A systematic review of interventions to improve male knowledge of fertility and fertility-related risk factors

Male infertility is a global health concern. The effectiveness of interventions developed to improve males' knowledge of fertility regulation and fertility-related risk factors remains unclear. This systematic review aimed to synthesize and evaluate the evidence for these interventions. Four databases were searched from inception to June 2023. Eligible studies examined interventions to increase fertility knowledge among presumed fertile males aged ≥16 years of age. Conference abstracts, protocols and studies without sex-disaggregated results for males were excluded. A narrative synthesis without meta-analysis was performed. A total of 4884 records were identified. Five studies (reported in six publications), all conducted in high-income countries, were included. Two were randomized control trials, and three were experimental studies. Interventions were delivered in person by a health professional (n = 3), online and via a mobile app. All studies showed a significant improvement in knowledge of fertility or fertility-related risk factors from baseline to follow-up. The largest improvement was observed for secondary and vocational students. A moderate, long-term retainment of knowledge was observed at two-year follow-up in one study. Available evidence suggests interventions to improve males' fertility knowledge are effective, particularly for younger, less educated males.

Women's views on content and delivery methods for interventions to improve preconception health: a qualitative exploration

Background

Systematic review evidence suggests preconception health interventions may be effective in improving a range of outcomes. However, few studies have explored women's views on potential content and delivery methods for these interventions.

Methods

Participants were purposively sampled from respondents (n = 313) of a survey. Semi-structured, in-depth interviews were conducted to explore their views on seven candidate delivery methods for preconception health interventions: general practitioners (GPs), nurse practitioners, pharmacists, social media, personal texts and emails, pregnancy tests, and health education in schools. Data were analyzed using a data-driven framework analysis.

Results

Twenty women were interviewed. Women wanted interventions to be easily accessible but allow them to conceal their pregnancy plans. They preferred to choose to receive preconception interventions but were receptive to health professionals raising preconception health during 'relevant' appointments such as contraceptive counseling and cervical smear tests. They wanted intervention content to provide trustworthy and positively framed information that highlights the benefits of good preconception health and avoids stigmatizing women for their weight and preconception actions. The inclusion of support for preconception mental health and the use of visual media, personalization, simple information, and interesting and unfamiliar facts were viewed favorably.

Conclusion

Interventions to improve preconception health should reflect the sensitivities of pregnancy intentions, be easy to access in a way that enables discretion, and be designed to seek consent to receive the intervention. These interventions should ideally be tailored to their target populations and provide trustworthy information from reputable sources. The potential for unintended harmful effects should be explored.

The Challenge of Weight Stigma for Women in the Preconception Period: Workshop Recommendations for Action from the 5th European Conference on Preconception Health and Care

Weight stigma is a well-recognised public health issue affecting many members of society including women during the preconception period. The impacts of preconception weight stigma on women are significant and may result in decreased access to and uptake of healthcare, and mental health concerns. The consequences of this weight stigma may translate to negative maternal outcomes and even intergenerational effects on the child. Eliminating weight stigma is therefore imperative. The aim of this paper is to report recommendations to reduce weight stigma for preconception women produced at a workshop with clinical and academic experts on preconception health and weight stigma at the 5th European Conference on Preconception Health and Care. The recommendations are related to two key areas: general societal recommendations prompting all people to acknowledge and adjust our attitudes towards larger-bodied people; and healthcare-specific recommendations imploring clinicians to upskill themselves to reduce weight stigma in practice. We therefore call for urgent approaches to address societal weight-stigmatising attitudes and norms related to both the general population and preconception women, while providing professional development opportunities for healthcare professionals relating to weight stigma. Eliminating weight stigma for preconception women may have positive impacts on the outcomes for mothers and children during pregnancy and beyond.

Women's knowledge, attitudes and views of preconception health and intervention delivery methods: a cross-sectional survey

Background

Several preconception exposures have been associated with adverse pregnancy, birth and postpartum outcomes. However, few studies have investigated women’s knowledge of and attitudes towards preconception health, and the acceptability of potential intervention methods.

Methods

Seven primary care centres in the West of England posted questionnaires to 4330 female patients aged 18 to 48 years. Without providing examples, we asked women to list maternal preconception exposures that might affect infant and maternal outcomes, and assessed their knowledge of nine literature-derived risk factors. Attitudes towards preconception health (interest, intentions, self-efficacy and perceived awareness and importance) and the acceptability of intervention delivery methods were also assessed. Multivariable multilevel regression examined participant characteristics associated with these outcomes.

Results

Of those who received questionnaires, 835 (19.3%) responded. Women were most aware of the preconception risk factors of diet (86.0%) and physical activity (79.2%). Few were aware of weight (40.1%), folic acid (32.9%), abuse (6.3%), advanced age (5.9%) and interpregnancy intervals (0.2%), and none mentioned interpregnancy weight change or excess iron intake. After adjusting for demographic and reproductive covariates, women aged 18–24-years (compared to 40–48-year-olds) and nulligravid women were less aware of the benefit of preconception folic acid supplementation (adjusted odds ratios (aOR) for age: 4.30 [2.10–8.80], gravidity: aOR 2.48 [1.70–3.62]). Younger women were more interested in learning more about preconception health (aOR 0.37 [0.21–0.63]) but nulligravid women were less interested in this (aOR 1.79 [1.30–2.46]). Women with the lowest household incomes (versus the highest) were less aware of preconception weight as a risk factor (aOR: 3.11 [1.65–5.84]) and rated the importance of preconception health lower (aOR 3.38 [1.90–6.00]). The most acceptable information delivery methods were websites/apps (99.5%), printed healthcare materials (98.6%), family/partners (96.3%), schools (94.4%), television (91.9%), pregnancy tests (91.0%) and doctors, midwives and nurses (86.8–97.0%). Dentists (23.9%) and hairdressers/beauticians (18.1%) were the least acceptable.

Conclusions

Our findings demonstrate a need to promote awareness of preconception risk factors and motivation for preconception health changes, particularly amongst younger and nulligravid women and women with lower incomes. Interventions to improve preconception health should focus on communication from healthcare professionals, schools, family members, and digital media.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05058-3.

The influence of patient centering on CT dose and image noise

Although x-ray intensity shaping filters (bowtie filters) have been used since the introduction of some of the earliest CT scanner models, the clinical implications on dose and noise are not well understood. To achieve the intended dose and noise advantage requires the patient to be centered in the scan field of view. In this study we explore the implications of patient centering in clinical practice. We scanned various size and shape phantoms on a GE LightSpeed VCT scanner using each available source filter with the phantom centers positioned at 0, 3, and 6 cm below the center of rotation (isocenter). Surface doses were measured along with image noise over a large image region. Regression models of surface dose and noise were generated as a function of phantom size and centering error. Methods were also developed to determine the amount of miscentering using a scout scan projection radiograph (SPR). These models were then used to retrospectively evaluate 273 adult body patients for clinical implications. When miscentered by 3 and 6 cm, the surface dose on a 32 cm CTDI phantom increased by 18% and 41% while image noise also increased by 6% and 22%. The retrospective analysis of adult body scout SPR scans shows that 46% of patients were miscentered in elevation by 20-60 mm with a mean position 23 mm below the center of rotation (isocenter). The analysis indicated a surface dose penalty of up to 140% with a mean dose penalty of 33% assuming that tube current is increased to compensate for the increased noise due to miscentering. Clinical image quality and dose efficiency can be improved on scanners with bowtie filters if care is exercised when positioning patients. Automatically providing patient specific centering and scan parameter selection information can help the technologist improve workflow, achieve more consistent image quality and reduce patient dose.

Difficult but necessary conversations--the case for advance care planning

Many patients at the end of life receive care that is inappropriate or futile and, if given the opportunity to discuss their care preferences well ahead of death, may well have chosen to forgo such care. Advance care planning (ACP) is a process of making decisions about future health care for patients in consultation with clinicians, family members and important others, and to safeguard such decisions if patients were to lose decisional capacity. Although ACP has existed as an idea for decades, acceptance and operationalisation of ACP within routine practice has been slow, despite evidence of its benefits. The chief barriers have been social and personal taboos about discussing the dying process, avoidance by medical professionals of responsibility for initiating, coordinating and documenting discussions about ACP, absence of robust and standardised procedures for recording and retrieving ACP documents across multiple care settings, and legal and ethical concerns about the validity of such documents. For ACP to become part of mainstream patient-centred care, accountable clinicians working in primary care, hospitals and nursing homes must effectively educate colleagues and patients about the purpose and mechanics of ACP, mandate ACP for all eligible patients, document ACP in accessible formats that enable patient wishes to accurately guide clinical management, devise methods for reviewing ACP decisions when clinically appropriate, and evaluate congruence between expressed patient wishes and actual care received. Public awareness campaigns coupled with implementation of ACP programs sponsored by collaborations between hospital and health services, Medicare locals and residential care facilities will be needed in making system-wide ACP a reality.

The Bundaberg emergency response team

A major crisis affected Bundaberg Hospital in 2005 following the exposure of the concerns about Dr Jayant Patel and the subsequent sudden exit of the Hospital Executive. The Bundaberg Emergency Response Team (BERT) was created as an emergency intervention whose brief was, over a 6-week period, to maintain the function of the hospital in the face of the community's loss of confidence in the service; to find out what had happened to Dr Patel's patients and to organise appropriate care and treatment for them. The authors acted as the senior members of BERT. Serious events such as these are rare and there was no framework to guide the team. BERT quickly established processes to assess the extent of harm to patients and to mobilise large scale clinical and counselling assistance for patients and staff. The team also managed the local health service, engagement with the community and assistance with the various investigations being conducted into Dr Patel. BERT was considered by the community and the former patients of Dr Patel to be an appropriate and professional response to the situation. The experience provides a framework for responses to these types of situations and herein we discuss key points for successful implementation.

Effects of select anions from the Hofmeister series on the gas-phase conformations of protein ions measured with traveling-wave ion mobility spectrometry/mass spectrometry

The gas-phase conformations of ubiquitin, cytochrome c, lysozyme, and α-lactalbumin ions, formed by electrospray ionization (ESI) from aqueous solutions containing 5 mM ammonium perchlorate, ammonium iodide, ammonium sulfate, ammonium chloride, ammonium thiocyanate, or guanidinium chloride, are examined using traveling-wave ion mobility spectrometry (TWIMS) coupled to time-of-flight (TOF) mass spectrometry (MS). For ubiquitin, cytochrome c, and α-lactalbumin, adduction of multiple acid molecules results in no significant conformational changes to the highest and lowest charge states formed from aqueous solutions, whereas the intermediate charge states become more compact. The transition to more compact conformers for the intermediate charge states occurs with fewer bound H(2)SO(4) molecules than HClO(4) or HI molecules, suggesting ion-ion or salt-bridge interactions are stabilizing more compact forms of the gaseous protein. However, the drift time distributions for protein ions of the same net charge with the highest levels of adduction of each acid are comparable, indicating that these protein ions all adopt similarly compact conformations or families of conformers. No significant change in conformation is observed upon the adduction of multiple acid molecules to charge states of lysozyme. These results show that the attachment of HClO(4), HI, or H(2)SO(4) to multiply protonated proteins can induce compact conformations in the resulting gas-phase protein ions. In contrast, differing Hofmeister effects are observed for the corresponding anions in solution at higher concentrations.

Investigation of the molecular origins of protein-arginine methyltransferase I (PRMT1) product specificity reveals a role for two conserved methionine residues

Protein-arginine methyltransferases aid in the regulation of many biological processes by methylating specific arginyl groups within targeted proteins. The varied nature of the response to methylation is due in part to the diverse product specificity displayed by the protein-arginine methyltransferases. In addition to site location within a protein, biological response is also determined by the degree (mono-/dimethylation) and type of arginine dimethylation (asymmetric/symmetric). Here, we have identified two strictly conserved methionine residues in the PRMT1 active site that are not only important for activity but also control substrate specificity. Mutation of Met-155 or Met-48 results in a loss in activity and a change in distribution of mono- and dimethylated products. The altered substrate specificity of M155A and M48L mutants is also evidenced by automethylation. Investigation into the mechanistic basis of altered substrate recognition led us to consider each methyl transfer step separately. Single turnover experiments reveal that the rate of transfer of the second methyl group is much slower than transfer of the first methyl group in M48L, especially for arginine residues located in the center of the peptide substrate where turnover of the monomethylated species is negligible. Thus, altered product specificity in M48L originates from the differential effect of the mutation on the two rates. Characterization of the two active-site methionines provides the first insight into how the PRMT1 active site is engineered to control product specificity.

Effects of supercharging reagents on noncovalent complex structure in electrospray ionization from aqueous solutions

The effects of two supercharging reagents, m-nitrobenzyl alcohol (m-NBA) and sulfolane, on the charge-state distributions and conformations of myoglobin ions formed by electrospray ionization were investigated. Addition of 0.4% m-NBA to aqueous ammonium acetate solutions of myoglobin results in an increase in the maximum charge state from 9+ to 19+, and an increase in the average charge state from 7.9+ to 11.7+, compared with solutions without m-NBA. The extent of supercharging with sulfolane on a per mole basis is lower than that with m-NBA, but comparable charging was obtained at higher concentration. Arrival time distributions obtained from traveling wave ion mobility spectrometry show that the higher charge state ions that are formed with these supercharging reagents are significantly more unfolded than lower charge state ions. Results from circular dichroism spectroscopy show that sulfolane can act as chemical denaturant, destabilizing myoglobin by ∼1.5 kcal/mol/M at 25°C. Because these supercharging reagents have low vapor pressures, aqueous droplets are preferentially enriched in these reagents as evaporation occurs. Less evaporative cooling will occur after the droplets are substantially enriched in the low volatility supercharging reagent, and the droplet temperature should be higher compared with when these reagents are not present. Protein unfolding induced by chemical and/or thermal denaturation in the electrospray droplet appears to be the primary origin of the enhanced charging observed for noncovalent protein complexes formed from aqueous solutions that contain these supercharging reagents, although other factors almost certainly influence the extent of charging as well.

Mechanism, localization and cure of atrial arrhythmias occurring after a new intraoperative endocardial radiofrequency ablation procedure for atrial fibrillation

OBJECTIVES

The purpose of this study was to test a new pattern of radiofrequency ablation for atrial fibrillation (AFib) intended to optimize atrial activation, and to demonstrate the usefulness of catheter techniques for mapping and ablation of postoperative atrial arrhythmias.

BACKGROUND

Linear radiofrequency lesions have been used to cure AFib, but the optimal pattern of lesions is unknown and postoperative tachyarrhythmias are common.

METHODS

A radial pattern of linear radiofrequency lesions (Star) was made using an endocardial open surgical approach in 25 patients. Postoperative arrhythmias were induced and characterized during electrophysiological studies in 15 patients.

RESULTS

The AFib was abolished in most patients (91%), but atrial flutter (AFlut) occurred in 96% of patients postoperatively. At postoperative electrophysiological studies, 37 flutter morphologies were studied in 15 patients (46% spontaneous, cycle length [CL] 223 +/- 25 ms). Seven mechanisms (lesions discontinuity, n = 6; focal mechanism, n = 1) of AFlut were characterized in six patients. In these cases, flutter was abolished using further catheter radiofrequency ablation. In the remaining cases, flutter was usually localized to an area involving the interatrial septum, but no critical isthmus was identified for ablation. After 16 +/-10 months, 15 patients (65%) were asymptomatic with (n = 3) or without (n = 12) antiarrhythmic medications. Eight (35%) patients had persistent arrhythmias. Postoperative atrial electrical activation was near physiological.

CONCLUSIONS

The AFib maybe abolished using a radial pattern of linear endocardial radiofrequency lesions, but postoperative AFlut is common even when lesions are made under optimal conditions. Endocardial mapping techniques can be used to characterize the flutter mechanisms, thus enabling subsequent successful catheter ablation.

Effect of atrial radiofrequency ablation designed to cure atrial fibrillation on atrial mechanical function

INTRODUCTION

The effects of linear radiofrequency lesions in the atria for cure of atrial fibrillation on atrial contraction have not previously been quantified.

METHODS AND RESULTS

Atrial function was measured before and 30 +/- 24 days after a biatrial ablation procedure designed to cure atrial fibrillation in eight dogs and after a sham procedure in three dogs. Atrial mechanical function was assessed using Doppler diastolic blood flow velocities, atrial systolic pressure wave amplitude, and assessment of atrial contribution to cardiac output estimated by comparison of AV sequential pacing to ventricular pacing at the same heart rate. The mitral Doppler A/E velocity ratio was 1.03 +/- 0.45 before and 0.72 +/- 0.43 after ablation (P = 0.048). The tricuspid A/E ratio was 0.88 +/- 0.17 before and 0.71 +/- 0.12 after ablation (P = 0.04). The estimated atrial contribution to cardiac output was 18% +/- 9% before and 5% +/- 4% after ablation (P < 0.01). The left atrial systolic pressure wave amplitude was 2.8 +/- 1.5 mmHg before and 1.7 +/- 1.0 mmHg after ablation (P = 0.1). These changes were not observed in control dogs. Lesions covered 25% +/- 6% of the atrial endocardial surface.

CONCLUSION

Multiple linear radiofrequency lesions in the atria designed to cure atrial fibrillation may impair atrial contractility. Reduced atrial function is partly due to loss of atrial myocardial mass, but regional delays in atrial activation and splinting of the atria by scarring also may contribute.

Diagnosis and management of Alzheimer disease

BACKGROUND

Alzheimer disease afflicts millions of older Americans, with an estimated cost to society approaching $100 million annually. Family physicians will care for an increasing number of patients with Alzheimer disease as well as their caregivers and families.

METHODS

A comprehensive and systematic review of the literature published between 1985 and 1998 about diagnosing and treating Alzheimer disease was conducted, using "dementia," "Alzheimer's disease," and "treatment" as search strategy key words. Data and information that reported significant conclusions were critically reviewed. Potentially important new data about new agents that might be of benefit when caring for patients with Alzheimer disease are discussed.

RESULTS AND CONCLUSIONS

The primary goals when treating Alzheimer disease patients are enhancing autonomy and functional abilities and maintaining quality of life for patients and caregivers. In addition to diagnostic and pharmacologic treatment, primary care physicians will be called upon to provide nonpharmacologic support to assist with behavioral, social, and living environment problems faced by these patients and their families. The most common pharmacologic treatment is cholinesterase inhibition. Two cholinesterase inhibitors, tacrine and donepezil, are effective in treating cognitive and global function. Newer cholinesterase inhibitors should soon be available that might offer safety advantages as well as efficacy in treating behavioral and psychiatric symptoms related to Alzheimer disease. Other agents, including vitamin E, nonsteroidal anti-inflammatory drugs, estrogen, and Ginkgo biloba, are under investigation. Nonpharmacologic measures are important components in the management of Alzheimer disease. Support groups can help to diminish behavioral problems, maintain the patient's independence, and provide relief for caregivers and families.

Predictors of functional ability in geriatric rehabilitation patients

This study explored the impact that motivation, cognitive status, depression, age, and physical status have on the functional ability of older adults in a rehabilitation program. The study was based on a hypothesized model and was conducted with 200 patients on a geriatric rehabilitation unit. Structural equation modeling was done to test the hypothesized model. The average age of participants was 78 years, and the majority were female, Caucasian, unmarried, and had been admitted for rehabilitation after an orthopedic event. The data fit the hypothesized model; however, only five paths were significant. Mental status was a significant predictor of function on admission and a direct and indirect predictor of function at discharge, and diagnosis and age directly predicted function at discharge.

Patient-caregiver functional unit scale: a new scale to assess the patient-caregiver dyad

BACKGROUND AND OBJECTIVES

This study evaluated the reliability and validity of the Patient-Caregiver Functional Unit Scale (PCFUS), a new instrument to assess the stability or endurance of patient-caregiver dyads.

METHODS

Patient-caregiver dyads were recruited from a nursing home (NH) (n = 38), a comprehensive geriatric assessment program (CGA) (n = 20), and an ambulatory medical clinic (controls) (n = 85). Caregivers were eligible if they assisted, or were available to assist, the patient with personal and instrumental activities of daily living, without pay. Data were collected by interviewer-administered questionnaires. Inter-rater and test-retest reliability were evaluated among the CGA sample. Validity was assessed by comparing PCFUS scores among the NH, CGA, and control groups and by correlation of PCFUS scores with other standardized caregiver burden measures.

RESULTS

The PCFUS had excellent inter-rater and test-retest reliability. Mean PCFUS scores were significantly lower (ie, less stable patient-caregiver dyad) in NH than CGA and control caregivers. PCFUS scores were significantly associated with Burden Interview, Perceived Stress Scale, and Geriatric Depression Scale scores and risk factors for caregiver stress (eg, patient's cognitive impairment, disruptive behaviors).

CONCLUSIONS

The PCFUS is a short, easily administered measure with good reliability and validity and is applicable to clinical and research settings.

The effect of cognitive status on outcomes following rehabilitation

BACKGROUND AND OBJECTIVES

Impaired cognition is a determinant of poor recovery following a hip fracture. Because of the risk of poorer outcomes, individuals with impaired cognitive function may be refused admission into a rehabilitation program. This study considered the impact of cognitive status on functional ability over time for older adults who participate in a rehabilitation program.

METHODS

We studied a convenience sample of 200 consecutive patients who participated in an inpatient rehabilitation program following an orthopedic event. We obtained complete follow-up data on 181 participants. Baseline data were collected within 48 hours of admission and included demographics, rehabilitation diagnosis, living location prior to admission, the Mini-mental State Examination, and the Barthel Index (BI). Telephone follow-up was made at 3, 6, and 12 months after discharge from rehabilitation, and we obtained information about demographic data and functional status (BI).

RESULTS

There were no differences in the demographic characteristics of the two groups except for race; a larger percentage of African-Americans were in the impaired group. There was a statistically significant main effect of time with functional ability of all participants, increasing over the 12-month follow-up period.

CONCLUSIONS

This study suggests that rehabilitation of the older adult, both with and without cognitive impairment, can result in improvement in functional ability that is sustained over a 12-month period. Although the findings indicate that those with cognitive impairment have lower functional performance at each testing period, these individuals improved functionally during the course of rehabilitation and maintained their discharge level of functioning for 1 year after discharge.

Weight change: an indicator of caregiver stress

This study evaluated weight change and caregiver stress in 200 informal caregivers to elderly patients discharged from a rehabilitation hospital. Previous laboratory and epidemiologic studies have shown that stress predisposes to weight change. Nineteen percent of the caregivers had gained or lost at least 10 pounds since becoming caregivers. Weight change was significantly associated with higher scores on standardized measures of burden and stress (e.g., Burden Interview, Perceived Stress Scale, Geriatric Depression Scale) and with lower education, poorer self-rated health, more psychotropic medication use, and caring for patients with more ADL limitations who had been hospitalized for stroke or a frail elderly condition. Caregivers to patients with a stroke or frail elderly condition reported 2.8 times more weight change than caregivers to patients with a rehabilitation problem. These results suggest that weight change is a valid indicator of stress in caregivers, and they have public health, clinical, and research applications.

Burden among white and black caregivers to elderly adults

Racial differences in caregiver burden were evaluated among 1,062 White and 159 Black caregivers from the 1982 National Long-term Care Survey and its supplement, the National Survey of Informal Caregivers. Black caregivers performed more caregiving activities and cared for persons with greater functional and cognitive impairment. However, White caregivers reported significantly more burden in linear regression analyses, controlling for covariates. Results of separate, race-specific regression models showed that caregiver demographics (being female, spouse of the care recipient, and poorer self-rated health), caregiving activities (helps with ADLs, extra time spent caregiving, unable to leave care recipient alone), and care recipient needs (IADL limitations, cognitive impairment or proxy interview, recent hospitalization) were significantly associated with burden among White caregivers. When this model was replicated in Black caregivers, the only statistically significant variables were poorer self-rated health, caregiving activities (helps with ADLs, extra time caregiving, unable to leave care recipient alone), and cognitive impairment of the care recipient. These results underscore the importance of caregiving activities in assessments of burden among White and Black caregivers.

Avoiding polypharmacy and iatrogenesis in the nursing home

The vast majority of nursing home patients over age 65 take at least one prescription medicine, and, on average, seven drugs are concurrently prescribed for each of these patients. One result of this polypharmacy is an increased risk of iatrogenic disease. The authors discuss traditional prescribing patterns in nursing homes and how these patterns contribute to drug-drug and drug-disease interactions in nursing home patients, as well as strategies to reduce polypharmacy and iatrogenesis.

Rehabilitation of the elderly patient with arthritis

The rehabilitation of an elderly patient with arthritis involves a cooperative effort on the part of patients and their caregivers, therapists, and physicians. If treatment is begun early in the course of the disease, the onset of functional decline and disability may be delayed or prevented. It may be useful for patients to contact the American Arthritis Foundation for further information and referral to support groups. Older people with arthritis must be included at a societal decision-making level in helping plan, design, and monitor community projects where handicap access questions arise. A major problem for people with disability is often the barriers they encounter in the environment and the attitudes of society. Treatment goals should be discussed and agreed on, and education and psychologic support should be provided for patients and their families. Each case must be individually assessed and a set of tailor-made rehabilitation interventions prescribed. Rest, exercise (active or passive), joint splinting, massage, heat (moist or dry heat), cold, pharmacotherapy, joint injection, surgery, and complementary treatment modalities such as homeopathy, acupuncture, education, and psychosocial support all have their role in the rehabilitation of the elderly patient with arthritis. For most patients, the course and prognosis are excellent. In general strength, ROM, and joint function can be preserved or improved to the point that participation in normal activities of daily living is possible.

Geriatric education and practice of family practice graduates: an alumni survey

BACKGROUND

The goal of this research was to study the relationship between family practice residency training in geriatrics and subsequent postresidency geriatric practice patterns.

METHODS

We surveyed all graduates of the University of Maryland Family Practice Residency Program through 1990 to determine their attitudes toward their geriatric training and the extent of their geriatric practice. Logistic regression analysis was used to identify factors associated with 1) making house calls, 2) making weekly nursing home visits, and 3) having a practice in which more than 25% of patients were older than age 65.

RESULTS

The responses of 143 graduates were analyzed. Most respondents (58.8%) made house calls, and the majority (51%) saw nursing home patients weekly. Older respondents and those possessing Certificates of Added Qualifications in Geriatric Medicine (CAQGMs) were more likely to treat patients older than age 65. Respondents with larger nursing home practices rated their geriatric training more favorably. Multivariate logistic regression analysis found that the following factors were associated with making house calls: working in a group family practice (odds ratio [OR] = 3.88, 95% confidence interval [CI] = 2.58-5.84) and a rural practice location (OR = 2.71, 95% CI = 1.77-4.17). Physicians who had additional training after residency (OR = 0.16, 95% CI = 0.10-0.25) were less likely to make house calls. Factors associated with making weekly nursing home visits were: additional training after residency (OR = 0.31, 95% CI = 0.19-0.50) and working in a group family practice (OR = 2.43, 95% CI = 1.63-3.65). Attainment of a CAQGM was the only factor associated with having more than 25% geriatric patients in the office practice (OR = 6.00, 95% CI = 2.72-13.24).

CONCLUSIONS

Most graduates of the University of Maryland Family Practice Residency Program maintain significant geriatric practices and value geriatric training, but whether favorable training experiences influence graduates' practices is unknown. Prospective studies of family practice residents are needed to clarify the influence of geriatric curricula on residents' future clinical practices.

A case of neurofibromatosis associated with a coronary artery aneurysm and myocardial infarction

Aneurysms of the aorta, vertebral arteries, carotid artery, thyrocervical trunk, and mesenteric and celiac arteries have been described in patients with neurofibromatosis. These aneurysms may have part of the vessel wall replaced by neurofibromatosis tissue. One previous case reports a coronary artery aneurysm in a patient with neurofibromatosis who suffered a myocardial infarction due to thrombosis formation within the aneurysm. We document a second case of aneurysmal dilatation of a coronary artery in a patient with neurofibromatosis. This patient also had a myocardial infarction in a vascular distribution not involved by the aneurysm. The vascular changes associated with neurofibromatosis are reviewed. Aneurysmal dilatation of the coronary arteries may be a further vascular manifestation of this condition.

Advance directives among patients in a house call program

BACKGROUND

Advance medical directives (the living will and the durable power of attorney) provide a means for competent persons to influence treatment decisions in the event of serious illness and loss of competence. Advance directives among elderly homebound patients.

METHODS

In a house call program for 120 elderly patients, a standardized telephone interview was conducted with 116 patients or their caregivers. They were asked whether they had a will, a living will, or had assigned a durable power of attorney. Those without advance directives were asked whether they knew what each directive was. Demographic and medical data were assessed by interview and chart review.

RESULTS

More than 60 percent of the patients knew about the durable power of attorney, and more than one-half had assigned a durable power of attorney. About one-third knew about living wills, but only 5 percent had one. One-third of the patients had a will.

CONCLUSIONS

Advance directives are important mechanisms whereby patients can extend autonomy over the circumstances of dying. Physicians and patients should consider and discuss the issues that surround treatment in the event of terminal illness or permanent unconsciousness.

Group G streptococcal infection in an elderly patient

It is only recently that GGS infections have been reported in the literature. These infections are rare, but they are serious when they occur. The organism is not very virulent, and serious infections occur only in patients who are immunocompromised, have some serious underlying disease such as cancer or intravenous drug abuse, or are at the extremes of age. I have described a fatal case of GGS meningitis and endocarditis in a previously healthy 84-year-old who had obtundation, irritability, and cellulitis. Many of the separately reported characteristics of serious GGS infections were present together in this case.

Pancytopenia associated with hypothermia

This is the first report of pancytopenia associated with moderate hypothermia occurring in an elderly patient, where no other etiologic or associated factors could account for the hematologic abnormalities found. Reversible pancytopenia should be added to the list of hematologic abnormalities that can be seen in patients with hypothermia.

Vitamin/mineral supplement use by geriatric outpatients in the United Kingdom

Many elderly people in the United States take vitamin/mineral supplements, but little is known about supplement use by the elderly in the United Kingdom. Among 203 patients referred to a geriatric outpatient clinic in Britain, 28% used supplements during the last year. Most supplement users consumed them daily and had used them for over a year. Multivitamins were the most frequent type of supplement taken, followed by Iron, B Vitamins, Vitamin C, and Vitamin E. The primary reasons for supplement use were for more energy, treating illness, and feeling stronger.

Vitamin/mineral supplement use among general practice patients in the United Kingdom

Many patients take vitamin/mineral supplements, sometimes in doses which may cause toxicity. A survey of 186 patients in one general practice showed that 44% consumed supplements; almost half of these took them daily, and over half had taken them for longer than a year. Younger patients were more likely to take vitamins than older ones. Multivitamins were the most frequently used supplement, followed by iron and vitamin C. Major reasons patients cited for supplement use were to ensure good nutrition, to prevent illness, and for tiredness/fatigue. Patients were most influenced in their decision to take vitamins by family and friends rather than by doctors. General practitioners may find it valuable to include questions about vitamin/mineral supplement use in the medical history.

Alternate drugs

It is important to consider a number of factors when deciding on drug therapy for elderly patients. The principles of efficacy, side effect profile, ease of administration, interaction with other drugs or concomitant illness, cost, and constant reevaluation of the need for continued treatment should be remembered for any treatment. In many cases the ideal drug may be initially no drug at all. A number of alternative drugs are available for most conditions, and the drug of choice for the elderly may actually be one of these alternative agents. We have attempted to consider these basic principles as they may be applied in making a decision for ideal drug therapy and for alternative therapies for elderly patients.

The medical evaluation of the elderly preoperative patient

Improvements in anesthesia and surgical techniques have greatly reduced the perioperative mortality and morbidity of elderly patients. Mortality is more closely correlated with pathology, type of surgery, and duration of anesthesia rather than with age. Particular attention should be directed toward cardiac and pulmonary status, because operative mortality and morbidity is related, for the most part, to cardiovascular and pulmonary complications. Postoperatively, the occurrence of pulmonary emboli and painless myocardial infarctions is more common in this age group. Elderly patients are more often confused postoperatively owing to the residual effect of anesthetics, analgesics, fever, and electrolyte disturbances. The stress of surgery and unfamiliar surroundings are also frequent precipitating causes. Orthostatic blood pressure and pulse readings should be checked before ambulating elderly patients who have been at bed rest for more than 2 to 3 days because of the frequent occurrence of orthostatic hypotension. Pressure sores, incontinence, and aspiration pneumonia may also occur owing to immobility. The elderly patient's functional status and mental status may be enhanced by simple encouragement, early mobilization, and by social interaction. It is not possible to precisely define the risks of proposed procedure, nor can the physician eliminate all risks from a surgical procedure. The risks a particular patient is subjected to depend on the complex interplay of the preoperative medical condition of the patient, the type of surgery proposed, and the skill and expertise of the anesthesiologist and surgeon. We must strive to achieve the goal of bringing our patient to the operating room in the best possible condition in the time available.

Sleep disorders in the elderly

Many elderly complain of serious difficulty getting to sleep or staying asleep. Sleep physiology changes with age. Furthermore, medical conditions that may affect sleep and serious pathologic sleep disorders are more prevalent among the elderly. Treatment should be directed toward any identified underlying condition after thorough evaluation by history, examination, and in certain instances, referral to a sleep disorders center.

Changes in free fatty acids, phospholipids, and cholesterol following impact injury to the rat spinal cord

Free fatty acids (FFA), phospholipid, and cholesterol levels were measured in spinal cord samples from rats subjected to low (25 g-cm), moderate (50 g-cm), or severe (100 g-cm) impact trauma to the T10 spinal segment. All degrees of injury caused early (15 min) declines in total phospholipids after trauma; phospholipid levels remained significantly below controls in rats subjected to moderate and severe injuries for up to 3 days, whereas phospholipids had returned to baseline values by 4 hr in the low injury group. Rapid and persistent decreases in cholesterol levels were observed for all injury groups. Severe trauma was associated with biphasic increases in FFA levels: levels were elevated at 5 and 15 min post-trauma and had declined by 30 min; a second elevation was observed at 1 hr, progressively increasing to reach a maximum at 24 hr, before declining over the next 6 days. Low and moderate injuries caused similar early total FFA increases; later increases were significantly smaller than in the severely injured group. Among the free fatty acids, significant increases were observed in palmitate, stearate, oleate, linoleate, linolenate, arachidonate, and docosahexaenoate. These findings indicate that traumatic spinal cord injury results in early, transient, postinjury membrane phospholipid hydrolysis, the magnitude of which is relatively independent of the severity of injury. More delayed and sustained lipid hydrolysis also occurs after trauma, the magnitude of which is related to the severity of injury.

Effect of impact trauma on neurotransmitter and nonneurotransmitter amino acids in rat spinal cord

N-Methyl-D-aspartate (NMDA) administration exacerbates neurological dysfunction after traumatic spinal cord injury in rats, whereas NMDA antagonists improve outcome in this model. These observations suggest that release of excitatory amino acids contributes to secondary tissue damage after traumatic spinal cord injury. To further examine this hypothesis, concentrations of free amino acids were measured in spinal cord samples from anesthetized rats subjected to various degrees of impact trauma to the T9 spinal segment. Levels of excitatory and inhibitory neurotransmitter amino acids [gamma-aminobutyric acid (GABA), glutamate, aspartate, glycine, taurine] and levels of nonneurotransmitter amino acids (asparagine, glutamine, alanine, threonine, serine) were determined at 5 min, 4 h, and 24 h posttrauma. Uninjured surgical (laminectomy) control animals showed modest but significant declines in aspartate and glutamate levels, but not in other amino acids, at all time points. In injured animals, the excitatory amino acids glutamate and aspartate were significantly decreased by 5 min posttrauma, and remained depressed at 4 h and 24 h as compared with corresponding laminectomy controls. In contrast, the inhibitory amino acids, glycine, GABA, and taurine, were decreased at 5 min postinjury, had partially recovered at 4 h, and were almost fully recovered at 24 h. The nonneurotransmitter amino acids were unchanged at 5 min posttrauma and significantly increased at 4 h, with partial recovery at 24 h. At 4 h postinjury, severe trauma caused significantly greater decreases in aspartate and glutamate than did either mild or moderate injury. These findings are consistent with the postulated role of excitatory amino acids in CNS trauma.

Anemia in the elderly

Controversy exists about the occurrence of an age-related decline in hematologic parameters. The etiology of anemia in elderly patients is often confounded by chronic and inapparent disease. The diagnosis is assisted by knowledge of the clues to the causes of hypoproliferative anemia, ineffective hematopoiesis and hemolysis.

Rehabilitation in the elderly

Prevention of disease should be every physician's goal, however, when primary or secondary prevention fail, rehabilitation of the patient becomes an additional goal. Elderly patient can be as successfully rehabilitated as younger patients, but their special needs are most successfully met by a multidisciplinary team. Almost every patient with a disability warrants a trial of rehabilitation aimed toward placing the patient in the least restrictive environment possible. Rehabilitation is especially useful in patients with arthritis, and following stroke, joint replacement, and amputation.