Safety of MR scanning in patients with nonferromagnetic aneurysm clips

The purpose of this study was to report our surveillance of patients with nonferromagnetic aneurysm clips (NFAC) who have undergone magnetic resonance imaging (MRI). Forty-six patients with NFAC underwent MRI over a 7-year period. Medical records were studied for evidence of subjective or objective clinical findings as a result of the MRI scan. In two patients with subjective complaints, computed tomograms (CT) were reviewed and patient interviews conducted. No significant neurologic signs or longterm symptoms were experienced. Two patients did not complete their MRI scans due to transient unilateral head pain in one and head "pressure" in another. CT scans in these patients demonstrated no evidence for hemorrhage or visible change in clip position. We documented no objective adverse outcome of patients undergoing MRI with NFAC, confirming that MRI can be performed safely in patients with nonferromagnetic aneurysm clips. The cause of subjective complaints in two of our patients is unknown.

Testing relationships from the hierarchical model of intrinsic and extrinsic motivation using flow as a motivational consequence

The purpose of this study was to test a motivational model based on Vallerand's (1997) Hierarchical Model of Intrinsic and Extrinsic Motivation. This model incorporates situational and contextual motivational variables, and was tested using a time-lagged design. Master's level swimmers (N = 104) completed a questionnaire on two separate occasions. At Time 1, situational social factors (perceptions of success and perceptions of the motivational climate), situational motivational mediators (perceptions of autonomy, competence, and relatedness), situational motivation, and flow were assessed immediately following a swim practice. Contextual measures of these same variables were assessed at Time 2, 1 week later, with the exception of flow. Results of a path analysis supported numerous links in the hypothesized model. Findings are discussed in light of research and theory on motivation and flow.

Effects of prolonged ACTH-stimulation on adrenocortical accumulation of lipofuscin granules in aged rats

Subcellular deposition of lipofuscin granules is a marker of aging. Human and rodent adrenal cortices accumulate lipofuscin granules with age, but the mechanism that leads to the accumulation is not known. The ultrastructural appearance of lipofuscin granules resembles that of secondary lysosomes. Since adrenocortical subcellular events are predominantly influenced by ACTH action, we therefore studied the effect of prolonged ACTH-stimulation on adrenocortical accumulation of secondary lysosome-like granules, designated herein as lipofuscin granules. Using aged Fischer 344 male rats as a model, we found that a 7 day ACTH stimulation exerts a reducing effect on adrenocortical lipofuscin accumulation. Thus, adrenocortical accumulation of lipofuscin granules with age in vivo may not be an irreversible process.

Prolonged hypoxic stress increases adrenal cholesterol reserve in rats without causing adrenal hypertrophy

1. It is known that, in rats, hypoxia stimulates adrenal steroidogenesis, but our understanding of the hypoxic effect on the glandular parameters remains incomplete. 2. Adrenals were collected and analysed from rats that had been exposed to hypoxic conditions for 3 weeks. 3. The results reveal increased adrenal concentrations of corticosterone, free cholesterol and total cholesterol without a change in glandular weight and protein concentration. The increased total cholesterol is primarily associated with enriched cholesteryl adrenate (CE22: 4), cholesteryl arachidonate (CE20: 4) and cholesteryl oleate (CE18: 1).

Effects of prolonged ACTH-stimulation on adrenocortical cholesterol reserve and apolipoprotein E concentration in young and aged Fischer 344 male rats

Changes in the morphology of rat adrenal cortex with age include increased accumulations of lipid droplets and lipofuscin granules. Because glandular concentrations of cholesteryl esters (CE) and apolipoprotein (apo) E are also increased in parallel, the utilization or metabolism of lipid-droplet stored CE for steroidogenesis might be altered in aging cells. To explore this possibility, adrenocortical cholesterol storage and utilization were studied in 3-6 months-old (mo) (Y) rats and 20-23 mo (O) Fischer 344 male rats. Both groups received either adrenocorticotropin (ACTH1-39, Acthar gel) or gelatin alone daily for seven consecutive days. We found that: (a) the CE concentration in O rats, but not Y animals, was diminished by ACTH. The depleted CE in stimulated-O rats was replenished within five days post stimulation. Failure to deplete CE in stimulated-Y rats was not associated with an insufficient dose of the hormone, since stimulation of Y animals with higher doses of ACTH actually increased the CE concentration. In contrast, adrenocortical free cholesterol concentration remained constant during stimulation regardless of age. (b) The depleted CE in stimulated-O rats was principally comprised of cholesteryl adrenate, cholesteryl arachidonate and cholesteryl cervonate. The accumulated CE in stimulated-Y animals was primarily comprised of cholesteryl adrenate, cholesteryl arachidonate and cholesteryl oleate. (c) Whereas in stimulated-Y rats adrenal apoE concentration declined, the concentration in stimulated O animals was well maintained. (d) In vitro, adrenal homogenate or cytosolic fraction from stimulated-O rats displayed a higher capacity to hydrolyze exogenous CE than its Y counterpart. However, cholesterol esterification with external fatty acid substrates in adrenal homogenate or microsomal fraction was comparable in the two age-groups. Our findings revealed altered adrenocortical cholesterol reserve in O rats to cope with prolonged ACTH-stimulation. Changes in apoE levels and CE hydrolysis activity may be factors associated with this alteration. Depletion and accumulation of adrenocortical CE are reflected in parallel changes in cholesteryl adrenate and cholesteryl arachidonate, suggesting physiologic importance of these polyunsaturated fatty acids during sustained steroidogenesis.

Do acute care for elders units increase hospital costs? A cost analysis using the hospital perspective

OBJECTIVE

To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self-care activities with the costs of usual care.

DESIGN

A randomized controlled study.

PARTICIPANTS

A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324).

MEASURES

The hospital's resource-based cost of caring for patients was determined from the hospital's cost-accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost.

RESULTS

The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual-care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual-care unit. Ninety-day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety-day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar.

CONCLUSION

Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward even though the intervention ward required a commitment of hospital resources.

Clinical epidemiology of endocrine disorders in the elderly

Many epidemiologic studies have examined age-related processes in humans. Some of the difficulties with these studies are noted. Endocrinologic changes of aging often are compensated for by feedback mechanisms and do not cause dysfunction. Common aging changes are reviewed.

A phase I trial of a new recombinant human beta-interferon (BG9015) for the treatment of patients with recurrent gliomas

Primary brain tumors represent an important cause of cancer-related morbidity and mortality in the United States. Despite advances in neurosurgery and radiotherapy, the median survival of patients with malignant gliomas remains less than 1 year. A contributing factor to the poor prognoses of these patients is the diffuse, infiltrative nature of these tumors, which limits the effectiveness of focal therapies (i.e., surgery and radiation). Unfortunately, standard chemotherapy has been of limited benefit in the treatment of malignant gliomas, underlying the necessity for new drugs with novel mechanisms of action. On the basis of promising in vitro and clinical data demonstrating significant antiglioma activity of purified IFN-beta and a synthetic IFN-beta (Betaseron), we conducted a Phase I trial of a new, nonmutated, glycosylated recombinant human IFN-beta (BG9015) in patients with recurrent, high-grade astrocytomas. In this trial, we demonstrate that the maximally tolerated dose of BG9015 is 6 million units/m2 delivered by intramuscular injection three times per week. Dose-limiting neurotoxicity was seen in both patients treated at 8 million units/m2. Additionally, we demonstrate that high BG9015 serum levels are associated with a fall in natural killer cell number, radiographic response, and prolonged survival. We conclude that BG9015 has activity in patients with malignant gliomas, although the therapeutic index may be narrow. Future studies will be needed to confirm the observation that natural killer cell number and activity as well as BG9015 serum levels are important markers of antitumor activity.

Characterization and identification of an adrenal age-related nonpolar fluorescent substance

The adrenal cortexes of humans and rodents accumulate lipofuscin with age, but the chemical nature of the substance that produces lipofuscin fluorescence in the gland is not known. Analysis of rat adrenal nonpolar lipids revealed a fluorescence profile with increased intensity in the lipids extracted from older animals (23-24 months > 6 months > 6 weeks). The peak occurred at a wavelength of 470 +/- 5 nm(n = 26) when excited at 340 nm. After sucrose density gradient centrifugation, the fluorescent substance was primarily concentrated in subcellular lipid droplets rather than supernatant or particulate. Prolonged stimulation of rats with ACTH for 7 consecutive days caused 14-51% decreases in the fluorescence levels, with a tendency of return to control levels poststimulation regardless of age. In contrast, the nonpolar lipids of mouse adrenal tumor (Y1) cells, which contain no lipofuscin, did not display this fluorescence in the presence or absence of ACTH. The chromatographic characteristics of the substance in a silica gel-60 column resembled those of authentic retinyl palmitate and cholesteryl oleate. Analysis of the substance by HPLC demonstrated at least three prominent peaks, designated XI-3 in order. X1 and X2 were minor peaks; X3 was the major peak. Whereas none of the peaks comigrated with cholesteryl esters, X1 comigrated with authentic retinyl palmitate. Determination of the fatty acid component of the major fluorescent substance X3 by gas-liquid chromatography disclosed stearic acid. Retinyl stearate was, therefore, synthesized. The fluorescent profiles, HPLC retention time and mass spectrometric fragmentation of purified X3 substance were all identical to those of the synthetic compound. In contrast, the rat liver principally accumulated retinyl palmitate with age. Thus, we conclude that 1) the major nonpolar fluorescent substance accumulated in the rat adrenal with age is retinyl stearate, which may be a fluorophore of adrenal lipofuscin; 2) ACTH action may be related to this accumulation; and 3) the type of retinyl ester accumulated in aged animals is organ specific.

Apolipoprotein E is increased in aged rat kidney

There is growing evidence to indicate that apolipoprotein (apo) E may be associated with age-related disorders and altered longevity in humans. Using rats as a model, we measured apoE in plasma, brain, heart, kidney, liver and spleen in aged (24-25 mo) and younger rats (6-8 mo). The results disclosed that: (a) the plasma concentrations of immunoreactive apoE in aged rats were higher than those in young animals by 70% (P < 0.01); (b) there was no age-related difference of apoE in the brain, heart, liver or spleen; (c) in contrast, the concentrations of apoE in the kidney of aged rats were markedly higher than those of young animals by 490% (P < 0.01). Our data suggest that, in the rat, age-related change in the organ concentrations of apoE is heterogeneous, and the selective increase in the kidney may have physiologic importance which merits further study.

A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients

BACKGROUND

Older persons who re hospitalized for acute illnesses often lose their independence and are discharged to institutions for long-term care.

METHODS

We studied 651 patients 70 years of age or older who were admitted for general medical care at a teaching hospital; these patients were randomly assigned to receive usual care or to be cared for in a special unit designed to help older persons maintain or achieve independence in self-care activities. The key elements of this program were a specially prepared environment (with, for example, uncluttered hallways, large clocks and calendars, and handrails); patient-centered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; discharge planning with the goal of returning the patient to his or her home; and intensive review of medical care to minimize the adverse effects of procedures and medications. The main outcome we measured ws the change from admission to discharge in the number of five basic activities of daily living (bathing, getting dressed, using the toilet, moving from a bed to a chair, and eating) that the patient could perform independently.

RESULTS

Twenty-four patients in each group died in the hospital. At the time of discharge, 65 (21 percent) of the 303 surviving patients in the intervention group were classified as much better in terms of their ability to perform basic activities of daily living, 39 (13 percent) as better, 151 (50 percent) as unchanged, 22 (7 percent) as worse, and 26 (9 percent) as much worse. In the usual care group, 40 (13 percent) of the 300 surviving patients were classified as much better, 33 (11 percent) as better, 163 (54 percent) as unchanged, 39 (13 percent) as worse, and 25 (8 percent) as much worse (P = 0.009). The difference between the groups remained significant (P = 0.04) in a multivariable model in which we controlled for potentially confounding base-line characteristics of the patients. Lengths of stay and hospital charges were similar in the two groups. Fewer patients assigned to the intervention group were discharged to long-term care institutions (43 patients [14 percent], as compared with 67 patients [22 percent] in the usual-care group; P = 0.01). Among the 493 patients discharged to private homes, similar proportions (about 10 percent) in the two groups were admitted to long-term care institutions during the three months after discharge.

CONCLUSIONS

Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of acutely ill older patients to perform basic activities of daily living at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care.

Aging in rats is associated with an increase in adrenal apolipoprotein E

Extrahepatic tissues including the adrenal cortex are capable of synthesizing apolipoprotein E (apoE). Locally synthesized apoE is believed to affect cellular uptake, transport and redistribution of cholesterol within that organ. We and another laboratory have previously reported that the adrenal cortex of aged rats has an elevated cholesteryl ester content. The aim of this work was to investigate whether this elevation is accompanied by increased adrenal apoE levels in aged rats. A Western blotting technique with polyclonal goat anti-human-apoE antiserum was employed as a probe for studies. The results showed that: (a) anti-human-apoE antiserum not only detected apoE in human plasma and adrenal homogenate, but also cross-reacted with a protein (or proteins) resembling apoE in rat plasma and adrenal homogenate (or supernatant) with a molecular weight of 34,000-36,000; (b) rat adrenal apoE concentration (per unit weight of protein) increased with age; (c) the increase did not result from blood trapped in the gland, because after organ perfusion the adrenal of aged rats persistently exhibited 58% more apoE than that of young animals. In conclusion, rat adrenal apoE concentration appears to increase with age. Whether this increase mechanistically causes the accumulation of cholesteryl esters in the aged rat adrenal remains to be investigated.

Analysis of adrenal cholesteryl esters by reversed phase high performance liquid chromatography

A reversed phase high performance liquid chromatographic (HPLC) method was developed for direct profiling and determination of adrenal cholesteryl ester composition. Cholesteryl adrenate and cholesteryl cervonate, which are not commercially available, were synthesized as markers. Lipid extracts of rat adrenal homogenates or lipid droplets were individually applied to a conditioned silica gel-60 column which separated cholesteryl esters from other native lipids. The eluted cholesteryl ester fraction was then analyzed by HPLC. With cholesteryl heptadecanoate as internal standard, seven adrenal cholesteryl esters were detected and quantified: cholesteryl cervonate, cholesteryl arachidonate, cholesteryl adrenate, cholesteryl myristate, cholesteryl oleate, cholesteryl palmitate, and cholesteryl stearate. Among them, cholesteryl adrenate appeared to be the major sterol ester stored in the rat adrenal.

A medical unit for the acute care of the elderly

Older patients often experience a loss of independent physical functioning during the course of an acute illness requiring hospitalization. This functional decline is associated with serious sequelae including prolonged hospital stay, nursing home placement, and mortality. Elements of hospitalization may contribute to the progression or persistence of functional decline. The Unit for Acute Care of the Elderly (ACE Unit) at University Hospitals of Cleveland is an acute care general medical service that is designed to foster the independent functioning of patients. The Prehab Program of Patient Centered Care on the ACE Unit is a multifaceted intervention that integrates geriatric assessment into the optimal medical and nursing care of patients in an interdisciplinary environment. The Prehab Program has several key elements tailored to each individual patient's needs: a prepared environment, patient-centered care, multidimensional assessment and nonpharmacologic prescriptions, medical care review, and home planning. Standards of care serve to reduce the risk of iatrogenic illness resulting from polypharmacy, use of physical restraints, and diagnostic procedures. Nurse-initiated guidelines contribute to prevention of functional decline and to restoration of independent patient functioning. The effectiveness of the ACE Unit is being evaluated in a randomized clinical trial.

Endogenous drug-like factors in a Polish population

In two hundred and twenty-five healthy volunteers not receiving any treatment the occurrence of drug-like factors in blood serum was studied. The examinations were carried out with the use of the fluorescence-polarization-immunoassay (FPIA)-TDx Abbott. The presence of endogenous phenytoin-like, theophylline-like and cyclosporin-like factors has been demonstrated.

Hospital Outcomes Project for the Elderly (HOPE): rationale and design for a prospective pooled analysis

OBJECTIVE

To describe a collaborative investigation that is based on a series of six clinical studies aimed at reducing functional decline in the acutely-ill hospitalized elderly.

DESIGN

A prospective, multicenter pooled analysis project involving collection of a common set of data from a group of related but distinct intervention trials with similar objectives.

SETTING

Five university-affiliated hospitals and one community hospital.

PARTICIPANTS

Elderly patients (age minimums from 65 to 75 years) admitted for a range of acute illnesses.

INTERVENTIONS

Site-specific interventions include exercise and physical therapy; developing and implementing methods to improve detection and evaluation of delirious patients; a multidisciplinary geriatric care unit; a multidisciplinary intervention implemented in-hospital that includes some post-discharge care; and a nursing-centered geriatric care program.

MAIN OUTCOME MEASURE

Functional status.

CONCLUSION

The prospective, multicenter design of the Hospital Outcomes Project for the Elderly (HOPE) provides an innovative approach for analysis of hospital outcomes in the elderly. Although differences in study populations and interventions exist, qualitative comparisons across sites will enhance generalizability and will provide a great opportunity to examine consistency among the sites. The HOPE pooled analysis project will impart greater statistical power to detect the primary and secondary outcomes compared with previous single-center trials that have assessed interventions related to functional decline in the hospitalized elderly.

Diminished adrenal steroidogenic activity in aging rats: new evidence from adrenal cells cultured from young and aged normal and hypoxic animals

Adrenal cells from 2-6-month-old young rats (Y cells) and from 19-25-month-old aged male rats (O cells) were adapted to primary monolayer culture. The cultures of Y and O cells appeared to be primarily epithelial and rounded up in response to stimulation with adrenocorticotropic hormone (ACTH). The general morphology of O cells was comparable to that observed in Y cells except for the presence of lipofuscin-like granules, a cellular marker of aging, in O cells, but not in Y cells. ACTH-stimulated steroid production by O cells was 52% lower than that by Y cells. Exposure of intact young rats to hypoxia (0.5 atmosphere) for 21 days prior to sacrifice and culture resulted in a 122% increase of ACTH-stimulated adrenal steroidogenic activity in the cultured cells, but this effect was not observed in adrenal cells cultured from hypoxic aged rats. The results suggest that there is an age-related diminution in rat adrenal steroidogenic capacity in response to ACTH stimulation in culture derived from Y and O animals; hypoxic stress magnifies this difference.

Further characterization of the inhibitory effect of monensin on adrenal steroidogenesis

We have previously reported that treatment of cultured mouse adrenal tumor cells with 0.6-1.2 microM monensin, a monovalent carboxylic ionophore, results in disruption of the organized structure of the Golgi complex. This is associated with an inhibition of adrenocorticotropic hormone (ACTH) or dibutyryl cAMP-stimulated steroidogenesis and impairment of mitochondrial cholesterol side-chain cleavage activity. The present report describes further investigations regarding possible mechanisms for the inhibition. Monensin inhibits both synthesis of fluorogenic steroids and incorporation of [14C]acetate into the end-product steroid 11 beta,20 alpha-dihydroxy-4-pregnen-3-one. Supplementation of monensin-treated cells with 25-hydroxycholesterol, a readily available substrate for steroidogenesis, does not reverse the inhibitory effect on the reaction. The incorporation of L-[35S]methionine into trichloroacetic acid precipitable proteins in the isolated mitochondria of monensin-treated cells is inhibited approximately by 40%, whereas the inhibitory effect on the proteins in the cell homogenate is marginal. These findings suggest that a deficiency of newly synthesized proteins in mitochondria, rather than the availability of the substrate cholesterol, may be the primary factor causing impairment of steroidogenesis.