Examination of Anesthetic Practitioners’ Decisions for the Design of a Cognitive Tool for Airway Management

The goal of this research was to examine the decisions made by anesthesia providers in emergency and routine clinical situations relating to airway management. A key function of anesthesia is to ensure oxygen can be delivered to the lungs via a patient’s airway. Failure to maintain adequate oxygen levels leads to brain damage and death. The anesthetic work environment is complex. Occasionally, stressful situations occur when difficulties in airway management arise. Members of the anesthesia team must then engage in complex cognitive activities such as rapid, collaborative decision-making. It is suggested that cognitive aids may support decision-making in these situations, although this has not yet been evaluated empirically from a Cognitive Systems Engineering perspective. This ongoing research combined two studies using Cognitive Task Analysis methods as part of a Decision-Centered Design process: observations and Critical Decision Method interviews. These will inform subsequent research phases concerning the development and evaluation of design concepts.

High Resolution CT and Bronchography in the Assessment of Bronchiectasis

To elucidate the reliability of CT in the assessment of bronchiectasis, a retrospective study of high resolution CT and bronchography was carried out. A segment by segment comparison of 259 segmental bronchi from 70 lobes of 27 lungs in 19 patients was performed using bronchography as standard. CT was positive in 87 of 89 segmental bronchi with bronchiectasis giving a false-negative rate of 2%. CT was negative in 169 of 170 segmental bronchi without bronchiectasis at bronchography, giving a false-positive rate of 1%. There was agreement between the two modalities in identifying the different types of bronchiectasis.

German, European or American burn guidelines - Is one superior to another?

Adequate medical care of severe burn injuries requires special organizational infrastructure and high educational standards, with an appropriate number of health care professionals. Guidelines were written by the German Society for Burn Treatment (DGV), the European Burns Association (EBA) and the American Burn Association (ABA) to assist with the delivery of such care. Current DGV (2010), EBA (2013) and ABA (2001/2006/2008) guidelines are compared, focusing on similarities, differences, conciseness and completeness. This publication presents advantages and disadvantages of each of them. DGV guidelines outline understandable treatment recommendations for first aid measures, clinical procedures and wound care. Extensive rehabilitation guidelines with clearly defined indications and precise infrastructure requirements for a Burn Centre are stated. Negative aspects are the presence of multiple documents containing redundant and confusing information. EBA guidelines offer the most comprehensive treatment recommendations with multidisciplinary approaches. Overall, infrastructural requirements are weighted much higher than staff qualification demands - in contrast to ABA guidelines. However, lack of conciseness and complicated criteria regarding transfer of patients to a Burn Center - including imprecise indications for rehabilitation treatment - have to be mentioned as disadvantages. ABA guidelines have a clear focus on staff qualifications and easy-to-understand transfer criteria. Another focus is on detailed clinical procedures. However, these guidelines lack burn definition and precise treatment recommendations for rehabilitation. The reviewed guidelines provide standardized treatment recommendations for burn patients. Despite their usefulness, they all have weaknesses and discrepancies. Findings should be used to improve each of them.

Endometriosis and fertility: women's accounts of healthcare

STUDY QUESTION

What do women with endometriosis recall being told about their fertility by their healthcare providers?

SUMMARY ANSWER

Women recalled being given varied information and advice, and gave examples of empathic and individualized care from doctors but also reported opportunities for enhancing clinical practice.

WHAT IS KNOWN ALREADY

There is evidence of an association between endometriosis and infertility. However, the strength of this association and the mechanisms that underlie it are not yet known nor are the implications for optimum healthcare.

STUDY DESIGN, SIZE, DURATION

This study used in-depth cross-sectional qualitative research methods.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged at least 18 years who lived in Victoria, Australia, and who had been surgically diagnosed with endometriosis were invited to participate in in-depth interviews about their experience of endometriosis. Twenty-six women of diverse backgrounds and experiences of endometriosis were interviewed from January to September 2014. Interviews were transcribed and analysed thematically using a data-driven approach.

MAIN RESULTS AND THE ROLE OF CHANCE

All women encountered medical professionals who were aware of the association between endometriosis and infertility, and who were proactive in ensuring fertility was addressed within endometriosis care. Women recalled being given varied, often conflicting, information about the consequences for their fertility of an endometriosis diagnosis. While some recounted positive experiences with the way their doctor communicated with them about endometriosis and fertility, all women reported adverse experiences such as receiving insufficient or inappropriate information or having their doctor prioritize their fertility over other aspects of their care, including quality of life and symptom relief, without first consulting them.

LIMITATIONS, REASONS FOR CAUTION

The perspectives of the women's doctors were not sought. The findings may not translate to settings that differ from a predominantly Anglo-Saxon country with both universal public and private healthcare systems.

WIDER IMPLICATIONS OF THE FINDINGS

Women's fertility needs and priorities differ for many reasons; there can be no 'one size fits all' approach to care. Women may benefit most from endometriosis care in which they are first asked about their fertility needs and preferences and in which medical uncertainty is acknowledged.

STUDY FUNDING/COMPETING INTERESTS

K.Y. receives a scholarship from the National Health and Medical Research Council and Australian Rotary Health. J.F. is supported by a Monash Professional Fellowship and the Jean Hailes Professional Fellowship which is funded by Perpetual Trustees Pty Ltd. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Reasons for palliative treatments in stage III non-small-cell lung cancer: what contribution is made by time-dependent changes in tumour or patient status?

INTRODUCTION

Stage iii lung cancer is the most advanced stage of lung cancer for which the potential of curative treatment is often discussed. However, a large proportion of patients are treated with palliative intent. An understanding of the time-dependent and -independent factors contributing to the choice of palliative-intent treatment is needed to help optimize patient outcomes.

METHODS

This retrospective cohort study of patients with stage iii non-small-cell lung cancer (nsclc) newly diagnosed between 1 January 2008 and 31 December 2012 at the Cancer Centre of Southeastern Ontario collected data including patient demographics, clinical characteristics, tumour characteristics, treatment, and outcomes.

RESULTS

Of 237 patients with stage iii nsclc included in the study, 130 were not treated with radical or curative intent (55%). Major time-independent variables cited for palliative-intent treatment included extreme age (5%), comorbidity (27%), patient choice (5%), and poor lung function (5%). Time-dependent variables included tumour progression on imaging (15%), weight loss (33%), performance status (32%), and the occurrence of a major complication such as hemoptysis, lung collapse, or pulmonary embolism (7%). A significant number of patients (20%) experienced a decline in performance status-to 2, 3, or 4 from 0 or 1-over the course of the diagnostic journey, and 12% experienced a transition from no weight loss to more than 10% weight loss.

CONCLUSIONS

A significant proportion of patients receive palliative therapy for stage iii nsclc because of changes that occur during the diagnostic journey. Shortening or altering that pathway to avoid tumour growth or patient deterioration during care could allow for more patients to be treated with curative intent.

Causes of death and subsequent treatment after initial radical or palliative therapy of stage III non-small-cell lung cancer

INTRODUCTION

Stage iii lung cancer is the most advanced stage of lung cancer for which radical (potentially curative) treatment is often discussed. Understanding the reasons for mortality and subsequent treatments in patients with stage iii non-small-cell lung cancer (nsclc) is important.

METHODS

This retrospective cohort study extracted demographic, clinical, treatment, and outcomes data for patients with newly diagnosed stage iii nsclc diagnosed between 1 January 2008 and 31 December 2012 at a single institution.

RESULTS

The study included 237 patients with stage iii nsclc, 130 of whom were not treated with radical or curative intent (55%). Median survival in the entire cohort was 14 months from diagnosis. For patients treated with radical-intent therapy, causes of death varied with the time period. The hazard rate for death was approximately 2.8 per 100 person-months of follow-up over the entire disease course and was highest between 6 months and 24 months. Over the entire time period, local causes accounted for 29% of deaths; systemic non-central nervous system metastases, for 25%; and brain metastases, for 14%. For patients treated with palliative intent, the overwhelming cause of death was local disease complications or progression (56% of deaths). Only 12% of patients in the palliative treatment group who progressed received subsequent chemotherapy; 23% of patients in the radical group who progressed received palliative chemotherapy. The most frequent subsequent treatment in both groups was radiation therapy.

CONCLUSIONS

The eventual life-ending event in stage iii nsclc varied for the patients who qualified for, and were treated with, radical or curative intent and for the patients who received palliative-intent therapy. Utilization of systemic chemotherapy in patients not fit for radical therapy is low.

Endoglin is required in Pax3-derived cells for embryonic blood vessel formation

Mutations in endoglin, a TGFβ/BMP coreceptor, are causal for hereditary hemorrhagic telangiectasia (HHT). Endoglin-null (Eng-/-) mouse embryos die at embryonic day (E)10.5-11.5 due to defects in angiogenesis. In part, this is due to an absence of vascular smooth muscle cell differentiation and vessel investment. Prior studies from our lab and others have shown the importance of endoglin expression in embryonic development in both endothelial cells and neural crest stem cells. These studies support the hypothesis that endoglin may play cell-autonomous roles in endothelial and vascular smooth muscle cell precursors. However, the requirement for endoglin in vascular cell precursors remains poorly defined. Our objective was to specifically delete endoglin in neural crest- and somite-derived Pax3-positive vascular precursors to understand the impact on somite progenitor cell contribution to embryonic vascular development. Pax3Cre mice were crossed with Eng+/- mice to obtain compound mutant Pax3(Cre/+);Eng+/- mice. These mice were then crossed with homozygous endoglin LoxP-mutated (Eng(LoxP/LoxP)) mice to conditionally delete the endoglin gene in specific lineages that contribute to endothelial and smooth muscle constituents of developing embryonic vessels. Pax3(Cre/+);Eng(LoxP/)(-) mice showed a variety of vascular defects at E10.5, and none of these mice survived past E12.5. Embryos analyzed at E10.5 showed malformations suggestive of misdirection of the intersomitic vessels. The dorsal aorta showed significant dilation with associated vascular smooth muscle cells exhibiting disorganization and enhanced expression of smooth muscle differentiation proteins, including smooth muscle actin. These results demonstrate a requirement for endoglin in descendants of Pax3-expressing vascular cell precursors, and thus provides new insight into the cellular basis underlying adult vascular diseases such as HHT.

Diseases of captive yellow seahorse Hippocampus kuda Bleeker, pot-bellied seahorse Hippocampus abdominalis Lesson and weedy seadragon Phyllopteryx taeniolatus (Lacépède)

Seahorses, pipefish and seadragons are fish of the Family Syngnathidae. From 1998 to 2010, 172 syngnathid cases from the Toronto Zoo were submitted for post-mortem diagnostics and retrospectively examined. Among the submitted species were yellow seahorses Hippocampus kuda Bleeker (n=133), pot-bellied seahorses Hippocampus abdominalis Lesson (n=35) and weedy seadragons Phyllopteryx taeniolatus (Lacépède; n=4). The three most common causes of morbidity and mortality in this population were bacterial dermatitis, bilaterally symmetrical myopathy and mycobacteriosis, accounting for 24%, 17% and 15% of cases, respectively. Inflammatory processes were the most common diagnoses, present in 117 cases. Seven neoplasms were diagnosed, environmental aetiologies were identified in 46 cases, and two congenital defects were identified.

Laparoscopic extralevator abdominoperineal excision of the rectum: short-term outcomes of a prospective case series

BACKGROUND

Laparoscopic approaches for the resection of low rectal cancer and the extralevator technique for abdominoperineal excision are both becoming increasingly popular. There are little published data regarding the combined application of these techniques to the resection of low rectal tumours. The aim of this study was to assess the feasibility of such an approach and to appraise short-term outcomes in a consecutive series of patients undergoing laparoscopic extralevator abdominoperineal excision (ELAPE).

METHODS

Consecutive patients undergoing laparoscopic ELAPE at our institution between 2008 and 2011 were identified from a prospectively maintained database. The abdominal phase of the operation was performed laparoscopically, and following extralevator resection, the perineum was reconstructed using a biologic mesh. All patients were enrolled in an enhanced recovery programme.

RESULTS

Of 166 patients undergoing radical resection of rectal cancer at our institution between 2008 and 2011, 28 underwent laparoscopic ELAPE. Median age was 70 years, median body mass index was 27.5 kg/m(2), and 71% were male. The conversion rate to laparotomy was 18%. Three patients (10.8%) had circumferential resection margins <1 mm; no intraoperative tumour perforation occurred. The median length of stay was 7 days, with a 30-day readmission rate of 21% and no 30-day mortality. Post-operative perineal wound complications occurred in 25%. At median 38-month follow-up (range 23-66 months), overall survival was 75%, disease-free survival was 71%, and there were three local recurrences (11%).

CONCLUSIONS

Laparoscopic extralevator abdominoperineal excision can be safely performed without compromising short-term outcomes.

Paediatric hand fractures

This retrospective study reviews the demographics, morphology and management of paediatric hand fractures. Notes of all children with hand injuries attending a plastic surgery paediatric trauma clinic over a one-year period were reviewed. Non-bony injuries were excluded. A total of 303 fractures in 283 patients were included. Fracture incidence rose after the age of seven, peaking at 14 years of age; 76% of fractures occurred in males. Sporting injuries accounted for 47% of fractures. Physeal fractures were present in 39% of cases. Open fractures accounted for only 4% of all fractures. Management was primarily conservative. Only 5% of cases required surgical fixation; 6% of patients experienced complications.

Racial/Ethnic Variations in Colorectal Cancer Screening Self-Efficacy, Fatalism and Risk Perception in a Safety-Net Clinic Population: Implications for Tailored Interventions

Ethnic and racial minority groups in the U.S. receive fewer colorectal cancer (CRC) screening tests and are less likely to be up-to-date with CRC screening than the population as a whole. Access, limited awareness of CRC and barriers may, in part, be responsible for inhibiting widespread adoption of CRC screening among racial and ethnic minority groups. The purpose of this study was to examine the role of self-efficacy, fatalism and CRC risk perception across racial and ethnic groups in a diverse sample. This study was a cross-sectional analysis from baseline measures gathered on a group of patients recruited into a trial to track colorectal cancer screening in underserved adults over 50. Out of 470 Participants, 42% were non-Hispanic; 27% Hispanic and 28% non-Hispanic White. Hispanic and non-Hispanic Blacks were more likely to have fatalistic beliefs about CRC than non-Hispanic Whites. Non-Hispanic Blacks perceived higher risk of getting colon cancer. Self-efficacy for completing CRC screening was higher among Non-Hispanic Blacks than among Hispanics. Racial and ethnic differences in risk perceptions, fatalism and self-efficacy should be taken into consideration in future CRC interventions with marginalized and uninsured populations.

Live-cell migration and adhesion turnover assays

Fluorescence microscopy has revolutionized the way live-cell imaging is achieved. At the same time, it is also potentially harmful to a living specimen. Therefore, the specimen must be monitored for viability and health before, during, and after imaging sessions. Methods for monitoring cell viability and health will be discussed in this chapter. Another key to successful live-cell imaging is to minimize light exposure as much as possible. A summary of strategies for minimizing light exposure including maximizing the light throughput of the microscope and the sensitivity of light detection is presented. Various fluorescence microscopy techniques are presented with a focus on how the light is delivered to the sample (i.e., light density) and pros and cons for use with living specimens. The reader is also directed to other publications that go into these topics in more detail. Methods are described on how to prepare samples for single cell migration assays, how to measure cell migration rates (e.g., bright-field, semi-automated, and automated), and how to measure focal adhesion turnover rates. Details of how to correct images for background intensity and field-illumination uniformity artifacts for quantitative imaging are also described. Overall, this chapter will be helpful to scientists who are interested in imaging live specimens using fluorescence microscopy techniques. It will be of particular interest to anyone wanting to perform quantitative fluorescence imaging, and wanting to measure cell migration rates, and focal adhesion dynamics.

High acceptability of a vaginal ring intended as a microbicide delivery method for HIV prevention in African women

Vaginal rings (VRs) are new methods for continuous delivery of microbicides. This is the first study to quantitatively and qualitatively explore the acceptability of rings in Africa: 157 HIV-negative, sexually active women aged 18-35 used a placebo silicone elastomer ring for 12 weeks. They completed product acceptability questionnaires every 4 weeks. We conducted 6 exit focus group discussions with a subset of 48 women and 19 in-depth interviews with male partners. Retention in the study was high (97 %). Initial insertion at the clinic was successful on first attempt for 81 % of participants. Most women were comfortable using the ring, and very few (≤2 %) could feel it during daily activities or had ring-related physical or emotional problems. In the qualitative interviews many participants reported that they initially had concerns about using the ring. However, only a minority of women actually reported concerns with the ring during the study. The most frequent concern was that the ring would get lost inside the body (20 %), and this was significantly correlated with study site, frequently thinking about the ring and reporting that the ring was not very easy to remove. Qualitative data suggest that informants grew to like the ring because it felt securely placed, was unnoticeable during daily activities, and felt "normal" during sex. The ring appeared to be highly acceptable for women and men. Initial concerns with this novel method suggest a need for enhanced product counseling when VRs are introduced.

Prediction of conversion from mild cognitive impairment to Alzheimer disease based on bayesian data mining with ensemble learning

Prediction of disease progress is of great importance to Alzheimer disease (AD) researchers and clinicians. Previous attempts at constructing predictive models have been hindered by undersampling, and restriction to linear associations among variables, among other problems. To address these problems, we propose a novel Bayesian data-mining method called Bayesian Outcome Prediction with Ensemble Learning (BOPEL). BOPEL uses a Bayesian-network representation with boosting, to allow the detection of nonlinear multivariate associations, and incorporates resampling-based feature selection to prevent over-fitting caused by undersampling. We demonstrate the use of this approach in predicting conversion to AD in individuals with mild cognitive impairment (MCI), based on structural magnetic-resonance and magnetic-resonance- spectroscopy data. This study includes 26 subjects with amnestic MCI: the converter group (n = 8) met MCI criteria at baseline, but converted to AD within five years, whereas the non-converter group (n = 18) met MCI criteria at baseline and at follow-up. We found that BOPEL accurately differentiates MCI converters from non-converters, based on the baseline volumes of the left hippocampus, the banks of the right superior temporal sulcus, the right entorhinal cortex, the left lingual gyrus, and the rostral aspect of the left middle frontal gyrus. Prediction accuracy was 0.81, sensitivity was 0.63 and specificity was 0.89. We validated the generated predictive model with an independent data set constructed from the Alzheimer Disease Neuroimaging Initiative database, and again found high predictive accuracy (0.75).

Perceived Muscle Soreness in Recreational Female Runners

The purpose of this study was to determine if rating of perceived exertion correlated with perceived muscle soreness during delayed onset muscle soreness (DOMS) in female runners. This study examined the pre and post running economy measures and perceived muscle soreness before and after a 30-min downhill run (DHR) at -15% grade and 70% of the subjects predetermined maximum oxygen uptake (VO2 peak). Six female recreational runners (mean age = 24.5) performed level running at 65%, 75%, and 85% of their VO2 peak prior to DHR (baseline economy runs), as well as, immediately following and 4 successive days after the DHR.

RESULTS

Subjective response related to perceived muscle soreness increased significantly from a mean of 2 (pre DHR) to 62 (2 days post DHR) on a scale of 1-100. Creatine kinase levels and oxygen consumption increased post DHR compared to pre DHR. Rating of perceived exertion did not change between the economy runs performed prior to or at any point after the DHR.

CONCLUSION

Perceived muscle soreness is a better tool than the RPE scale to monitor exercise intensity for recreational female runners during periods of DOMS and running economy is adversely affected by DOMS.

Network-level analysis of cortical thickness of the epileptic brain

Temporal lobe epilepsy (TLE) characterized by an epileptogenic focus in the medial temporal lobe is the most common form of focal epilepsy. However, the seizures are not confined to the temporal lobe but can spread to other, anatomically connected brain regions where they can cause similar structural abnormalities as observed in the focus. The aim of this study was to derive whole-brain networks from volumetric data and obtain network-centric measures, which can capture cortical thinning characteristic of TLE and can be used for classifying a given MRI into TLE or normal, and to obtain additional summary statistics that relate to the extent and spread of the disease. T1-weighted whole-brain images were acquired on a 4-T magnet in 13 patients with TLE with mesial temporal lobe sclerosis (TLE-MTS), 14 patients with TLE with normal MRI (TLE-no), and 30 controls. Mean cortical thickness and curvature measurements were obtained using the FreeSurfer software. These values were used to derive a graph, or network, for each subject. The nodes of the graph are brain regions, and edges represent disease progression paths. We show how to obtain summary statistics like mean, median, and variance defined for these networks and to perform exploratory analyses like correlation and classification. Our results indicate that the proposed network approach can improve accuracy of classifying subjects into two groups (control and TLE) from 78% for non-network classifiers to 93% using the proposed approach. We also obtain network "peakiness" values using statistical measures like entropy and complexity-this appears to be a good characterizer of the disease and may have utility in surgical planning.

Histology classification is not a predictor of clinical outcomes in advanced non-small cell lung cancer (NSCLC) treated with vinorelbine or gemcitabine combinations

BACKGROUND

Until recently, histology has not been clearly or consistently described in the literature as a prognostic or predictive variable in advanced NSCLC studies. We have categorised patients treated with vinorelbine and gemcitabine based first line chemotherapy regimes for advanced NSCLC as either squamous or non-squamous, and also as either adenocarcinoma and non-adenocarcinoma, and compared outcome.

MATERIAL AND METHODS

420 patients treated with platinum/gemcitabine, platinum/vinorelbine or single agent gemcitabine or vinorelbine as first line chemotherapy for advanced NSCLC were identified. The influence of pathology on progression free survival (PFS) and overall survival (OS) has been investigated by means of a Cox regression analysis. Hazard ratios with 95% CIs have been given for each pathological type after adjusting for the effects of age, gender, stage (III vs. IV), PS (0/1 vs. 2/3) and treatment type (platinum doublet vs. single agent).

RESULTS

Neither univariate nor multivariate analysis suggested that there was a significant difference in the response rates for adenocarcinoma vs. non-adenocarcinoma or between squamous and non-squamous pathology. There was no difference in PFS between adenocarcinoma and non-adenocarcinoma pathologies until 8 months (p = 0.98), and there was a statistically significant advantage in PFS for squamous vs. non-squamous pathologies (p = 0.04). Using multivariate Cox regression analysis to adjust for the effects of age, gender, stage, PS, and treatment type, the pathology subtype was not significant. There was no difference in OS in any group.

CONCLUSIONS

These results suggest that histology may not be considered as a predictor of clinical outcome using these drugs.

Cyber disorders: the mental health concern for the new millennium

Anecdotal evidence has suggested that mental health practitioners' report increased caseloads of clients whose primary complaint involves the Internet. However, little is known about the incidence, associated behaviors, attitudes of practitioners, and interventions involved related to this relatively new phenomenon. Therefore, this study surveyed therapists who have treated clients suffering from cyber-related problems to gather such outcome information. Respondents reported an average caseload of nine clients who they classified as Internet-addicted, with a range between 2 and 50 clients treated within the past year. Five general subtypes of Internet addiction were categorized based on the most problematic types of online applications, and they include addictions to Cybersex, Cyber-relationships, online stock trading or gambling, information surfing, and computer games. Treatment strategies included cognitive-behavioral approaches, sexual offender therapy, marital and family therapy, social skills training, and pharmacological interventions. Based on their client encounters, efforts to initiate support groups and recovery programs specializing in the treatment of Internet addiction were being considered. Finally, based upon the findings, this article examines the impact of cyberdisorders on future research, treatment, and public policy issues for the new millennium.

An alternative method for noise analysis using pixel variance as part of quality control procedures on digital mammography systems

According to the European Guidelines for quality assured breast cancer screening and diagnosis, noise analysis is one of the measurements that needs to be performed as part of quality control procedures on digital mammography systems. However, the method recommended in the European Guidelines does not discriminate sufficiently between systems with and without additional noise besides quantum noise. This paper attempts to give an alternative and relatively simple method for noise analysis which can divide noise into electronic noise, structured noise and quantum noise. Quantum noise needs to be the dominant noise source in clinical images for optimal performance of a digital mammography system, and therefore the amount of electronic and structured noise should be minimal. For several digital mammography systems, the noise was separated into components based on the measured pixel value, standard deviation (SD) of the image and the detector entrance dose. The results showed that differences between systems exist. Our findings confirm that the proposed method is able to discriminate systems based on their noise performance and is able to detect possible quality problems. Therefore, we suggest to replace the current method for noise analysis as described in the European Guidelines by the alternative method described in this paper.

Galantamine-induced improvements in cognitive function are not related to alterations in alpha(4)beta (2) nicotinic receptors in early Alzheimer's disease as measured in vivo by 2-[18F]fluoro-A-85380 PET

INTRODUCTION

The nicotinic acetylcholine receptor (nAChR) system plays a regulatory role in a number of cognitive processes. Cholinesterase inhibitors (i.e., galantamine) that potentiate cholinergic neurotransmission improve cognitive function in Alzheimer's disease (AD); however, the relationship between these effects and associated changes in nAChRs are yet to be established in vivo.

MATERIALS AND METHODS

2-[18F]Fluoro-A-85380 (2-FA) binds to nAChRs and with positron emission tomography (PET) imaging provides a composite measure of receptor density and ligand affinity. This study aimed to: (1) quantify nAChRs in vivo in 15 drug-naïve patients with mild AD before and after chronic treatment with galantamine, using 2-FA and PET, and (2) examine the relationship between treatment-induced changes in nAChRs and improvements in cognitive function. Participants were nonsmokers and underwent extensive cognitive testing and a PET scan after injection of approximately 200 MBq of 2-FA on two occasions (before and after 12 weeks, galantamine treatment). A 3-day washout period preceded the second scan. Brain regional 2-FA binding was assessed through a simplified estimation of distribution volume (DV(S)).

RESULTS

Performance on global measures of cognition significantly improved following galantamine treatment (p < 0.05). This improvement extended to specific cognitive measures of language and verbal learning. No significant differences in nAChR DV(S) before and after galantamine treatment were found. The treatment-induced improvement in cognition was not correlated with regional or global nAChR DV(S), suggesting that changes in nAChRs may not be responsible for the improvements in cognition following galantamine in patients with mild AD.

Non-invasive ventilation in chronic obstructive pulmonary disease: management of acute type 2 respiratory failure

Non-invasive ventilation (NIV) in the management of acute type 2 respiratory failure in patients with chronic obstructive pulmonary disease (COPD) represents one of the major technical advances in respiratory care over the last decade. This document updates the 2002 British Thoracic Society guidance and provides a specific focus on the use of NIV in COPD patients with acute type 2 respiratory failure. While there are a variety of ventilator units available most centres now use bi-level positive airways pressure units and this guideline refers specifically to this form of ventilatory support although many of the principles encompassed are applicable to other forms of NIV. The guideline has been produced for the clinician caring for COPD patients in the emergency and ward areas of acute hospitals.