Prevalence and population characteristics associated with frailty in a rural low socioeconomic area in Denmark: the Lolland-Falster Health Study

BACKGROUND

Frailty is a major geriatric syndrome that predicts increased vulnerability to minor stressor events and adverse outcomes such as falls, fractures, disability and death. The prevalence of frailty among individuals above the age of 65 varies widely with an overall weighted prevalence of 10.7%.

OBJECTIVES

The purpose of this study was to examine the prevalence of prefrailty and frailty in community-dwelling older adults from the regions of Lolland-Falster, which is one of the most socioeconomically disadvantaged areas of Denmark with lower income and lower life expectancy compared with the general Danish population. Moreover, the objective was to find selected individual characteristics associated with frailty.

DESIGN

An observational, cross-sectional registry-based population study with data from the regions of Lolland-Falster collected between February 2016 and February 2020.

RESULTS

The study included 19 000 individuals. There were 10 154 above the age of 50 included for analysis. Prevalence of frailty in the age group of 50-64 years was 4.7% and 8.7% in the age group of 65 years and above.The study demonstrates associations between frailty and high age, female gender, low education level, low income, smoking, living alone, frequency of seeing one's children and getting help when needed. These associations are comparable with findings from other studies.

CONCLUSION

The syndrome of frailty consists of not only physiological and medical issues but also education, life conditions such as living alone and living in poverty and how you evaluate your own health.

Self-reported dizziness, falls, and self-rated health in a rural population in Denmark

PURPOSE

To investigate associations between dizziness, hearing loss, medication, and self-perceived health in the region of Lolland-Falster in Denmark.

METHODS

A cross-sectional population-based study using data from questionnaires and physical examinations between February 8th, 2016, and February 13th, 2020. Individuals aged 50 years or above in the region of Lolland-Falster were randomly invited to participate.

RESULTS

Of 10,092 individuals (52% female), the mean age was 64.7 and 65.7 years for females and males, respectively. 20% reported dizziness during the past 30 days, and prevalence increased with age. 24% of dizzy females suffered from falls compared to 21% of males. 43% sought treatment for dizziness. Logistic regression revealed a higher odds ratio of dizziness in groups with poor self-perceived health (OR = 2.15, 95% CI [1.71, 2.72]) and very poor self-perceived health (OR = 3.62 [1.75, 7.93]) compared to moderate self-perceived health. A higher OR was found for seeking treatment for dizziness in the group that had experienced falls (OR = 3.21 [2.54, 4.07]). 40% reported hearing loss. Logistic regression revealed a higher OR for dizziness in the group with severe hearing loss (OR = 2.40 [1.77, 3.26]) and moderate hearing loss (OR = 1.63 [1.37, 1.94]) compared to no hearing loss.

CONCLUSION

One of five participants reported dizziness during the last month. Dizziness was negatively associated with self-perception of good health also after adjusting for comorbidities. Almost half of the dizzy participants sought treatment for dizziness and 21% experienced falls. Identification and treatment of dizziness are important to prevent falls from happening.

CLINICAL TRIAL REGISTRATION

http://www.

CLINICALTRIALS

gov (NCT02482896).

Perspective of geriatric patients on advance care planning in Denmark: a qualitative study

OBJECTIVE

Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations.

DESIGN

Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method.

SETTING

Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark.

PARTICIPANTS

We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview.

RESULTS

This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will.

CONCLUSION

Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Feasibility, quality and validity of narrative multisource feedback in postgraduate training: a mixed-method study

OBJECTIVES

To examine a narrative multisource feedback (MSF) instrument concerning feasibility, quality of narrative comments, perceptions of users (face validity), consequential validity, discriminating capacity and number of assessors needed.

DESIGN

Qualitative text analysis supplemented by quantitative descriptive analysis.

SETTING

Internal Medicine Departments in Zealand, Denmark.

PARTICIPANTS

48 postgraduate trainees in internal medicine specialties, 1 clinical supervisor for each trainee and 376 feedback givers (respondents).

INTERVENTION

This study examines the use of an electronic, purely narrative MSF instrument. After the MSF process, the trainee and the supervisor answered a postquestionnaire concerning their perception of the process. The authors coded the comments in the MSF reports for valence (positive or negative), specificity, relation to behaviour and whether the comment suggested a strategy for improvement. Four of the authors independently classified the MSF reports as either 'no reasons for concern' or 'possibly some concern', thereby examining discriminating capacity. Through iterative readings, the authors furthermore tried to identify how many respondents were needed in order to get a reliable impression of a trainee.

RESULTS

Out of all comments coded for valence (n=1935), 89% were positive and 11% negative. Out of all coded comments (n=4684), 3.8% were suggesting ways to improve. 92% of trainees and supervisors preferred a narrative MSF to a numerical MSF, and 82% of the trainees discovered performance in need of development, but only 53% had made a specific plan for development. Kappa coefficients for inter-rater correlations between four authors were 0.7-1. There was a significant association (p<0.001) between the number of negative comments and the qualitative judgement by the four authors. It was not possible to define a specific number of respondents needed.

CONCLUSIONS

A purely narrative MSF contributes with educational value and experienced supervisors can discriminate between trainees' performances based on the MSF reports.

[The chronically dizzy patient]

Many medical, neurologic and psychiatric conditions as well as drugs can give chronic dizziness, and a systematic diagnostic workup is essential. Chronic vestibular syndrome is a clinical syndrome of chronic vertigo, dizziness or unsteadiness lasting months to years. There is generally a persistent unilateral or bilateral vestibular loss. Treatment depends on the aetiology, but in general, treatment with vestibular rehabilitation is effective, which is summarised in this review. Betahistin or other anti-vertigo-drugs are not indicated in the treatment of chronic vertigo.

Predictive validity of PRISMA-7 as a screening instrument for frailty in a hospital setting

OBJECTIVES

Frailty is a major clinical geriatric syndrome associated with serious adverse events including functional disability, falls, hospitalisation, increased morbidity and mortality. The aim of this study was to study the associations between frailty defined as Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA-7) score ≥3 and use of healthcare resources in hospital and in the municipality as well as association between frailty and mortality.

DESIGN

Register-based retrospective study.

SETTING

The target population consists of patients aged 75 years or above who, during hospital stay, were assessed by a physiotherapist, and at discharge from hospital were prescribed further physical training in the community.

PARTICIPANTS

973 individuals aged 75+ years were included.

OUTCOME MEASURES

We examined associations between frailty and use of healthcare resources in hospital and in the municipality as well as the association between frailty and mortality.

RESULTS

973 individuals aged 75+ years were included. Of these, 63.9% had a PRISMA-7 score ≥3 and were thus defined as frail. Frail individuals were older compared with non-frail with mean ages of 84.6 and 80.4 years, respectively, p>0.001. Age and gender-adjusted mortality after 1 year was higher among the frail (OR 2.46, 95% CI 1.53 to 3.97). Use of healthcare services in the municipality as well as hospital admissions was significantly higher among frail individuals.

CONCLUSIONS

Based on these findings we consider PRISMA-7 to be useful in an in-hospital setting as a screening tool to identify frail elderly patients who may profit from further geriatric assessment during hospital stay.

TRIAL REGISTRATION NUMBER

ID REG-070-2017.

Danish register-based study on the association between specific antipsychotic drugs and fractures in elderly individuals

Background

antipsychotic drugs (APs) have been associated with falls and fractures in elderly individuals but limited knowledge on specific drugs exist.

Objective

to investigate the association between individual APs and fractures in elderly persons.

Design and setting

nationwide register-based cohort study.

Subjects

all Danish individuals aged ≥65 who had not been in treatment with any AP in the year before inclusion.

Methods

incidence rate ratios (IRRs) of fractures of hip, pelvis or upper extremities during treatment with commonly used APs were assessed in multivariable Poisson models. Exposure was divided into time periods from initiation of treatment: 0-30 days, 31-365 days or >365 days.

Results

one year prior to inclusion, 1,540,915 individuals ≥65 years had not received APs and of these 93,298 initiated treatment with APs. Mean follow-up was 9.6 years. During follow-up, 246,057 (16%) experienced a fracture. Associations were for all APs highest in the initial treatment period (0-30 days) with IRRs for risperidone 1.97 (95% CI: 1.70-2.28), olanzapine 2.31 (95% CI: 1.96-2.73), quetiapine 2.09 (95% CI: 1.73-2.52), zuclopenthixol 2.19 (95% CI: 1.82-2.63), chlorprothixen 1.62 (95% CI: 1.18-2.24), flupenthixol 1.43 (95% CI: 1.06-1.93), levomepromazine 1.19 (95% CI 0.86-1.66), haloperidol 2.98 (95% CI 2.57-3.45), compared with the background population.

Conclusions

use of APs is associated with fractures in elderly persons especially in the initial treatment period. If AP use in an elderly person is deemed necessary, individual falls prophylaxis should be considered.

Antidepressants and the risk of hyponatremia: a Danish register-based population study

OBJECTIVE

To examine the association between classes of antidepressants and hyponatremia, and between specific antidepressants and hyponatremia.

DESIGN

Retrospective register-based cohort study using nationwide registers from 1998 to 2012.

SETTING

The North Denmark Region.

PARTICIPANTS

In total, 638 352 individuals were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Plasma sodium was obtained from the LABKA database. The primary outcome was hyponatremia defined as plasma sodium (p-sodium) below 135 mmol/L and secondary outcome was severe hyponatremia defined as p-sodium below 130 mmol/L. The association between use of specific antidepressants and hyponatremia was analysed using multivariable Poisson regression models.

RESULTS

An event of hyponatremia occurred in 72 509 individuals and 11.36% (n=6476) of these events happened during treatment with antidepressants. Incidence rate ratios and CIs for the association with hyponatremia in the first p-sodium measured after initiation of treatment were for citalopram 7.8 (CI 7.42 to 8.20); clomipramine 4.93 (CI 2.72 to 8.94); duloxetine 2.05 (CI 1.44 to 292); venlafaxine 2.90 (CI 2.43 to 3.46); mirtazapine 2.95 (CI 2.71 to 3.21); and mianserin 0.90 (CI 0.71 to 1.14).

CONCLUSIONS

All antidepressants except mianserin are associated with hyponatremia. The association is strongest with citalopram and lowest with duloxetine, venlafaxine and mirtazapine.

European postgraduate training in geriatric medicine: data of a systematic international survey

INTRODUCTION

High-quality education and training standards in geriatric medicine are important to develop the profession of geriatric medicine. The objective of the study was to give a structured update on postgraduate specialty training in geriatric medicine throughout Europe to assess the need for further developments in postgraduate education.

METHODS

The study was performed as a cross-sectional structured quantitative online survey with qualitative comments. The survey content covered organization, content and educational aspects of specialty training in geriatric medicine in European countries. After piloting, the questionnaire was sent to experts in geriatric medicine with a special interest in postgraduate training who are members of one of the following organizations; European Union of Medical Specialists (UEMS), European Academy for the Medicine of Aging (EAMA), and European Union Geriatric Medicine Society (EUGMS).

RESULTS

Respondents to the survey represented 31 European countries. Geriatric medicine is recognized as an independent postgraduate specialty in 61.3 % (19/31) and as a subspecialty in 29.0 % (9/31) of the countries. In 5 of the 31 countries geriatric medicine is not recognized at all. Nearly all countries offering postgraduate training in geriatric medicine have written, competence-based curricula covering different learning domains. 20/31 countries (64.5 %) have some kind of specialist assessment.

DISCUSSION

The survey tries to give an actual condensed picture of postgraduate specialty training in geriatric medicine across Europe. Results show a consistent improvement in the recognition of geriatric medicine as independent specialty over the last decade. Continuous development of specialty training in geriatric medicine is required to medical address the public health needs of an aging population. Competence-based educational models including adequate forms of assessment should be targeted throughout Europe. To emphasize the importance of postgraduate geriatric training, it should be a mission to harmonize training standards across Europe.

[Working environment and educational environment are two sides of the same coin]

Educational environment is of major importance for job satisfaction and it consists of several components including curriculum and values of the organization. Educational climate is the environment, as the individual physicians perceive it. Motivation is important for job satisfaction as well as for learning. Autonomy, responsibility, supervision, feedback are all important factors influencing motivation and learning. These factors must be supported through appropriate organization of work in hospital departments and in general practice.

Measurement of health-related quality of life in dermatological research and practice: outcome of the EADV Taskforce on Quality of Life

In the last decade, the importance of the measurement of health-related quality of life (HRQoL) has grown significantly. Today, HRQoL measurement is generally considered to be important in clinical trials, in the assessment of disease severity, in patient management and in the field of health economics. Therefore, a good understanding of the concept of HRQoL and its measurement instruments is a prerequisite for both researchers and clinicians. The European Academy for Dermatology and Venereology (EADV) Taskforce on Quality of Life encourages the application of HRQoL instruments in research and clinical practice, and with this manuscript, the Taskforce aims to contribute to the quality of this application. In dermatology, a large number of HRQoL instruments exist and herewith, we summarize the most commonly used generic and dermatology-specific HRQoL instruments. Information is given on the most important psychometric characteristics of these instruments, including: scale structure, reliability, validity and responsiveness. Furthermore, a flow chart is provided to support researchers and clinicians in selecting an existing instrument or, in case an appropriate instrument does not exist, in finding alternative solutions. The present manuscript is the first of a series of manuscripts to be written on behalf of the EADV Taskforce on Quality of Life, aiming to contribute to the scientific knowledge and measurement of patient reported outcomes in dermatological research and practice.

Patient-Oriented SCORAD (PO-SCORAD): a new self-assessment scale in atopic dermatitis validated in Europe

BACKGROUND

Patient-oriented medicine is an emerging concept, encouraged by the World Health Organization, to greater involvement of the patient in the management of chronic diseases. The Patient-Oriented SCORing Atopic Dermatitis (PO-SCORAD) index is a self-assessment score allowing the patient to comprehensively evaluate the actual course of atopic dermatitis (AD), using subjective and objective criteria derived mainly from the SCORAD, a validated AD severity clinical assessment tool.

OBJECTIVES

To validate the PO-SCORAD index in a large European population of patients exhibiting all forms of AD severity by assessing its correlation with the SCORAD index.

PATIENTS/METHODS

Four hundred and seventy-one patients (185 adults, 286 children) consulting for AD in hospitals from 9 European countries were recruited. The investigators and the patients used the SCORAD and PO-SCORAD scales, respectively, to assess AD severity at inclusion (D0) and 28 ± 7 days later (D28).

RESULTS

Patient-Oriented SCORing Atopic Dermatitis and SCORAD scores were significantly correlated at D0 [r = 0.67 (95% CI: 0.62; 0.72), P < 0.0001]. Consistency was confirmed at D28, with a stronger linear correlation between both scales [r = 0.79 (95% CI: 0.75; 0.83), P < 0.0001]. Absolute changes from baseline in SCORAD and PO-SCORAD scores were also significantly correlated [r= 0.71 (95% CI: 0.64; 0.76), P < 0.0001]. Although no specific intervention was investigated, AD improved over the study, with a decrease of PO-SCORAD and SCORAD scores from D0 to D28 by -19.19% and -24.39%, respectively. The consistency of the correlations was similar in the adult and children groups.

CONCLUSIONS

This study validated the use of PO-SCORAD to self-assess AD severity and demonstrated its good correlation with SCORAD.

[Evidence-based pedagogical principles used at medical specialist workshop]

How should a theoretical postgraduate course be organized to obtain maximum effect? We report an example of a two-day course planned and implemented according to educational approaches previously shown to be effective. The theme of the course is "The old patient", and the course is compulsory for residents in internal medicine. This case study showed that the methods used were feasible, and the participants gained knowledge. A multiple-choice test before and after the course showed 44% (before) and 64% (after) correct answers, p < 0.001.

Assessment of atopic eczema: clinical scoring and noninvasive measurements

BACKGROUND

Clinical scoring systems are widely used in clinical trials of atopic eczema (AE), while noninvasive methods are more often used for research purposes. Positive correlations between the two types of methods may be used in support of the validity of both in a clinical context. Few studies are available of the association between clinical scores and instrumental assessment of disease severity obtained with noninvasive instruments.

OBJECTIVES

To compare clinical scores in AE with biometric data in AE.

METHODS

Transepidermal water loss, stratum corneum hydration, erythema, scaling and subepidermal oedema were measured. 'Scoring of Atopic Dermatitis (SCORAD)', 'Eczema Area and Severity Index (EASI)' and 'Atopic Dermatitis Severity Index (ADSI)' were used for clinical scores. Two assessments at 6-month intervals at the antecubital fossa, dorsal forearm and popliteal fossa in 101 patients with AE and 30 controls were carried out.

RESULTS

Significant correlations were found within the clinical scores (P < 0.0001 and r = 0.85-0.91) and between instruments and clinical scores (P < 0.0001 and r = 0.61-0.79).

CONCLUSIONS

The various instruments and clinical scores showed internal agreement and noninvasive methods correlated significantly with the three different clinical scorings systems. This observation suggests that both methods provide data of clinical (scores) and biological (instrumental measures) relevance, and may be useful in future studies of AE. It is speculated that combined measures including scores and selected instruments may be particularly useful.

[Fall or syncope?]

Falls among older adults are a major health problem. When older adults fall, it is difficult to determine whether it is just a simple fall or is caused by syncope, as people often have amnesia for the loss of consciousness. We report three cases in which cardiac monitoring, for seven days or more, showed that falls had been caused by cardiac-related syncopes.

The handicap caused by atopic dermatitis--sick leave and job avoidance

BACKGROUND

The handicap caused by skin diseases is insufficiently described in comparison to other types of diseases (e.g. rheumatological diseases). Estimates of disease handicap provide important data for overall disease assessment, resource planning and background data for planning possible preventive intervention studies.

OBJECTIVE

Primarily to describe the degree of handicap caused by atopic dermatitis (AD) in relation to the choice of education and occupation. Secondarily to describe the frequency of social pensions awarded due to AD in Denmark and the development of pensions awarded over time.

METHODS

A descriptive study based on questionnaires gathered from members of the Danish Association of Atopic Eczema. Information was obtained on age, disease duration, severity, localization of eczema and Dermatology Life Quality Index (DLQI). Additional data about sick days due to eczema and patients' choice of education or employment were obtained from the Danish Ministry of Social Affairs.

RESULTS

Study population 112 (24 males and 88 females), aged 15 years and older, self-assessed morbidity was mild (1/3), moderate (1/2) or severe (approximately 1/5). Mean DLQI score was 9.67. Mean loss of working days due to AD was 5.8 days/6 months (95% CI: 0.36-11.30). The mean total loss of working days due to eczema alone was 148% of the national average, and 38% of the respondents had abstained from a specific education or a job due to AD. Since 1970, the average number of pension due to AD awarded in Denmark has grown from 4.2 per year for 1970-1976 to 18.0 per year for 1999-2002.

CONCLUSION

Even mild to moderate AD causes handicap as seen from increased sick leave and the number of awarded early retirement pensions. There are therefore both individual as well as societal consequences of AD.

Parent gender and assessment of infant life quality

OBJECTIVES

The primary objective was to examine the influence of parents' gender on the assessment of quality of life among infants with atopic dermatitis. The secondary objective was to examine the psychological factors affecting the assessment.

METHODS

Questionnaires were completed by 28 couples, as a basis for gender comparison. Data were gathered on disease severity, confidence of treatment, Major Depression Index (MDI), Spielberger Trait Anxiety Inventory (STAI) and the Infants' Dermatitis Quality of Life Index (IDQOL).

RESULTS

The mothers' scores were higher than those of fathers for all assessments, although differences were not statistically significant. Significant correlations were found between MDI and severity assessment for mothers only and between MDI and STAI for both genders. Multiple linear regression analysis suggested gender differences in the proposed model, where only depression was appearing statistically significant (P = 0.029).

CONCLUSION

Our data presented suggest that no significant gender-dependent differences occur in parents' overall severity assessment of the eczema in their children, but the influence of the different factors studied is not equal in the two sexes. Future instruments aimed at surrogate assessment of disease severity in children by their parents should take this into account and provide explicit testing of possible gender differences.

Life quality assessment among patients with atopic eczema

BACKGROUND

Quantification of quality of life (QoL) related to disease severity is important in patients with atopic eczema (AE), because the assessment provides additional information to the traditional objective clinical scoring systems.

OBJECTIVES

To measure health-related QoL (HRQoL) in patients with AE; to analyse discriminant, divergent and convergent validity by examining the association between various QoL methods; and to examine the association between disease severity assessed by an objective Severity Scoring of Atopic Dermatitis (SCORAD) and QoL.

METHODS

HRQoL was assessed at two visits at a 6-monthly interval in 101 patients with AE and 30 controls with one dermatology-specific questionnaire [Dermatology Life Quality Index (DLQI) or Children's DLQI (CDLQI)], one generic instrument (SF-36) and three visual analogue scales (VASs) of severity and pruritus. Objective SCORAD was used to measure disease severity.

RESULTS

Patients with AE had significantly lower QoL than healthy controls and the general population. DLQI /CDLQI, pruritus, and patient and investigator overall assessment of eczema severity were significantly (P < 0.0001) and positively correlated with SCORAD, while the generic questionnaire showed only poor correlation. A gender difference was found for the mental component score of SF-36 (P = 0.019).

CONCLUSIONS

AE has an impact on HRQoL. Patients' mental health, social functioning and role emotional functioning seem to be more affected than physical functioning. A simple VAS score of patients' assessment of disease severity showed the highest and most significant correlations with most of the HRQoL methods used. There is evidence to support the ability of patients with AE to make an accurate determination of their disease severity and QoL.

Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up

OBJECTIVES

To compare the effect of graded physiotherapeutic training of the rotator cuff versus arthroscopic subacromial decompression in patients with subacromial impingement.

METHODS

Randomised controlled trial with 12 months' follow up in a hospital setting. Ninety consecutive patients aged 18 to 55 years were enrolled. Symptom duration was between six months and three years. All fulfilled a set of diagnostic criteria for rotator cuff disease, including a positive impingement sign. Patients were randomised either to arthroscopic subacromial decompression, or to physiotherapy with exercises aiming at strengthening the stabilisers and decompressors of the shoulder. Outcome was shoulder function as measured by the Constant score and a pain and dysfunction score. "Intention to treat" analysis was used, with comparison of means and control of confounding variables by general equation estimation analysis.

RESULTS

Of 90 patients enrolled, 84 completed follow up (41 in the surgery group, 43 in the training group). The mean Constant score at baseline was 34.8 in the training group and 33.7 in the surgery group. After 12 months the mean scores improved to 57.0 and 52.7, respectively, the difference being non-significant. No group differences in mean pain and dysfunction score improvement were found.

CONCLUSIONS

Surgical treatment of rotator cuff syndrome with subacromial impingement was not superior to physiotherapy with training. Further studies are needed to qualify treatment choice decisions, and it is recommended that samples are stratified according to disability level.

Statistical physics of grain-boundary engineering

Percolation theory is now standard in the analysis of polycrystalline materials where the grain boundaries can be divided into two distinct classes, namely "good" boundaries that have favorable properties and "bad" boundaries that seriously degrade the material performance. Grain-boundary engineering (GBE) strives to improve material behavior by engineering the volume fraction c and arrangement of good grain boundaries. Two key percolative processes in GBE materials are the onset of percolation of a strongly connected aggregate of grains, and the onset of a connected path of weak grain boundaries. Using realistic polycrystalline microstructures, we find that in two dimensions the threshold for strong aggregate percolation c(SAP) and the threshold for weak boundary percolation c(WBP) are equivalent and have the value c(SAP) = c(WBP) =0.38 (1) , which is slightly higher than the threshold found for regular hexagonal grain structures, c(RH) =2 sin (pi/18) =0.347... . In three dimensions strong aggregate percolation and weak boundary percolation occur at different locations and we find c(SAP) =0.12 (3) and c(WBP) =0.77 (3) . The critical current in high T(c) materials and the cohesive energy in structural systems are related to the critical manifold problem in statistical physics. We develop a theory of critical manifolds in GBE materials, which has three distinct regimes: (i) low concentrations, where random manifold theory applies, (ii) critical concentrations where percolative scaling theory applies, and (iii) high concentrations, c> c(SAP) , where the theory of periodic elastic media applies. Regime (iii) is perhaps most important practically and is characterized by a critical length L(c) , which is the size of cleavage regions on the critical manifold. In the limit of high contrast epsilon-->0 , we find that in two dimensions L(c) proportional, gc/ (1-c) , while in three dimensions L(c) proportional, g exp [ b(0) c/ (1-c) ] / [c (1-c) ](1/2) , where g is the average grain size, epsilon is the ratio of the bonding energy of the weak boundaries to that of the strong boundaries, and b(0) is a constant which is of order 1. Many of the properties of GBE materials can be related to L(c) , which diverges algebraically on approach to c=1 in two dimensions, but diverges exponentially in that limit in three dimensions. We emphasize that GBE percolation processes and critical manifold behavior are very different in two dimensions as compared to three dimensions. For this reason, the use of two dimensional models to understand the behavior of bulk GBE materials can be misleading.

Scaling laws for critical manifolds in polycrystalline materials

We study the surfaces of lowest energy through model polycrystalline materials in two and three dimensions. When the grain boundaries are sufficiently weak, these critical manifolds (CM's) lie entirely on grain boundaries, while when the grain boundaries are strong, cleavage occurs. A scaling theory for the intergranular to transgranular transition of CM's is developed. The key parameters are the average grain size g, the ratio of grain boundary to the grain interior energy, epsilon, and the sample size L. The key result is that a critical length scale exists, L(c)(g,epsilon), so that on short length scales l<L(c) cleavage is observed while at long length scales, l>L(c), the critical manifold is rough. We develop a scaling theory for L(c) and find that in two dimensions L(c) approximately gx(y(2)), while in three dimensions L(c) approximately g exp(bx(y(3))), where x=epsilon/(1-epsilon) and b is a constant. Data from realistic polycrystalline grain structures are used to test the scaling theory. The exact lowest energy surface through model grain structures is found using a mapping to the minimum-cut/maximum-flow problem in computer science. As a function of grain-boundary energy, we observe the crossover from grain-boundary rupture to mixed mode failure (a mixture of transgramular and intergranular modes) and finally cleavage and that the two-dimensional data are consistent with y(2) approximately 3.0+/-0.3, while the three-dimensional data are more difficult to analyze, but are consistent with y(3) approximately 3.5+/-1.0.

[Who should be admitted to a geriatric unit?]

Potential geriatric patients are frail old persons characterized by the presence of one or several geriatric conditions: polypharmacy, socio-economic problems, vision/hearing impairment, confusion, impaired mobility, incontinence, weight loss, depression, falls, dementia, and prolonged bedrest. Admission of these frail old patients to a geriatric unit may reduce mortality, improve function, and decrease the risk of nursing home placement. These frail old patients may not all be able to profit from geriatric rehabilitation. The published randomized trials showing substantial effect of geriatric rehabilitation exclude patients with severe dementia, terminal disease or those with a single medical disease for which there is no further treatment. Careful selection of patients is necessary in order to achieve superior, clear-cut effect when compared to conventional treatment in general medical wards.

Vasculitis occurring during leflunomide therapy

Leflunomide has recently been introduced for systemic treatment of rheumatoid arthritis. It has both immunosuppressive effects and anti-inflammatory properties. We report a patient treated with leflunomide who developed vasculitis as an adverse side effect. As far as we are aware, this is the first published report of vasculitis associated with leflunomide therapy.

[Acne neonatorum/acne infantum]

Acne is generally considered to be a disease of adolescence. However 20% of newborns have acne neonatorum, which may to be overlooked because it is usually mild and transient. Acne can also be seen in infants and children, where the skin lesions are normally more severe. We describe a case of a ten-month-old boy with severe acne without other underlying diseases. Treatment with systemic erythromycin and local application with isotretinoin gel was moderately successful, but the eruption cleared when treated with isotretinoin 0.5 mg/kg.

Dietary protein restriction and the progression of chronic renal insufficiency: a review of the literature

It is well known that dietary protein restriction can delay the appearance of uraemic symptoms and give symptomatic relief in patients with chronic renal failure. During the last decade, several investigators have argued that protein restriction instituted at an early phase in renal disease may influence the rate of progression of renal failure favourably. Animal experiments have given strong evidence that, in the case of nephron loss, high dietary protein promotes further loss of renal function. Many studies have been conducted to investigate the possible favourable effect of a protein-restricted diet in patients with renal disease. However, the scientific proof that long-term protein restriction delays the progression of chronic renal insufficiency in man is still missing.

[Alcoholic ketoacidosis]

Alcoholic ketoacidosis is an acute metabolic disorder that occurs in ethanol abusers who because of gastritis or other concurrent illness stop eating and drinking and vomit repeatedly. This causes dehydration and ketoacidosis with little or no hyperglycaemia and glucosuria. A case of severe alcoholic ketoacidosis is presented and the literature on alcoholic ketoacidosis is reviewed.

[The yellow nail syndrome]

The yellow nail syndrome is the combination of slow growing yellow discoloured nails, lymphoedema and pleural effusion. The symptoms are supposed to be due to impaired lymphatic drainage. It is a rare clinical condition: through the last 30 years only about a hundred cases have been reported. The treatment is symptomatic (diuretics and pleuradesis). We review the literature and report four cases.

[Patterns of tuberculosis manifestation in the county of Roskilde]

The epidemiological and clinical features of all adult tuberculosis (tbc) cases in a Danish county over a 12 year period (82 cases) are presented. Most patients with pulmonary disease have thorax X-ray pictures showing pathological changes. Of the patients who only have extrapulmonary disease, 88% have normal X-ray examinations of the lungs. The patients can be divided into two groups: Danes and foreigners. The Danish patients are older, 81% are over the age of forty. They mostly have pulmonary disease (85%). They often have one or several concomitant diseases. The foreigners are younger, 90% are below the age of forty. They frequently have extrapulmonary disease (35%). They seldom have concomitant diseases.