Vascular dementia - clinical case

Introduction

Vascular Dementia (VD) is the second most frequent cause of dementia (20–30% of cases) with a similar percentage associated with Alzheimer’s disease (AD). Due to increased prevalence, its early diagnosis is of particular importance for prevention and correction of risk factors.

Clinical case

An 82-year-old Caucasian woman has been taken to the emergency department by her husband, presenting changes in behaviour defined by aggressiveness, delusional and paranoid ideation with 1M of progression. She had also suffered cognitive impairment (memory deficits, prosoprognosia, disorientation) and some functional decline. She also experienced isolation and reduced communication, anxiety, almost total insomnia, emotional lability, slurred speech, slowed gait and urinary incontinence.

Discussion

This elderly patient with multiple medical comorbidities (HTA, DM, chronic AF hypocoagulated, MI, Craneoencephalic trauma with a stroke episode) was admitted to the Department of Psychiatry and investigated with auxiliary diagnostic tests and neuroimaging. We found ischemic injury and haemorrhagic sequelae in the latter and in the neuropsychological assessment cognitive deficits were found (executive function, attentional, semantic memory and visuoespacial). Due to this findings and the rapid evolution of symptoms, the diagnosis was Cortical and Subcortical VD.

The patient was treated with a minor anxiolytic, a hypnotic inducer and an antidemencial, with improvement, after one week, of her emotional lability, behavioural symptoms and remission of delusional ideation. At discharge, she maintained slow gait, urinary incontinence, as well as attentional, mnesic and executive deficits, and she was partially oriented, in spite of anosognosia.

She was transferred to geriatrics and to a day center.

Delirium in older adults: assessment scales review

Introduction

Delirium is characterized by the rapid onset of symptoms which fluctuate, with an altered level of consciousness, global disturbance of cognition, perceptual abnormalities and evidence of a physical cause (DSM-IV-R, 2002).

Aim

To review the characteristics and psychometric properties of thirteen Delirium scales available in research and clinical practice.

Methods

MEDLINE database was used to identify the delirium scales in use (1990–2010), using the keywords: delirium, confusion, questionnaires, scales, severity and screening. Only validation studies were included. Exclusion criteria were children and alcohol/drug delirium assessment scales. This study included seven screening scales: Confusion Assessment Method, Intensive Care Delirium Screening Checklist, Delirium Symptom Interview, NEECHAM Confusion Scale, Cognitive Test for Delirium, Delirium Observation Screening, Nursing Delirium Screening Scale and seven severity scales: Delirium Rating Scale, Memorial Delirium Assessment Scale, Confusional State Evaluation, Delirium Severity Scale, Delirium Index and Delirium-O-Meter.

Results

The majority of scales were based on the Diagnosis Statistical Manual Criteria as well as on a review of selected symptoms of Delirium informed by systematic clinical observation and formal brief assessment of mental status. In most of the studies, for psychometric analysis, the inter-rater reliability and validity with severity of Delirium assessment and cognitive screening tests were used.

Conclusion

Bearing in mind the recent review studies included, we can conclude that CAM is the most widely used instrument for delirium assessment.

Delirium and parkinsonic syndrome in elderly

Delirium is an acute or subacute syndrome characterized by a fluctuating global disorder of cognition, impairment of attention and awareness, disorganization of thought and speech, perceptual disturbances, hallucinations, as well as hypo or hyperactivity.

We present a case report of a 76-year-old woman who developed disorientation, lack of familiar recognition and functional impairment, three days before admission. She was admitted to a Medicine Department and submitted to several laboratory and imaging studies.

During this period she presented attention, consciousness fluctuations and agitation that required several treatments, including neuroleptics. Like these symptoms were linked to an important life even that triggered reactive depression, she was transferred to a psychiatric ward. Progressively her clinical state worsened, she became permanently bedridden and was observed by Neurology. She presented moderate to severe parkinsonian signs, namely akinesia and rigidity, predominantly on her left side. Reviewing her clinical past, she had suffered these symptoms during the two years before this episode (apathy, small stepped gait, flexed posture, and left hand rest tremor). Treatment with antiparkinsonic drugs produced a dramatic improvement in the patient’s mental and physical status. A I-Ioflupane-SPECT (DaTscan) confirmed striatal presynaptic dopaminergic degeneration, more on the right side, which was the proof of the presence of a degenerative parkinsonian syndrome.

The present clinical case shows Delirium with degenerative Parkinsonism comorbidity, worsened by the use of neuroleptics. We emphasize the importance previously undiagnosed Parkinsonism in old age which is highlighted by usefulness of dopamine transporter imaging in this scenery.

Efficacy of patient education and supervised exercise vs patient education alone in patients with hip osteoarthritis: a single blind randomized clinical trial

OBJECTIVE

To compare the efficacy of patient education and supervised exercise with that of patient education alone for the management of pain in patients with hip osteoarthritis (OA).

DESIGN

Single blind randomized clinical trial.

SETTING

Recruitment of patients from hospitals, primary health care and advertisement, Oslo, Norway.

PARTICIPANTS

109 patients with radiographic and symptomatic hip OA with mild to moderate symptoms.

INTERVENTIONS

Patient education (PE). Patient education and supervised exercise (PE+SE).

PRIMARY OUTCOME MEASURE

The pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC pain).

RESULTS

No significant between group differences were found for WOMAC pain over the 16-month follow-up. Significant improvements were found for the secondary outcome WOMAC physical function (P=0.011) in the group receiving PE+SE compared to the group receiving PE only. No significant differences were found for WOMAC stiffness, the SF-36 subscales or the activity scale. The effect sizes (95% confidence interval) for WOMAC pain were -0.26 (0.11, -0.64), -0.35 (0.07, -0.77), and -0.30 (0.15, -0.75), and for WOMAC physical function -0.29 (0.09, -0.67), -0.48 (-0.06, -0.91), and -0.47 (-0.02, -0.93) at 4, 10 and 16 months, respectively, in favor of the group receiving both PE and SE. All patients attended the three-session PE program, and 75% performed ≥16 sessions of the 12-week SE program.

CONCLUSION

The study could not demonstrate a significant difference in pain reduction over time between PE+SE vs PE alone. Adding SE to PE may improve physical function, but the magnitude of possible benefit is unknown as the 95% confidence intervals around the mean difference were wide.

TRIAL REGISTRATION

Clinical Trials NCT00319423.

Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with asthma

BACKGROUND AND AIM

The Control of Allergic Rhinitis and Asthma Test (CARAT) was developed to be used in the concurrent management of these diseases, as recommended by the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. However, it was necessary to statistically identify and remove redundant questions and to evaluate the new version's factor structure, internal consistency and concurrent validity.

METHODS

In this cross-sectional study 193 adults with allergic rhinitis and asthma from 15 outpatient clinics in Portugal were included. The CARAT questionnaire was reduced using descriptive analysis, exploratory factor analysis and internal consistency. Spearman's correlations were used to compare the CARAT scores with a medical evaluation and other measures of control, including the Asthma Control Questionnaire and symptoms' visual analogue scales. The performance against physician rating of control was summarized using the area under the curve (AUC) from receiver operating characteristic analysis. In addition, CARAT was compared with the physician's decision to reduce, maintain or increase treatment.

RESULTS

The reduced version has 10 questions and 2 factors (CARAT10). The Cronbach's alpha was 0.85. All correlation coefficients of CARAT10 and factors with the different measures of control met the a priori predictions, ranging from 0.58 to 0.79. The AUC was 0.82. For the physician's decision groups of reduce, maintain or increase treatment, the mean (IC95%) scores of CARAT10 were 24 (21.4;26.6), 21 (19.4;21.9) and 15 (13.6;16.5), respectively.

CONCLUSION

CARAT10 has high internal consistency and good concurrent validity, making it useful to compare groups in clinical studies.

Many roads to data exchange

Federal dollars are spurring efforts for health information exchange, but to say there is more than one approach is an understatement. Providers and payers are taking local, state, regional, and federal routes in search of connected healthcare.

Strongyloides stercoralis: a cause of morbidity and mortality for indigenous people in Central Australia

BACKGROUND

Strongyloides stercoralis may cause a complicated infection in immunocompromised patients, which has a high case fatality rate. Death generally results from sepsis with enteric pathogens. Globally, infection with the human T-cell lymphotropic virus type 1 (HTLV-1) is a major risk factor for this syndrome. Both S. stercoralis and HTLV-1 are endemic to Central Australia.

AIMS

The aim of the study was to determine whether complicated strongyloidiasis occurs in association with HTLV-1 infection in Central Australia.

METHODS

A retrospective audit of all cases of complicated strongyloidiasis presenting to Alice Springs Hospital between January 2000 and December 2006 was carried out. Diagnosis was defined as definite or probable according to whether diagnosis was made by faecal studies or serology respectively. The medical records, investigations and outcomes of patients who met predetermined criteria for a diagnosis of complicated strongyloidiasis were reviewed.

RESULTS

Eighteen indigenous patients met the criteria for complicated strongyloidiasis (definite 9, probable 9). Seven of 11 patients tested were HTLV-1 seropositive. At diagnosis, no treatment was documented for nine patients (definite 4, probable 5), three received a single dose of ivermectin and one a single dose of albendazole. Fifteen patients (83%) died because of sepsis (definite 7, probable 8). Pathogens isolated and their foci of infection included Klebsiella pneumoniae pneumonia (4), bloodstream infection with Enterococcus spp. (2), K. pneumoniae peritonitis (1) and streptococcal meningitis (1).

CONCLUSION

Complicated strongyloidiasis occurs in association with HTLV-1 infection in central Australia. This finding has significant implications for the management of S. stercoralis in the region.

Multi-language translation and cross-cultural adaptation of the OARSI/OMERACT measure of intermittent and constant osteoarthritis pain (ICOAP)

AIM

To conduct a multi-language translation and cross-cultural adaptation of the Intermittent and Constant OsteoArthritis Pain (ICOAP) questionnaire for hip and knee osteoarthritis (OA).

METHODS

The questionnaires were translated and cross-culturally adapted in parallel, using a common protocol, into the following languages: Czech, Dutch, French (France), German, Italian, Norwegian, Spanish (Castillan), North and Central American Spanish, Swedish. The process was conducted following five steps: (1)--independent translation into the target language by two or three persons; (2)--consensus meeting to obtain a single preliminary translated version; (3)--backward translation by an independent bilingual native English speaker, blinded to the English original version; (4)--final version produced by a multidisciplinary consensus committee; (5)--pre-testing of the final version with 10-20 target-language-native hip and knee OA patients.

RESULTS

The process could be followed and completed in all countries. Only slight differences were identified in the structure of the sentences between the original and the translated versions. A large majority of the patients felt that the questionnaire was easy to understand and complete. Only a few minor criticisms were expressed. Moreover, a majority of patients found the concepts of constant pain and pain that comes and goes to be of a great pertinence and were very happy with the distinction.

CONCLUSION

The ICOAP questionnaire is now available for multi-center international studies.

Moisturizing effect of oleogel/hydrogel mixtures

The aim of this study was to obtain new vehicles for topical formulations based on the mixture of hydrogels (aqueous systems) with oleogels (lipophilic systems). Several formulations were prepared using different oleogels mixed with polyacrylic acid hydrogel without addition of other ingredients. The moisturizing effect of the bigels was assessed along with the hydrogel and oleogels used in their preparation by carrying out an in vivo study with 14 healthy volunteers. Corneometer measurements were taken each hour during a five-hour period after product's application. Stability tests (storage at 20 and 40 degrees C for six months) and mechanical characterization were also carried out. Stability tests showed no modifications of the textural properties and appearance over a six-month period at 20 degrees C. At accelerated conditions, modifications of colour and textural properties were detected after six months' storage. While retaining the mechanical and sensory properties of the hydrogel, the bigels showed simultaneously an enhanced moisturizing effect, making them promising candidates for topical formulations.

Investigation of organic, inorganic and synthetic adsorbents for the pretreatment of landfill leachate

An investigation into the use of organic, inorganic and synthetic adsorbents for the pretreatment of landfill leachate, generated by the City of Ottawa Trail Road Landfill, was carried out. The purpose of this project was to reduce the concentration of contaminants in order to meet the local Sewer Use By-Laws, prior to transporting the leachate from the generating site to the local municipal sewage treatment plant, and thereby reducing the disposal fees. Peat moss, compost, clinoptilolite, basalt and two types of activated carbon (DSR-A and F400) were investigated to determine the adsorption capacity for contaminants from leachate. Kinetic studies were also performed. The results based on batch adsorption isotherms show that peat moss has the highest adsorption capacity for boron (B) and barium (Ba), compared with the other adsorbents. Also peat moss has good removals of Total Kjeldahl Nitrogen (TKN), Total Organic Carbon (TOC), and benzene, toluene, ethylbenzene and xylene (BTEX), but these are lower than the removals obtained with activated carbon. Because of its relatively low cost and higher adsorption of B and Ba, peat moss was selected as the filter media for the column studies. The treated leachate was tested for B, Ba, TKN, carbonaceous biological oxygen demand (CBOD5) and hydrogen sulfide (H2S). The breakthrough curves for B and Ba showed the effectiveness of peat moss in removing these contaminants.

Improving sample treatment for in-solution protein identification by peptide mass fingerprint using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Three ultrasonic energy sources were studied to speed up the sample treatment for in-solution protein identification by peptide mass fingerprint using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Protein reduction, alkylation, and enzymatic digestion steps were done in 15 min. Nine proteins, including zinc resistance-associated protein precursor from Desulfovibrio desulfuricans strain G20 and split-soret cytochrome c from D. desulfuricans ATCC27774 were successfully identified with the new protocol.

Degradation of municipal solid waste in aerobic bioreactor landfills

The biodegradation of municipal solid waste (MSW) was investigated in simulated bioreactor landfills under aerobic conditions. The bioreactors were operated to determine the amount of leachate recirculation and municipal wastewater sludge addition required to optimize waste degradation. The leachate generated was recycled over 47 weeks, leachate samples were collected on a weekly basis and analyzed for pH, biochemical oxygen demand (BOD), chemical oxygen demand (COD), Total Kjeldahl Nitrogen (TKN), and ammonia nitrogen (NH3-N). The temperature of the MSW in the bioreactors was measured on a daily basis. Leachate and sludge were added at the rates of 5 l wk(-1) to 15 l wk(-1) and 0.5 l wk(-1) to 1.5 l wk(-1), respectively. Within 27 weeks enhanced MSW degradation was observed at a leachate recirculation rate of 15 l wk(-1) (855 mg l(-1) of MSW d(-1)) and sludge addition rate of 1.5 l wk(-1) (85 mg l(-1) of MSW d(-1)). During this period, the COD concentration in the leachate dropped significantly. A reduction in the leachate recirculation and sludge addition rate increased the waste stabilization period up to 45 weeks.

The evolution of a conjugative plasmid and its ability to increase bacterial fitness

Conjugative plasmids are extra-chromosomal DNA elements that are capable of horizontal transmission and are found in many natural isolated bacteria. Although plasmids may carry beneficial genes to their bacterial host, they may also cause a fitness cost. In this work, we studied the evolution of the R1 plasmid and we found that, in spite of the R1 plasmid conferring an initial cost to its host, after 420 generations the cost disappeared in all five independent evolution experiments. In fact, in two of these five experiments evolved conjugative plasmids actually conferred a fitness advantage to their hosts. Furthermore, the relative fitness of the ancestral clone bearing one of the evolved plasmids is significantly higher than both the plasmid-free ancestral cells and the evolved cells carrying the evolved plasmid. Given that the R1 plasmid may spread among different species of enterobacteria, we wondered what the effect of the evolved plasmid would be inside Salmonella enterica cells. We found that the evolved plasmid is also able to dramatically increase the relative fitness of these cells. Our results suggest that even if general usage of antibiotics is halted, conjugative plasmids that have been selected with antibiotics in previous years can still persist among bacterial populations or even invade new strains.

Sonoreactor-Based Technology for Fast High-Throughput Proteolytic Digestion of Proteins

Fast (120 s) and high-throughput (more than six samples at once) in-gel trypsin digestion of proteins using sonoreactor technology has been achieved. Successful protein identification was done by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, MALDI-TOF-MS. Specific identification of the adenylylsulphate reductase alfa subunit from a complex protein mixture from Desulfovibrio desulfuricans ATCC 27774 was done as a proof of the methodology. The new sample treatment is of easy implementation, saves time and money, and can be adapted to online procedures and robotic platforms.