effects observed from HIV/LPS CM in astrocyte-poor neuronal cultures and may contribute to the pathophysiology of HIV-1-associated dementia.

fMRI activation in response to odorants orally delivered in aqueous solutions

During food intake flavor perception results from simultaneous stimulation of the gustatory, olfactory and trigeminal systems. Olfactory stimulation occurs mainly through the retronasal pathway and the resulting perception is often interpreted as a taste perception, thus leading to the well-known sensory confusion between taste and olfaction. The present experiment was designed to study, with functional magnetic resonance imaging (fMRI), the cortical representation of olfactory perception in humans in response to retronasal stimulation by odorants delivered in aqueous solution. Psychophysical evaluation confirmed that the stimuli acted as pure olfactory stimuli through the retronasal pathway and did not present any taste component. Results showed activation in all brain regions previously described with neuroimaging techniques using olfactory stimulation with an odorized air flow. Piriform and orbitofrontal cortex were found activated as well as the hippocampal region, the amygdala, the insular lobe, the cingulate gyrus and the cerebellum. These results demonstrate the feasibility of efficiently stimulating the olfactory system in an fMRI scanner through the retronasal pathway with liquids delivered to the oral cavity. The presentation of olfactory stimuli in liquids to the mouth is a realistic model for the study of food-related flavor perception. This stimulation protocol furthermore allows presenting taste and olfactory stimuli separately or combined, thus allowing for direct comparisons between single modality representation, taste or olfaction, and representation of multi-modality mixtures.

Dual function of rhoD in vesicular movement and cell motility

The trafficking of intracellular membranes requires the coordination of membrane-cytoskeletal interactions. Rab proteins are key players in the regulation of vesicular transport, while Rho family members control actin-dependent cell functions. We have previously identified a rho protein, rhoD, which is localized to the plasma membrane and early endosomes. When overexpressed, rhoD alters the actin cytoskeleton and plays an important role in endosome organization. We found that a rhoD mutant exerts its effect on early endosome dynamics through an inhibition in organelle motility. In these studies, the effect of rhoD on endosome dynamics was evaluated in the presence of a constitutively active, GTPase-deficient mutant of rab5, rab5Q79L. As rab5Q79L itself stimulates endosome motility, rhoD might counteract this stimulation, without itself exerting any effect in the absence of rab5 activation. We have now addressed this issue by investigating the effect of rhoD in the absence of co-expressed rab5. We find that rhoDG26V alone alters vesicular dynamics. Vesicular movement, in particular the endocytic/recycling circuit, is altered during processes such as cell motility. Due to the participation of vesicular motility and cytoskeletal rearrangements in cell movement and the involvement of rhoD in both, we have addressed the role of rhoD in this process and have found that rhoDG26V inhibits endothelial cell motility.

Apolipoprotein E ε4 positive individuals demonstrate delayed olfactory event-related potentials

Apolipoprotein E epsilon4 positive individuals have deficits in the ability to identify and remember odors, as demonstrated by psychophysical measures of olfactory function. The purpose of the present study was to identify olfactory deficits in this population using an objective electrophysiological measure: the olfactory event-related potential (OERP). Olfactory and auditory ERPs were recorded from the Fz, Cz, and Pz electrode sites in 10 epsilon4 positive individuals and 10 age and gender-matched epsilon4 negative individuals in a single-stimulus paradigm. The results indicate: (1) individuals who are positive for the apolipoprotein E epsilon4 allele demonstrated delays (of approximately 100 ms) in the processing of olfactory information compared to those who are epsilon4 negative; (2) OERP latency is more sensitive than psychophysical measures of olfactory function; (3) delays in the cognitive P3 component of the OERP are associated with deficits in the ability to identify an odor; and (4) unlike the moderate ranges found in auditory ERP, OERP latency showed high sensitivity and specificity in classifying epsilon4 positive and negative individuals.