Effects of residential socioeconomic polarization on high blood pressure among nursing home residents

OBJECTIVE

Neighborhood concentration of racial, income, education, and housing deprivation is known to be associated with higher rates of hypertension. The objective of this study is to examine the association between tract-level spatial social polarization and hypertension in a cohort with relatively equal access to health care, a Veterans Affairs nursing home.

METHODS

41,973 long-term care residents aged ≥65 years were matched with tract-level Indices of Concentration at the Extremes across four socioeconomic domains. We modeled high blood pressure against these indices controlling for individual-level cardiovascular confounders.

RESULTS

We found participants who had resided in the most disadvantaged quintile had a 1.10 (95% 1.01, 1.19) relative risk of high blood pressure compared to those in the other quintiles for the joint measuring race/ethnicity and income domain.

CONCLUSIONS

We achieved our objective by demonstrating that concentrated deprivation is associated with worse cardiovascular outcomes even in a population with equal access to care. Measures that jointly consider economic and racial/ethnic polarization elucidate larger disparities than single domain measures.

Statins, Mortality, and Major Adverse Cardiovascular Events Among US Veterans With Chronic Kidney Disease

Importance

There are limited data for the utility of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) and death in adults with chronic kidney disease (CKD).

Objective

To evaluate the association of statin use with all-cause mortality and major adverse cardiovascular events (MACE) among US veterans older than 65 years with CKD stages 3 to 4.

Design, Setting, and Participants

This cohort study used a target trial emulation design for statin initiation among veterans with moderate CKD (stages 3 or 4) using nested trials with a propensity weighting approach. Linked Veterans Affairs (VA) Healthcare System, Medicare, and Medicaid data were used. This study considered veterans newly diagnosed with moderate CKD between 2005 and 2015 in the VA, with follow-up through December 31, 2017. Veterans were older than 65 years, within 5 years of CKD diagnosis, had no prior ASCVD or statin use, and had at least 1 clinical visit in the year prior to trial baseline. Eligibility criteria were assessed for each nested trial, and Cox proportional hazards models with bootstrapping were run. Analysis was conducted from July 2021 to October 2023.

Exposure

Statin initiation vs none.

Main Outcomes and Measures

Primary outcome was all-cause mortality; secondary outcome was time to first MACE (myocardial infarction, transient ischemic attack, stroke, revascularization, or mortality).

Results

Included in the analysis were 14 828 veterans. Mean (SD) age at CKD diagnosis was 76.9 (8.2) years, 14 616 (99%) were men, 10 539 (72%) White, and 2568 (17%) Black. After expanding to person-trials and assessing eligibility at each baseline, there were 151 243 person-trials (14 685 individuals) of nonstatin initiators and 2924 person-trials (2924 individuals) of statin initiators included. Propensity score adjustment via overlap weighting with nonparametric bootstrapping resulted in covariate balance, with mean (SD) follow-up of 3.6 (2.7) years. The hazard ratio for all-cause mortality was 0.91 (95% CI, 0.85-0.97) comparing statin initiators to noninitiators. The hazard ratio for MACE was 0.96 (95% CI, 0.91-1.02). Results remained consistent in prespecified subgroup analyses.

Conclusions and Relevance

In this target trial emulation of statin initiation in US veterans older than 65 years with CKD stages 3 to 4 and no prior ASCVD, statin initiation was significantly associated with a lower risk of all-cause mortality but not MACE. Results should be confirmed in a randomized clinical trial.

Stakeholder Perspectives on Factors Related to Deprescribing Potentially Inappropriate Medications in Older Adults Receiving Dialysis

BACKGROUND

Potentially inappropriate medications, or medications that generally carry more risk of harm than benefit in older adults, are commonly prescribed to older adults receiving dialysis. Deprescribing, a systematic approach to reducing or stopping a medication, is a potential solution to limit potentially inappropriate medications use. Our objective was to identify clinicians and patient perspectives on factors related to deprescribing to inform design of a deprescribing program for dialysis clinics.

METHODS

We conducted rapid qualitative analysis of semistructured interviews and focus groups with clinicians (dialysis clinicians, primary care providers, and pharmacists) and patients (adults receiving hemodialysis aged 65 years or older and those aged 55-64 years who were prefrail or frail) from March 2019 to December 2020.

RESULTS

We interviewed 76 participants (53 clinicians [eight focus groups and 11 interviews] and 23 patients). Among clinicians, 24 worked in dialysis clinics, 18 worked in primary care, and 11 were pharmacists. Among patients, 13 (56%) were aged 65 years or older, 14 (61%) were Black race, and 16 (70%) reported taking at least one potentially inappropriate medication. We identified four themes (and corresponding subthemes) of contextual factors related to deprescribing potentially inappropriate medications: ( 1 ) system-level barriers to deprescribing (limited electronic medical record interoperability, time constraints and competing priorities), ( 2 ) undefined comanagement among clinicians (unclear role delineation, clinician caution about prescriber boundaries), ( 3 ) limited knowledge about potentially inappropriate medications (knowledge limitations among clinicians and patients), and ( 4 ) patients prioritize symptom control over potential harm (clinicians expect resistance to deprescribing, patient weigh risks and benefits).

CONCLUSIONS

Challenges to integration of deprescribing into dialysis clinics included siloed health systems, time constraints, comanagement behaviors, and clinician and patient knowledge and attitudes toward deprescribing.

Immunogenicity of adjuvanted versus high-dose inactivated influenza vaccines in older adults: a randomized clinical trial

BACKGROUND

Adjuvanted inactivated influenza vaccine (aIIV) and high-dose inactivated influenza vaccine (HD-IIV) are U.S.-licensed for adults aged ≥ 65 years. This study compared serum hemagglutination inhibition (HAI) antibody titers for the A(H3N2) and A(H1N1)pdm09 and B strains after trivalent aIIV3 and trivalent HD-IIV3 in an older adult population.

RESULTS

The immunogenicity population included 342 participants who received aIIV3 and 338 participants who received HD-IIV3. The proportion of participants that seroconverted to A(H3N2) vaccine strains after allV3 (112 participants [32.8%]) was inferior to the proportion of participants that seroconverted after HD-IIV3 (130 participants [38.5%]) at day 29 after vaccination (difference, - 5.8%; 95%CI, - 12.9% to 1.4%). There were no significant differences between the vaccine groups in percent seroconversion to A(H1N1)pdm09 or B vaccine strains, in percent seropositivity for any of the strains, or in post-vaccination GMT for the A(H1N1)pdm09 strain. The GMTs for the post-vaccination A(H3N2) and B strains were higher after HD-IIV than after aIIV3.

CONCLUSIONS

Overall immune responses were similar after aIIV3 and HD-IIV3. For the primary outcome, the aIIV3 seroconversion rate for H3N2 did not meet noninferiority criteria compared with HD-IIV3, but the HD-IIV3 seroconversion rate was not statistically superior to the aIIV3 seroconversion rate.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03183908.

Geriatric Syndromes and Health-Related Quality of Life in Older Adults with Chronic Kidney Disease

Key Points

In older adults with CKD, geriatric syndromes are common and are associated with reduced quality of life. Addressing geriatric syndromes could potentially improve quality of life for older adults with CKD.

Background

Geriatric syndromes, which are multifactorial conditions common in older adults, predict health-related quality of life (HRQOL). Although CKD is associated with lower HRQOL, whether geriatric syndromes contribute to HRQOL in CKD is unknown. Our objective was to compare associations of geriatric syndromes and medical conditions with HRQOL in older adults with CKD.

Methods

This was a secondary analysis of a parallel-group randomized controlled clinical trial evaluating a 12-month exercise intervention in persons 55 years or older with CKD stage 3b–4. Participants were assessed for baseline geriatric syndromes (cognitive impairment, poor appetite, dizziness, fatigue, and chronic pain) and medical conditions (diabetes, hypertension, coronary artery disease, cancer, or chronic obstructive pulmonary disease). Participants' HRQOL was assessed with the Short Form Health Survey-36 (SF-36), EuroQol 5-Dimensions 5-Level, and the EuroQol Visual Analogue Scale. We examined the cross-sectional and longitudinal associations of geriatric syndromes and medical conditions with HRQOL using multiple linear regression.

Results

Among 99 participants, the mean age was 68.0 years, 25% were female, and 62% were Black. Participants had a baseline mean of 2.0 geriatric syndromes and 2.1 medical conditions; 49% had ≥ two geriatric syndromes and ≥ two medical conditions concurrently. Sixty-seven (68%) participants underwent 12-month assessments. In models using geriatric syndromes and medical conditions as concurrent exposures, the number of geriatric syndromes was cross-sectionally associated with SF-36 scores for general health (β =−0.385) and role limitations because of physical health (β =−0.374) and physical functioning (β =−0.300, all P <0.05). The number of medical conditions was only associated with SF-36 score for role limitations because of physical health (β =−0.205).

Conclusions

In older adults with CKD stage 3b–4, geriatric syndromes are common and are associated with lower HRQOL. Addressing geriatric conditions is a potential approach to improve HRQOL for older adults with CKD.

Clinical Trial registry name and registration number:

NCT01462097 ; Registration Date–October 26, 2011.

Effect of Long-term Exercise Training on Physical Performance and Cardiorespiratory Function in Adults With CKD: A Randomized Controlled Trial

RATIONALE & OBJECTIVE

The safety and efficacy of long-term exercise training in reducing physical functional loss in older adults with advanced CKD and comorbidity is uncertain.

STUDY DESIGN

Multicenter, parallel group, randomized controlled trial.

SETTINGS & PARTICIPANTS

Adults 55 years and older with estimated glomerular filtration rate (eGFR) of 15 to <45 mL/min/1.73 m2 enrolled from centers in Baltimore and Boston.

INTERVENTION

Twelve months of in-center supervised exercise training incorporating majority aerobic but also muscle strengthening activities or a group health education control intervention, randomly assigned in 1:1 ratio.

OUTCOME

Primary outcomes were cardiorespiratory fitness and submaximal gait at 6 and 12 months quantified by peak oxygen consumption (Vo2peak) on graded exercise treadmill test and distance walked on the 6-minute walk test, respectively. Secondary outcomes were changes in lower extremity function, eGFR, albuminuria, glycemia, blood pressure, and body mass index.

RESULTS

Among 99 participants, the mean age was 68 years, 62% were African American, and the mean eGFR was 33 mL/min/1.73 m2; 59% had diabetes, and 29% had coronary artery disease. Among those randomized to exercise, 59% of exercise sessions were attended in the initial 6 months. Exercise was well tolerated without excess occurrence of adverse events. At 6 months, aerobic capacity was higher among exercise participants (17.9 ± 5.5 vs 15.9 ± 7.0 mL/kg/min, P = 0.03), but the differences were not sustained at 12 months. The 6-minute walk distance improved more in the exercise group (adjusted difference: 98 feet [P = 0.02; P = 0.03 for treatment-by-time interaction]). The exercise group had greater improvements on the Timed Up and Go Test (P = 0.04) but not the Short Physical Performance Battery (P = 0.8).

LIMITATIONS

Planned sample size was not reached. Loss to follow-up and dropout were greater than anticipated.

CONCLUSIONS

Among adults aged ≥55 years with CKD stages 3b-4 and a high level of medical comorbidity, a 12-month program of in-center aerobic and resistance exercise training was safe and associated with improvements in physical functioning.

FUNDING

Government grants (National Institutes of Health).

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT01462097.

Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden

OBJECTIVE

To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood.

METHODS

The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden.

RESULTS

The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects).

CONCLUSION

NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.

Trends in blood pressure diagnosis, treatment, and control among VA nursing home residents, 2007-2018

BACKGROUND

Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms.

METHODS

Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65 years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs.

RESULTS

The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend <0.001). Rates of BP treatment and control among residents with hypertension at admission declined slightly over time (p-values for trend <0.001) but remained high (80.3% treated in FY2017-2018, 80.1% with average BP <140/90 mmHg). The age-adjusted prevalence of chronic low BP (average <90/60 mmHg) also declined from 11.1% in FY2007-2008 to 4.7% in FY2017-2018 (p-value for trend <0.001). Persons identified as Black race or Hispanic ethnicity and those with a history of diabetes, stroke, and renal disease were less likely to have an average BP <140/90 mmHg.

CONCLUSIONS

Hypertension is well controlled in VA nursing homes, and recent trends of less intensive BP control were accompanied by a lower prevalence of chronic low BP. Nonetheless, some high-risk populations have average BP levels >140/90 mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.

Effect of Structured, Moderate Exercise on Kidney Function Decline in Sedentary Older Adults: An Ancillary Analysis of the LIFE Study Randomized Clinical Trial

Importance

Observational evidence suggests that higher physical activity is associated with slower kidney function decline; however, to our knowledge, no large trial has evaluated whether activity and exercise can ameliorate kidney function decline in older adults.

Objective

To evaluate whether a moderate-intensity exercise intervention can affect the rate of estimated glomerular filtration rate per cystatin C (eGFRCysC) change in older adults.

Design, Setting, and Participants

This ancillary analysis of the Lifestyle Interventions and Independence For Elders randomized clinical trial enrolled 1199 community-dwelling, sedentary adults aged 70 to 89 years with mobility limitations and available blood specimens. The original trial was conducted across 8 academic centers in the US from February 2010 through December 2013. Data for this study were analyzed from March 29, 2021, to February 28, 2022.

Interventions

Structured, 2-year, partially supervised, moderate-intensity physical activity and exercise (strength, flexibility) intervention compared with a health education control intervention with 2-year follow-up. Physical activity was measured by step count and minutes of moderate-intensity activity using accelerometers.

Main Outcomes and Measures

The primary outcome was change in eGFRCysC. Rapid eGFRCysC decline was defined by the high tertile threshold of 6.7%/y.

Results

Among the 1199 participants in the analysis, the mean (SD) age was 78.9 (5.2) years, and 800 (66.7%) were women. At baseline, the 2 groups were well balanced by age, comorbidity, and baseline eGFRCysC. The physical activity and exercise intervention resulted in statistically significantly lower decline in eGFRCysC over 2 years compared with the health education arm (mean difference, 0.96 mL/min/1.73 m2; 95% CI, 0.02-1.91 mL/min/1.73 m2) and lower odds of rapid eGFRCysC decline (odds ratio, 0.79; 95% CI, 0.65-0.97).

Conclusions and Relevance

Results of this ancillary analysis of a randomized clinical trial showed that when compared with health education, a physical activity and exercise intervention slowed the rate of decline in eGFRCysC among community-dwelling sedentary older adults. Clinicians should consider targeted recommendation of physical activity and moderate-intensity exercise for older adults as a treatment to slow decline in eGFRCysC.

Trial Registration

ClinicalTrials.gov Identifier: NCT01072500.

The Impact of Care Partners on the Mobility of Older Adults Receiving Hemodialysis

Rationale & Objective

Many older adults receiving hemodialysis have mobility limitations and rely on care partners, yet data are sparse regarding the support provided by care partners. Our aim was to examine how care partners support the mobility of an older adult receiving hemodialysis.

Study Design

Qualitative study.

Setting & Participants

Using purposive sampling, we recruited persons aged 60 years or more receiving maintenance hemodialysis and care partners aged 18 years or more who were providing support to an older adult receiving hemodialysis. We conducted in-person semi-structured interviews about mobility with each individual.

Analytical Approach

We conducted descriptive and focused coding of interview transcripts and employed thematic analysis. Our outcome was to describe perceived mobility supports provided by care partners using qualitative themes.

Results

We enrolled 31 older adults receiving hemodialysis (42% women, 68% Black) with a mean age of 73 ± 8 years and a mean dialysis duration of 4.6 ± 3.5 years. Of these, 87% of patients used assistive devices and 90% had care partners. We enrolled 12 care partners (75% women, 33% Black) with a mean age of 54 ± 16 years. From our patient and care partner interviews, we found three themes: (1) what care partners see, (2) what care partners do, and (3) what care partners feel. Regarding what they see, care partners witness a decline in patient mobility. Regarding what they do, care partners guide and facilitate activities and manage others who also assist. Regarding what they feel, care partners respect the patient’s autonomy but experience frustration and worry about the patient’s future mobility.

Limitations

Modest sample size; single geographic area.

Conclusions

In older adults receiving hemodialysis, care partners observe a decline in mobility and provide support for mobility. They respect the patient’s autonomy but worry about future mobility losses. Future research should incorporate care partners in interventions that address mobility in older adults receiving hemodialysis.

Pilot study of autologous fecal microbiota transplants in nursing home residents: Feasibility and safety

Introduction

Antibiotic resistant bacterial infections (ARBIs) are extremely common in nursing home residents. These infections typically occur after a course of antibiotics, which eradicate both pathological and beneficial organisms. The eradication of beneficial organisms likely facilitates subsequent ARBIs. Autologous fecal microbiota transplant (aFMT) has been proposed as a potential treatment to reduce ARBIs in nursing home residents. Our objective was to determine the feasibility and safety of aFMT in a nursing home population.

Methods

Pilot clinical trial. We evaluated feasibility as total number of stool samples collected for aFMT production and safety as the number and relatedness of serious (SAE) and non-serious adverse events (AE).

Results

We screened 468 nursing home residents aged ≥18 years for eligibility; 67 enrolled, distributed among three nursing homes. Participants were 62.7% female and 35.8% Black. Mean age was 82.2 ± 8.5 years. Thirty-three participants underwent successful stool collection. Seven participants received antibiotics; four participants underwent aFMT. There were 40 SAEs (17 deaths) and 11 AEs. In the aFMT group, there were 3 SAEs (2 deaths) and 10 AEs. All SAEs and AEs were judged unrelated to the study intervention.

Conclusions

In this pilot study of aFMT in nursing home residents, less than half were able to provide adequate stool samples for aFMT. There were no related SAEs or AEs during the study. In sum, we conclude aFMT has limited feasibility in a nursing home population due to logistic and technical challenges but is likely safe.

Trial registration

ClinicalTrials.gov Identifier: NCT03061097.

[Multimodal imaging analysis of the cyst like lesion of condyle in temporomandibular joint]

Objective: To investigate the imaging features of condylar cystic degeneration of temporomandibular joint (TMJ) by cone-beam CT (CBCT), spiral CT, MRI and radionuclide bone imaging. Methods: From January 2018 to December 2020, thirty-two patients with cyst-like lesions of condylein temporomandibular joint were examined by CBCT, spiral CT, MRI and radionuclide bone imaging at the Department of Oral and Maxillofacial Surgery in General Hospital of Chinese PLA. There were 12 males and 20 females involved, aged from 16 to 65 years with an average age of (33.9±12.5) years. The characteristics of CBCT, spiral CT, MRI and radionuclide bone imaging were analyzed. Condylar cyst like lesions were classified as type A and type B based on the presence or absence of surface bone defects. Condylar cyst like lesions were classified as type Ⅰ(yes) and type Ⅱ(no) according to the accompanying bone marrow edema-like lesions of the condyles. The incidence of condylar bone marrow edema, disc displacement and abnormal bone metabolism were analyzed. Results: A total of 64 joint images of 32 patients were included, including 34 sides with TMJ cyst-like lesion and 6 sides with multiple cyst-like lesions,the total cyst-like lesions were 42. The largest diameter of cyst-like lesion ranged from 1.0 to 12.4 mm, with an average length of (3.7± 1.8) mm. There were 24 cases of type A TMJ cyst like lesion and 10 cases of type B cyst-like lesion. The detection rate of CBCT was 95.2% (40/42) and that of spiral CT was 100% (42/42), there was no significant difference (Calibration Chi-square=0.51, P=0.474). The detection rate of nuclear magnetic resonance was 80.1% (34/42), and the detection rate of cyst-like lesions less than 2 mm was 3/11. In the cyst like lesion side, there were 9 sides with anterior disc displacement with reduction, 20 sides with anterior disc displacement without reduction. In the non-cyst like lesion side, 10 sides with anterior disc displacement with reduction and 6 sides with anterior disc displacement without reduction. There was a significant difference in the displacement of the disc between cyst-like and non-cystic lesion side (χ²=7.80, P=0.005). MRI showed that 6 cases of cystic side[17.6% (6/34)] had bone marrow edema-like lesions (all type A), 1 case of non-cyst like lesions side [3.3% (1/30)] had bone marrow edema-like lesion, there was no significant difference between cystic and non-cystic lesions (Calibration Chi-square=2.04, P=0.153). There was a significant difference between type A and B cystic lesions (Fisher exact probability method, P=0.024). Radionuclide bone imaging showed abnormal bone metabolism in 26 patients in the cyst-like lesion side and 5 patients in the non-cyst like lesion side (χ²=22.82, P<0.001). Conclusions Multi-slice Spiral CT could detect the cyst-like lesion of TMJ condyle in the early stage, which is different from the large joint. And the formation mechanism may vary from the different classifications.

[Multimodal imaging analysis of the cyst like lesion of condyle in temporomandibular joint]

Objective: To investigate the imaging features of condylar cystic degeneration of temporomandibular joint (TMJ) by cone-beam CT (CBCT), spiral CT, MRI and radionuclide bone imaging. Methods: From January 2018 to December 2020, thirty-two patients with cyst-like lesions of condylein temporomandibular joint were examined by CBCT, spiral CT, MRI and radionuclide bone imaging at the Department of Oral and Maxillofacial Surgery in General Hospital of Chinese PLA. There were 12 males and 20 females involved, aged from 16 to 65 years with an average age of (33.9±12.5) years. The characteristics of CBCT, spiral CT, MRI and radionuclide bone imaging were analyzed. Condylar cyst like lesions were classified as type A and type B based on the presence or absence of surface bone defects. Condylar cyst like lesions were classified as type Ⅰ(yes) and type Ⅱ(no) according to the accompanying bone marrow edema-like lesions of the condyles. The incidence of condylar bone marrow edema, disc displacement and abnormal bone metabolism were analyzed. Results: A total of 64 joint images of 32 patients were included, including 34 sides with TMJ cyst-like lesion and 6 sides with multiple cyst-like lesions,the total cyst-like lesions were 42. The largest diameter of cyst-like lesion ranged from 1.0 to 12.4 mm, with an average length of (3.7±1.8) mm. There were 24 cases of type A TMJ cyst like lesion and 10 cases of type B cyst-like lesion. The detection rate of CBCT was 95.2% (40/42) and that of spiral CT was 100% (42/42), there was no significant difference (Calibration Chi-square=0.51, P=0.474). The detection rate of nuclear magnetic resonance was 80.1% (34/42), and the detection rate of cyst-like lesions less than 2 mm was 3/11. In the cyst like lesion side, there were 9 sides with anterior disc displacement with reduction, 20 sides with anterior disc displacement without reduction. In the non-cyst like lesion side, 10 sides with anterior disc displacement with reduction and 6 sides with anterior disc displacement without reduction. There was a significant difference in the displacement of the disc between cyst-like and non-cystic lesion side (χ²=7.80, P=0.005). MRI showed that 6 cases of cystic side[17.6% (6/34)] had bone marrow edema-like lesions (all type A), 1 case of non-cyst like lesions side [3.3% (1/30)]had bone marrow edema-like lesion, there was no significant difference between cystic and non-cystic lesions (Calibration Chi-square=2.04, P=0.153). There was a significant difference between type A and B cystic lesions (Fisher exact probability method, P= 0.024). Radionuclide bone imaging showed abnormal bone metabolism in 26 patients in the cyst-like lesion side and 5 patients in the non-cyst like lesion side (χ²=22.82, P<0.001). Conclusions Multi-slice Spiral CT could detect the cyst-like lesion of TMJ condyle in the early stage, which is different from the large joint. And the formation mechanism may vary from the different classifications.

Mobility in Older Adults Receiving Maintenance Hemodialysis: A Qualitative Study

RATIONALE & OBJECTIVE

For older adults, maintaining mobility is a major priority, especially for those with advanced chronic diseases like kidney failure. However, our understanding of the factors affecting mobility in older adults receiving maintenance hemodialysis is limited.

STUDY DESIGN

Descriptive qualitative study.

SETTING AND PARTICIPANTS

Using purposive sampling, we recruited 1) persons aged ≥ 60 years receiving maintenance hemodialysis and 2) care partners (≥ 18 years) providing regular support to an older adult receiving hemodialysis. During a single in-person home visit, we assessed mobility using the Short Physical Performance Battery (SPPB) and conducted individual one-on-one interviews regarding important personal factors related to mobility.

ANALYTIC APPROACH

Descriptive statistics were used for demographic and SPPB data. Transcripts underwent thematic coding, informed by the International Classification of Function framework of mobility. We used conceptual content analysis to inductively extract themes and subthemes.

RESULTS

We enrolled 31 older adults receiving hemodialysis (42% female, 68% Black) with mean age of 73±8 years and mean dialysis duration of 4.6±3.5 years; mean SPPB was 3.6±2.8 points. Among 12 care partners (75% female, 33% Black), mean age was 54±16 years and mean SPPB was 10.1±2.4 points. Major themes extracted were: 1) mobility represents independence; 2) mobility is precarious; 3) limitations in mobility cause distress; 4) sources of encouragement and motivation are critical; and 5) adaptability is key.

LIMITATIONS

Modest sample from single geographic area.

CONCLUSIONS

For older adults receiving hemodialysis, mobility is severely limited and is often precarious in nature, causing distress. Older adults receiving hemodialysis and their care partners have identified sources of encouragement and motivation for mobility, and cite an adaptable mindset as important. Future studies should conceptualize mobility as a variable condition, and build upon this outlook of adaptability in the development of interventions.

Safety, Reactogenicity, and Health-Related Quality of Life After Trivalent Adjuvanted vs Trivalent High-Dose Inactivated Influenza Vaccines in Older Adults: A Randomized Clinical Trial

IMPORTANCE

Trivalent adjuvanted inactivated influenza vaccine (aIIV3) and trivalent high-dose inactivated influenza vaccine (HD-IIV3) are US-licensed for adults aged 65 years and older. Data are needed on the comparative safety, reactogenicity, and health-related quality of life (HRQOL) effects of these vaccines.

OBJECTIVE

To compare safety, reactogenicity, and changes in HRQOL scores after aIIV3 vs HD-IIV3.

DESIGN, SETTING, AND PARTICIPANTS

This randomized blinded clinical trial was a multicenter US study conducted during the 2017 to 2018 and 2018 to 2019 influenza seasons. Among 778 community-dwelling adults aged at least 65 years and assessed for eligibility, 13 were ineligible and 8 withdrew before randomization. Statistical analysis was performed from August 2019 to August 2020.

INTERVENTIONS

Intramuscular administration of aIIV3 or HD-IIV3 after age-stratification (65-79 years; ≥80 years) and randomization.

MAIN OUTCOMES AND MEASURES

Proportions of participants with moderate-to-severe injection-site pain and 14 other solicited reactions during days 1 to 8, using a noninferiority test (5% noninferiority margin), and serious adverse events (SAE) and adverse events of clinical interest (AECI), including new-onset immune-mediated conditions, during days 1 to 43. Changes in HRQOL scores before and after vaccination (days 1, 3) were also compared between study groups.

RESULTS

A total of 757 adults were randomized, 378 to receive aIIV3 and 379 to receive HD-IIV3. Of these participants, there were 420 women (55%) and 589 White individuals (78%) with a median (range) age of 72 (65-97) years. The proportion reporting moderate-to-severe injection-site pain, limiting or preventing activity, after aIIV3 (12 participants [3.2%]) (primary outcome) was noninferior compared with HD-IIV3 (22 participants [5.8%]) (difference -2.7%; 95% CI, -5.8 to 0.4). Ten reactions met noninferiority criteria for aIIV3; 4 (moderate-to-severe injection-site tenderness, arthralgia, fatigue, malaise) did not. It was inconclusive whether these 4 reactions occurred in higher proportions of participants after aIIV3. No participant sought medical care for a vaccine reaction. No AECI was observed. Nine participants had at least SAE after aIIV3 (2.4%; 95% CI,1.1% to 4.5%); 3 had at least 1 SAE after HD-IIV3 (0.8%; 95% CI, 0.2% to 2.2%). No SAE was associated with vaccination. Changes in prevaccination and postvaccination HRQOL scores were not clinically meaningful and not different between the groups.

CONCLUSIONS AND RELEVANCE

Overall safety and HRQOL findings were similar after aIIV3 and HD-IIV3, and consistent with prelicensure data. From a safety standpoint, this study's results support using either vaccine to prevent influenza in older adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03183908.

[Anatomical study of rat trigeminal motor nucleus-lateral pterygoid muscle projection pathway]

Objective: To determine the opening and closing action of the external muscle, the projection pathway of the axon terminal of trigeminal motor nucleus (Vmo) neuron to the lateral pterygoid muscle was revealed. Methods: In this study, 10 SD rats of 8 weeks old were included. The left lateral pterygoid muscle of SD rats was surgically exposed, and the wound was closed after intramuscular injection of hydroxystilbamidine/fluorogold (FG) 3-5 μl. Seven days after the operation, the experimental animals were perfused, samples collected and sectioned for immunofluorescence staining. After FG injection into the lateral pterygoid muscle, the FG reversed in the Vmo neurons. Results: In the Vmo neurons on the FG injection side (left side), a large number of FG reversed neurons were found in the corpus luteum and dendrites. These neurons were not only distributed in the dorsolateral part of the trigeminal motor nucleus that innervated the closed muscle, but also in the ventral medial portion of the trigeminal nucleus of the open muscle. Conclusions: The neuronal conduction pathway between the Vmo and the lateral pterygoid muscle innervates the lateral pterygoid muscle. The neurons are distributed both in the dorsolateral and in the nucleus of the ventral ventricle. It is concluded that the lateral pterygoid muscle involve in the jaw closing and opening movement.

NUTRITIONAL RISK STATUS, DIETARY INTAKE AND COGNITIVE PERFORMANCE IN OLDER ADULTS WITH MOTORIC COGNITIVE RISK SYNDROME

Background

Modifiable lifestyle factors such as diet are associated with cognitive decline and dementia. Greater understanding of the nutritional intake of older adults who are at increased risk for cognitive decline may allow for the development of more effective dietary interventions to prevent or delay the onset of dementia.

Objectives

The purpose of this study was to characterize the nutritional status, diet quality and individual nutritional components of older adults with motoric cognitive risk syndrome (MCR). MCR is a pre-dementia syndrome classified by slow gait speed and subjective memory impairments.

Design

Cross-sectional analysis.

Setting

A community-based senior center located in an urban setting.

Participants

Twenty-five community-dwelling older adults with MCR aged 60-89 yrs.

Measurements

Nutritional risk status was determined using the Nestle Mini Nutritional Assessment (MNA). A food frequency questionnaire was used to quantify: overall dietary quality using the Healthy Eating Index (HEI); adherence to the Mediterranean-DASH for Neurodegenerative Delay (MIND) dietary pattern; and intake of individual nutritional components shown to be protective or harmful for cognitive function in older adults. Participants completed a computerized cognitive testing battery to assess cognitive abilities.

Results

More than one third (36%) of participants were at increased risk for malnutrition. Participants at lower risk for malnutrition had better working memory (r = 0.40, p = 0.04), executive functioning (r = 0.44, p = 0.03), and overall cognition (r = 0.44, p = 0.03). While participants generally consumed a reasonable quality diet (HEI = 65.15), 48% of participants had poor adherence to a neuroprotective MIND dietary pattern. Higher intake of B-complex vitamins was associated with better task switching (r = 0.40, p ≤ 0.05) and faster processing speeds (r = 0.39, p ≤ 0.05). Higher vitamin C intake was associated with better executive functioning (r = 0.40, p ≤ 0.05).

Conclusions

Our findings suggest that a significant proportion of older adults with MCR may be at increased risk for malnutrition. While the diet quality of older adults with MCR appeared to need improvement, future studies should investigate the effects of more specific nutritional interventions, including the MIND diet, on cognition in at-risk older adults.

Effect of Losartan and Fish Oil on Plasma IL-6 and Mobility in Older Persons. The ENRGISE Pilot Randomized Clinical Trial

BACKGROUND

Low-grade chronic inflammation, characterized by elevations in plasma Interleukin-6 (IL-6), is an independent risk factor of impaired mobility in older persons. Angiotensin receptor blockers and omega-3 polyunsaturated fatty acids (ω-3) may reduce IL-6 and may potentially improve physical function. To assess the main effects of the angiotensin receptor blocker losartan and ω-3 as fish oil on IL-6 and 400 m walking speed, we conducted the ENRGISE Pilot multicenter randomized clinical trial.

METHODS

The ENRGISE Pilot enrolled participants between April 2016 and June 2017, who participated for 12 months. Participants were aged ≥70 years with mobility impairment, had IL-6 between 2.5 and 30 pg/mL, and were able to walk 400 m at baseline. Participants were randomized in three strata 2 × 2 factorial to: (i) losartan 50-100 mg/d or placebo (n = 43), (ii) fish oil 1,400-2,800 mg/d or placebo (n = 180), and (iii) with both (n = 66).

RESULTS

Two hundred eighty-nine participants were randomized (mean age 78.3 years, 47.4% women, 17.0% black). There was no effect of losartan (difference of means = -0.065 ± 0.116 [SE], 95% confidence interval [CI]: -0.293-0.163, p = .58) or fish oil (-0.020 ± 0.077, 95% CI: -0.171-0.132, p = .80) on the log of IL-6. Similarly, there was no effect of losartan (-0.025 ± 0.026, 95% CI: -0.076-0.026, p = .34) or fish oil (0.010 ± 0.017, 95% CI: -0.025-0.044, p = .58) on walking speed (m/s).

CONCLUSIONS

These results do not support the use of these interventions to prevent mobility loss in older adults at risk of disability with low-grade chronic inflammation.

REGISTRATION

Clinicaltrials.gov NCT02676466.

Translating the Lifestyle Interventions and Independence for Elders Clinical Trial to Older Adults in a Real-World Community-Based Setting

BACKGROUND

The Lifestyle Interventions and Independence for Elders (LIFE) clinical trial demonstrated that a structured program of physical activity (PA) reduced mobility-disability in older adults by up to 28%. It remains unknown whether the benefits of LIFE PA can be translated to older adults at risk for mobility-disability in real-world community-based settings. To address this knowledge gap, we conducted the ENhancing independence using Group-based community interventions for healthy AGing in Elders (ENGAGE) pilot study and examined the safety, feasibility, and preliminary effectiveness of translating LIFE PA to a community-based senior center.

METHODS

Forty older adults with severe lower extremity functional limitations (age: 76.9 ± 7.3 years; body mass index: 32.7 ± 8 kg/m2; 85% female; short physical performance battery score: 6.3 ± 2.2) were randomized to 24 weeks of PA or a health education control intervention.

RESULTS

Community-based PA was safe (serious adverse events: PA vs health education, 0:2; nonserious adverse events: PA vs health education, 3:1) and participants successfully adhered to the PA intervention (65.2%). Compared to health education, PA participants who attended ≥25% of scheduled visits had meaningful and sustained short physical performance battery improvements at follow-up (between group short physical performance battery score differences: ~0.7 units).

CONCLUSIONS

ENGAGE has demonstrated the preliminary safety, feasibility, and effectiveness of LIFE PA in a real-world community-based setting. Larger-scale translational studies are needed to further disseminate the benefits of LIFE PA to vulnerable older adults in a variety of community-based settings.

Effect of 24-month physical activity on cognitive frailty and the role of inflammation: the LIFE randomized clinical trial

BACKGROUND

Whether physical activity can reduce cognitive frailty-a relatively new "compound" phenotype proposed in 2013-and whether the effect of physical activity differs based on levels of inflammation are unknown. Therefore, this study aimed to evaluate the effect of physical activity on cognitive frailty and whether baseline interleukin-6 (IL-6) levels modified this effect.

METHODS

We used data from the Lifestyle Interventions and Independence for Elders (LIFE) Study, a multicenter, single-blinded randomized trial conducted at eight US field centers between February 2010 and December 2013. The main outcome was cognitive frailty at 24 months, expressed as an ordinal variable based on the six combinations of its two components: frailty (non-frail, pre-frail, and frail) and mild cognitive impairment (yes, no). Frailty and cognition were assessed by the Study of Osteoporotic Fractures (SOF) index and the Modified Mini-Mental State Examination (3MSE) scale, respectively. Plasma IL-6 was measured at baseline. Of the 1635 original randomized sedentary participants (70-89 years), this study included 1298 participants with data on both cognitive frailty and IL-6 assessments at baseline.

RESULTS

After adjusting for field center, sex, and baseline levels of cognitive frailty, the ordinal logistic regression model revealed that participants in the physical activity group had 21% lower odds (odds ratio, 0.79; 95% confidence interval, 0.64-0.98) of worsening cognitive frailty over 24 months than those in the health education group. The effect of physical activity on cognitive frailty did not differ according to baseline IL-6 levels (P for interaction = 0.919). The results did not change after additional adjustment for IL-6 subgroups and the inverse probability of remaining in the study. Comparable results were observed according to age, sex, ethnicity/race, and short physical performance battery score (P for interaction = 0.835, 0.536, 0.934, and 0.458, respectively).

CONCLUSIONS

A 24-month structured, moderate-intensity physical activity program reduced cognitive frailty compared with a health education program in sedentary older persons, and this beneficial effect did not differ according to baseline levels of inflammatory biomarker IL-6. These findings suggest that the new cognitive frailty construct is modifiable and highlight the potential of targeting cognitive frailty for promoting healthy aging.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01072500.

Effect of Physical Activity on Frailty: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Limited evidence suggests that physical activity may prevent frailty and associated negative outcomes in older adults. Definitive data from large long-term randomized trials are lacking.

OBJECTIVE

To determine whether a long-term, structured, moderate-intensity physical activity program is associated with a lower risk for frailty and whether frailty status alters the effect of physical activity on the reduction in major mobility disability (MMD) risk.

DESIGN

Multicenter, single-blind, randomized trial.

SETTING

8 centers in the United States.

PARTICIPANTS

1635 community-dwelling adults, aged 70 to 89 years, with functional limitations.

INTERVENTION

A structured, moderate-intensity physical activity program incorporating aerobic, resistance, and flexibility activities or a health education program consisting of workshops and stretching exercises.

MEASUREMENTS

Frailty, as defined by the SOF (Study of Osteoporotic Fractures) index, at baseline and 6, 12, and 24 months, and MMD, defined as the inability to walk 400 m, for up to 3.5 years.

RESULTS

Over 24 months of follow-up, the risk for frailty (n = 1623) was not statistically significantly different in the physical activity versus the health education group (adjusted prevalence difference, -0.021 [95% CI, -0.049 to 0.007]). Among the 3 criteria of the SOF index, the physical activity intervention was associated with improvement in the inability to rise from a chair (adjusted prevalence difference, -0.050 [CI, -0.081 to -0.020]). Baseline frailty status did not modify the effect of physical activity on reducing incident MMD (P for interaction = 0.91).

LIMITATION

Frailty status was neither an entry criterion nor a randomization stratum.

CONCLUSION

A structured, moderate-intensity physical activity program was not associated with a reduced risk for frailty over 2 years among sedentary, community-dwelling older adults. The beneficial effect of physical activity on the incidence of MMD did not differ between frail and nonfrail participants.

PRIMARY FUNDING SOURCE

National Institute on Aging, National Institutes of Health.

[Proton nuclear magnetic resonance spectroscopy recognition of metabolic patterns in fecal extracts for early diagnosis of colorectal cancer]

Objective: To characterize the metabolic " fingerprint" of fecal extracts for diagnosis of early-stage colorectal cancer(CRC)using proton nuclear magnetic resonance spectroscopy(¹H-NMR)-based metabolomics coupled with pattern recognition. Methods: From January 2014 to December 2014, we collected fecal samples at the Second Affiliated Hospital of Shantou University Medical College, from 25 patients with colorectal adenomas(CR-Ad), 20 with stage Ⅰ/Ⅱ CRC, and 32 healthy controls(HCs). The patients were diagnosed by histopathology. No subjects had any complicating diseases. HCs showed no abnormalities from blood tests, endoscopic examination, diagnostic imaging, and/or medical interviews. We excluded participants who used antibiotics, NSAIDS, statins, or probiotics within two months of study participation, and any patients who underwent chemotherapy or radiation treatments prior to surgery. We used orthogonal partial least-squares-discriminant analysis(OPLS-DA)for pattern recognition(dimension reduction)on ¹H-NMR processed data(¹H frequency of 400.13 MHz), to find metabolic differences among CR-Ad, carcinoma and HC fecal samples; and receiver operating characteristic(ROC)analysis to determine the diagnostic value of the fecal metabolic biomarkers. Results: Fecal samples were collected from 20 patients with Stage Ⅰ/Ⅱ CRC(11 M, 9 F, median age(52±13)years), 25 with CR-Ad(14 M, 11 F, median age(53 ± 11)years)and 32 HCs(15 M, 17 F, median age(53 ± 14)years). OPLS-DA clearly distinguished CR-Ad and stage Ⅰ/Ⅱ CRC from HC samples, based on their metabolomic profiles. Relative signal intensities in HCs were significantly lower than in the cancer patients for butyrate(HC: 23.0±6.0; CR-Ad: 18.0±5.0; CRC: 14.0±6.0; Z=-2.07, P=0.008), acetate(HC: 45.0±11.0; CR-Ad: 31.0±11.0; CRC: 24.0±8.0; Z=- 2.32, P=0.011), propionate(HC: 26.0 ± 7.0; CR-Ad: 22.0 ± 6.0; CRC: 19.0 ± 5.0; Z=- 2.43, P=0.032), glucose(HC: 37.0±7.0; CR-Ad: 31.0±7.0; CRC: 26.0±8.0; Z=-2.07, P=0.044)and glutamine(HC: 4.5±2.0; CR-Ad: 4.9 ± 1.0; CRC: 5.4 ± 1.0; Z=2.21, P=0.044). However, relative signal intensities in HCs were significantly higher than in patients for lactate(HC: 4.8±1.0; CR-Ad: 6.9±2.0; CRC: 4.8± 1.0; Z=2.02, P= 0.038), glutamate(HC: 3.2 ± 2.0; CR-Ad: 4.9 ± 1.0; CRC: 3.2 ± 2.0; Z=2.21, P=0.044)and succinate(HC: 12.0±2.0; CR-Ad: 15.0±3.0; CRC: 12.0± 2.0; Z=2.25, P=0.011). Among the potential biomarkers, acetate at 1.92 ppm, and succinate at 2.41 ppm displayed relatively high area under ROC, with sensitivity and specificity both >90%, to distinguish early-stage CRC patients from HCs. Conclusion: Fecal metabolic profiles distinguish of HCs from patients with CRC patients, even in the early stages(stage Ⅰ/Ⅱ), highlighting the potential of NMR-based fecal metabolomic fingerprinting as tools for early CRC diagnosis.

The Effect of Chronic Kidney Disease on a Physical Activity Intervention: Impact on Physical Function, Adherence, and Safety

Background

Because chronic kidney disease (CKD) is associated with muscle wasting, older adults with CKD are likely to have physical function deficits. Physical activity can improve these deficits, but whether CKD attenuates the benefits is unknown. Our objective was to determine if CKD modified the effect of a physical activity intervention in older adults.

Methods

This is an exploratory analysis of the LIFE-P study, which compared a 12-month physical activity program (PA) to a successful aging education program (SA) in older adults. CKD was defined as a baseline eGFR < 60 mL/min/1.73 m². We examined the Short Physical Performance Battery (SPPB) at baseline, 6 and 12 months. Secondary outcomes included serious adverse events (SAE) and adherence to intervention frequency. Linear mixed models were adjusted for age, sex, diabetes, hypertension, CKD, intervention, site, visit, baseline SPPB, and interactions of intervention and visit and of intervention, visit, and baseline CKD.

Results

The sample included 368 participants. CKD was present in 105 (28.5%) participants with a mean eGFR of 49.2 ± 8.1 mL/min/1.73 m². Mean SPPB was 7.38 ± 1.41 in CKD participants; 7.59 ± 1.44 in those without CKD (p = 0.20). For CKD participants in PA, 12-month SPPBs increased to 8.90 (95% CI 8.32, 9.47), while PA participants without CKD increased to 8.40 (95% CI 8.01, 8.79, p = 0.43). For CKD participants in SA, 12-month SPPBs increased to 7.67 (95% CI 7.07, 8.27), while participants without CKD increased to 8.12 (95% CI 7.72, 8.52, p = 0.86). Interaction between CKD and intervention was non-significant (p = 0.88). Number and type of SAEs were not different between CKD and non-CKD participants (all p > 0.05). In PA, adherence for CKD participants was 65.5 ± 25.4%, while for those without CKD was 74.0 ± 22.2% (p = 0.12).

Conclusion

Despite lower adherence, older adults with CKD likely derive clinically meaningful benefits from physical activity with no apparent impact on safety, compared to those without CKD.

Effect of Structured Physical Activity and Nutritional Supplementation on Physical Function in Mobility-Limited Older Adults: Results from the VIVE2 Randomized Trial

OBJECTIVES

The interactions between nutritional supplementation and physical activity on changes in physical function among older adults remain unclear. The primary objective of this study was to examine the impact of nutritional supplementation plus structured physical activity on 400M walk capacity in mobility-limited older adults across two sites (Boston, USA and Stockholm, Sweden).

DESIGN

All subjects participated in a physical activity program (3x/week for 24 weeks), involving walking, strength, balance, and flexibility exercises. Subjects were randomized to a daily nutritional supplement (150kcal, 20g whey protein, 800 IU vitamin D) or placebo (30kcal, non-nutritive).

SETTING

Participants were recruited from urban communities at 2 field centers in Boston MA USA and Stockholm SWE.

PARTICIPANTS

Mobility-limited (Short Physical Performance Battery (SPPB) ≤9) and vitamin D insufficient (serum 25(OH) D 9 - 24 ng/ml) older adults were recruited for this study.

MEASUREMENTS

Primary outcome was gait speed assessed by the 400M walk.

RESULTS

149 subjects were randomized into the study (mean age=77.5±5.4; female=46.3%; mean SPPB= 7.9±1.2; mean 25(OH)D=18.7±6.4 ng/ml). Adherence across supplement and placebo groups was similar (86% and 88%, respectively), and was also similar across groups for the physical activity intervention (75% and 72%, respectively). Both groups demonstrated an improvement in gait speed with no significant difference between those who received the nutritional supplement compared to the placebo (0.071 and 0.108 m/s, respectively (p=0.06)). Similar effects in physical function were observed using the SPPB. Serum 25(OH)D increased in supplemented group compared to placebo 7.4 ng/ml versus 1.3 ng/ml respectively.

CONCLUSION

Results suggest improved gait speed following physical activity program with no further improvement with added nutritional supplementation.

Effect of Load Deflection on Corrosion Behavior of NiTi Wire

For dental orthodontic applications, NiTi wires are used under bending conditions in the oral environment for a long period. The purpose of this study was to investigate the effect of bending stress on the corrosion of NiTi wires using potentiodynamic and potentiostatic tests in artificial saliva. The results indicated that bending stress induces a higher corrosion rate of NiTi wires in passive regions. It is suggested that the passive oxide film of specimens would be damaged under bending conditions. Auger electron spectroscopic analysis showed a lower thickness of passive films on stressed NiTi wires compared with unstressed specimens in the passive region. By scanning electron microscopy, localized corrosion was observed on stressed Sentalloy specimens after a potentiodynamic test at pH 2. In conclusion, this study indicated that bending stress changed the corrosion properties and surface characteristics of NiTi wires in a simulated intra-oral environment.

Nephrolithiasis among male patients with newly diagnosed gout

INTRODUCTION

An elevated serum urate level is recognised as a cause of gouty arthritis and uric acid stone. The level of serum uric acid that accelerates kidney stone formation, however, has not yet been clarified. This study aimed to find out if a high serum urate level is associated with nephrolithiasis.

METHODS

Patients were recruited from the rheumatology clinic of Taipei City Hospital (Renai and Zhongxing branches) in Taiwan from March 2015 to February 2016. A total of 120 Chinese male patients with newly diagnosed gout and serum urate concentration of >7 mg/dL and no history of kidney stones were divided into two groups according to their serum urate level: <10 mg/dL (group 1, n=80) and ≥10 mg/dL (group 2, n=40). The mean body mass index, blood urea nitrogen level, creatinine level, urinary pH, and kidney ultrasonography were compared between the two groups.

RESULTS

There were no significant differences in blood urea nitrogen or creatinine level between the two groups. The urine pH in both groups was similar and not statistically significant. Kidney stone formation was detected via ultrasonography in 6.3% (5/80) and 82.5% (33/40) of patients in groups 1 and 2, respectively (P<0.05).

CONCLUSION

A serum urate level of ≥10 mg/dL may precipitate nephrolithiasis. Further studies are warranted to substantiate the relationship between serum urate level and kidney stone formation.

Effect of Structured Physical Activity on Respiratory Outcomes in Sedentary Elderly Adults with Mobility Limitations

OBJECTIVES

To evaluate the effect of structured physical activity on respiratory outcomes in community-dwelling elderly adults with mobility limitations.

DESIGN

Multicenter, randomized trial of physical activity vs health education, with respiratory variables prespecified as tertiary outcomes over an intervention period of 24-42 months. Physical activity included walking (goal of 150 min/week) and strength, flexibility, and balance training. Health education included workshops on topics relevant to older adults and upper extremity stretching exercises.

SETTING

Lifestyle Interventions and Independence in Elders (LIFE) Study.

PARTICIPANTS

Community-dwelling persons aged 70-89 with Short Physical Performance Battery scores less than 10 (N = 1,635).

MEASUREMENTS

Dyspnea severity (defined as moderate to severe according to a Borg index >2 immediately after a 400-m walk), forced expiratory volume in 1 second (FEV1) (<lower limit of normal (LLN) defined low breathing capacity), and maximal inspiratory pressure (MIP) (<LLN defined respiratory muscle weakness) were assessed at baseline and 6, 18, and 30 months. Hospitalization for exacerbation of obstructive airways disease (EOAD) and pneumonia was also ascertained over the 42-month follow-up period.

RESULTS

The randomized groups were similar in baseline demographics, including mean age (79) and sex (67% female). The effect of physical activity on dyspnea severity, FEV1, and MIP was no different from that of health education but was associated with higher likelihood of respiratory hospitalization, significantly for EOAD (hazard ratio (HR) = 2.34, 95% confidence interval (CI) = 1.19-4.61, P = .01) and marginally for pneumonia (HR = 1.54, 95% CI = 0.98-2.42, P = .06).

CONCLUSION

In older persons with mobility limitations, physical activity was associated with higher likelihood of respiratory hospitalization than health education, but differences in dyspnea severity, FEV1, and MIP did not accompany this effect-indicating that higher hospital use could be attributable to greater participant contact.

Biomarkers of oxidative stress are associated with frailty: the Framingham Offspring Study

Cardiovascular disease and frailty frequently occur together. Both are associated with inflammation, which may be partially triggered by oxidative stress, especially in cardiovascular disease. We investigated whether inflammatory and oxidative stress biomarkers linked to cardiovascular disease were associated with frailty and the related outcome of gait speed. We report cross-sectional associations of biomarkers and frailty assessed at Framingham Offspring Study cycle eight. Participants ≥60 years were eligible if they had information on frailty and at least one of the following: C-reactive protein, interleukin-6, tumor necrosis factor receptor 2, 8-epi-FGFα isoprostanes (isoprostanes), lipoprotein phospholipase A2 (LpPLA2) mass or activity, osteoprotegerin, intracellular adhesion molecule-1, monocyte chemoattractant protein-1 or P-selectin. Stepwise logistic models were utilized for frailty and stepwise linear models for gait speed. Covariates included age, sex, body mass index, smoking, and co-morbidities. Odds ratios (ORs) and slope estimates (B) are reported per standard deviation increase of loge-transformed biomarker. Of the 1919 participants, 142 (7 %) were frail. In a stepwise model, frailty odds increased with higher interleukin-6 (OR 1.90, 95 % CI 1.51, 2.38), isoprostanes (OR 1.46, 95 % CI 1.12, 1.92), and LpPLA2 mass (OR 1.29, 95 % CI 1.00, 1.65). Stepwise regression found that slower gait speeds were associated with interleukin-6 (B = -0.025 m/s, 95 % CI 0.04, -0.01), isoprostanes (B = -0.019, 95 % CI -0.03, -0.008), LpPLA2 mass (B = -0.016, 95 % CI -0.03, -0.004), and osteoprotegerin (B = -0.015, 95 % CI -0.03, -0.002, all p < 0.05). Interleukin-6, isoprostanes, and LpPLA2 mass were associated with greater frailty odds and slower gait speeds. Oxidative stress may be a mechanism contributing to frailty.

No increased risk of coronary heart disease for patients receiving androgen deprivation therapy for prostate cancer in Chinese/Taiwanese men

The relationship between androgen deprivation therapy (ADT) and coronary heart disease (CHD) remains controversial. Furthermore, the majority of such studies focused on Caucasian populations, and there is still a paucity of studies among Asian populations. This population-based study aimed to investigate the relationship between ADT and CHD in an ethnic Chinese (i.e., Taiwanese) population. We used data sourced from the Taiwan 'Longitudinal Health Insurance Database'. This study included 1278 patients with prostate cancer in the study group and 1278 subjects without prostate cancer in the comparison group. Each patient was individually tracked for a 3-year period to identify those who had subsequently received a diagnosis of CHD. The results showed that the incidence rate of CHD during the 3-year follow-up period was 4.69 (95% CI: 2.99-5.48) per 100 person-years and 2.67 (95% CI: 2.15-3.27) per 100 person-years for the study and comparison cohort, respectively. The Cox proportional hazard regression showed that the hazard ratio for CHD during the 3-year follow-up period for prostate cancer patients was 1.65 (95% confidence interval (CI) = 1.25-2.16) compared with comparison subjects after adjusting for patients' geographic location, monthly income, urbanization level, hypertension, diabetes, hyperlipidemia, and stroke. However, we failed to find a significant difference in the adjusted hazard of CHD during the 3-year follow-up period between prostate cancer patients who did and those who did not receive ADT (hazard ratio = 1.12, 95% CI = 0.79-1.59). We concluded that prostate cancer but not ADT was significantly associated with CHD. In addition, a common cause of prostate cancer and coronary heart disease could exist.

Effect of Structured Physical Activity on Sleep-Wake Behaviors in Sedentary Elderly Adults with Mobility Limitations

OBJECTIVES

To evaluate the effect of structured physical activity on sleep-wake behaviors in sedentary community-dwelling elderly adults with mobility limitations.

DESIGN

Multicenter, randomized trial of moderate-intensity physical activity versus health education, with sleep-wake behaviors prespecified as a tertiary outcome over a planned intervention period ranging from 24 to 30 months.

SETTING

Lifestyle Interventions and Independence for Elders Study.

PARTICIPANTS

Community-dwelling persons aged 70 to 89 who were initially sedentary and had a Short Physical Performance Battery score less than 10 (N = 1,635).

MEASUREMENTS

Sleep-wake behaviors were evaluated using the Insomnia Severity Index (ISI) (≥8 defined insomnia), Epworth Sleepiness Scale (ESS) (≥10 defined daytime drowsiness), and Pittsburgh Sleep Quality Index (PSQI) (>5 defined poor sleep quality) administered at baseline and 6, 18, and 30 months.

RESULTS

The randomized groups were similar in terms of baseline demographic variables, including mean age (79) and sex (67% female). Structured physical activity resulted in a significantly lower likelihood of having poor sleep quality (adjusted odds ratios (aOR) for PSQI >5 = 0.80, 95% confidence interval (CI) = 0.68-0.94), including fewer new cases (aOR for PSQI >5 = 0.70, 95% CI = 0.54-0.89), than health education but not in resolution of prevalent cases (aOR for PSQI ≤5 = 1.13, 95% CI = 0.90-1.43). No significant intervention effects were observed for the ISI or ESS.

CONCLUSION

Structured physical activity resulted in a lower likelihood of developing poor sleep quality (PSQI >5) over the intervention period than health education but had no effect on prevalent cases of poor sleep quality or on sleep-wake behaviors evaluated using the ISI or ESS. These results suggest that the benefit of physical activity in this sample was preventive and limited to sleep-wake behaviors evaluated using the PSQI.

Combined reduced forced expiratory volume in 1 second (FEV1) and peripheral artery disease in sedentary elders with functional limitations

OBJECTIVES

Because they are potentially modifiable and may coexist, we evaluated the combined occurrence of a reduced forced expiratory volume in 1 second (FEV1) and peripheral artery disease (PAD), including its association with exertional symptoms, physical inactivity, and impaired mobility, in sedentary elders with functional limitations.

DESIGN

Cross sectional.

SETTING

Lifestyle Interventions and Independence in Elder (LIFE) Study.

PARTICIPANTS

A total of 1307 sedentary community-dwelling persons, mean age 78.9, with functional limitations (Short Physical Performance Battery [SPPB] <10).

MEASUREMENTS

A reduced FEV1 was defined by a z-score less than -1.64 (

RESULTS

A combined reduced FEV1 and PAD was established in 6.0% (78/1307) of participants. However, among those who had a reduced FEV1, 34.2% (78/228) also had PAD, whereas 20.8% (78/375) of those who had PAD also had a reduced FEV1. The 2 combined conditions were associated with exertional dyspnea (adjusted odds ratio [adjOR] 2.59 [1.20-5.60]) and slow gait speed (adjOR 3.15 [1.72-5.75]) but not with exertional leg symptoms, high sedentary time, and moderate-to-severe mobility impairment.

CONCLUSIONS

In sedentary community-dwelling elders with functional limitations, a reduced FEV1 and PAD frequently coexisted and, in combination, were strongly associated with exertional dyspnea and slow gait speed (a frailty indicator that increases the risk of deleterious outcomes).

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Key Words

• FEV1
• mobility
• peripheral artery disease
• sedentary

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MESH Headings

• Aged
• Aged, 80 and over
• Cross-Sectional Studies
• Female
• Forced Expiratory Volume
• Gait/physiology
• Geriatric Assessment
• Humans
• Male
• Mobility Limitation
• Peripheral Vascular Diseases/physiopathology
• Sedentary Behavior
• Spirometry

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Grants

• UL1 RR029890 NCRR NIH HHS
• UL1 TR000064 NCATS NIH HHS
• R01 HL121023 NHLBI NIH HHS
• U01 AG22376 NIA NIH HHS
• P30AG21342 NIA NIH HHS
• 3U01AG022376-05A2S NIA NIH HHS
• U01 AG022376 NIA NIH HHS
• K07AG043587 NIA NIH HHS
• K07 AG043587 NIA NIH HHS
• P30 AG028740 NIA NIH HHS
• P30 AG021342 NIA NIH HHS
• UL1 TR000142 NCATS NIH HHS
• I01 CX000927 CSRD VA

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Respiratory impairment and dyspnea and their associations with physical inactivity and mobility in sedentary community-dwelling older persons

OBJECTIVES

To evaluate the prevalence of respiratory impairment and dyspnea and their associations with objectively measured physical inactivity and performance-based mobility in sedentary older persons.

DESIGN

Cross-sectional.

SETTING

Lifestyle Interventions and Independence for Elders Study.

PARTICIPANTS

Community-dwelling older persons (n = 1,635, mean age 78.9) who reported being sedentary (<20 min/wk of regular physical activity and <125 min/wk of moderate physical activity in past month).

MEASUREMENTS

Respiratory impairment was defined as low ventilatory capacity (forced expiratory volume in 1 second less than lower limit of normal (LLN)) and respiratory muscle weakness (maximal inspiratory pressure <LLN). Dyspnea was defined as moderate to severe ratings on the modified Borg index, immediately after a 400-m walk test (400-MWT). Physical inactivity was defined according to high sedentary time as the highest quartile of participants with accelerometry-measured activity of <100 counts/min. Performance-based mobility was evaluated using the Short Physical Performance Battery (≤ 7 defined as moderate to severe mobility impairment) and 400-MWT gait speed (<0.8 m/s defined as slow).

RESULTS

Prevalence rates were 17.7% for low ventilatory capacity, 14.7% for respiratory muscle weakness, 31.6% for dyspnea, 44.7% for moderate to severe mobility impairment and 43.6% for slow gait speed. Significant associations were found between low ventilatory capacity and slow gait speed (adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI) = 1.03-1.92), between respiratory muscle weakness and moderate to severe mobility impairment (aOR = 1.42, 95% CI = 1.03-1.95), and between dyspnea and high sedentary time (aOR = 1.98, 95% CI = 1.28-3.06) and slow gait speed (aOR = 1.70, 95% CI = 1.22-2.38).

CONCLUSION

Respiratory impairment and dyspnea are prevalent in sedentary older persons and are associated with objectively measured physical inactivity and poor performance-based mobility. Because they are modifiable, respiratory impairment and dyspnea should be considered in the evaluation of sedentary older persons.

The impact of sarcopenia on a physical activity intervention: the Lifestyle Interventions and Independence for Elders Pilot Study (LIFE-P)

OBJECTIVE

To determine if sarcopenia modulates the response to a physical activity intervention in functionally limited older adults.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Three academic centers.

PARTICIPANTS

Elders aged 70 to 89 years at risk for mobility disability who underwent dual-energy x-ray absorptiometry (DXA) for body composition at enrollment and follow-up at twelve months (N = 177).

INTERVENTION

Subjects participated in a physical activity program (PA) featuring aerobic, strength, balance, and flexibility training, or a successful aging (SA) educational program about healthy aging.

MEASUREMENTS

Sarcopenia as determined by measuring appendicular lean mass and adjusting for height and total body fat mass (residuals method), Short Physical Performance Battery score (SPPB), and gait speed determined on 400 meter course.

RESULTS

At twelve months, sarcopenic and non-sarcopenic subjects in PA tended to have higher mean SPPB scores (8.7±0.5 and 8.7±0.2 points) compared to sarcopenic and non-sarcopenic subjects in SA (8.3±0.5 and 8.4±0.2 points, p = 0.24 and 0.10), although the differences were not statistically significant. At twelve months, faster mean gait speeds were observed in PA: 0.93±0.4 and 0.95±0.03 meters/second in sarcopenic and non-sarcopenic PA subjects, and 0.89±0.4 and 0.91±0.03 meters/second in sarcopenic and non-sarcopenic SA subjects (p = 0.98 and 0.26), although not statistically significant. There was no difference between the sarcopenic and non-sarcopenic groups in intervention adherence or number of adverse events.

CONCLUSION

These data suggest that older adults with sarcopenia, who represent a vulnerable segment of the elder population, are capable of improvements in physical performance after a physical activity intervention.

Chronic kidney disease defined by cystatin C predicts mobility disability and changes in gait speed: the Framingham Offspring Study

BACKGROUND

As creatinine-based estimates of renal function are inaccurate in older adults, an alternative is an estimated glomerular filtration rate (eGFR(cys)) based on cystatin C. We examined the prospective association between chronic kidney disease (CKD(cys)) as determined by eGFR(cys) with the primary outcome of incident mobility disability and the secondary outcome of change in gait speed.

METHODS

Framingham Offspring Study participants older than 60 years and free of mobility disability at baseline (1998-2001) were eligible. Baseline CKD(cys) was defined as eGFR(cys) less than 60 mL/min/1.73 m(2). At follow-up (2005-2008), the outcomes of mobility disability, defined as self-reported inability to walk 1/2 mile and/or climb a flight of stairs, and gait speed were measured. Logistic and linear regression models were adjusted for age, sex, body mass index, smoking, diabetes, C reactive protein, and physical activity.

RESULTS

Of 1,226 participants, 230 (19%) had CKD(cys) at baseline. After a mean follow-up of 6.6 years, 185 (15%) developed mobility disability. Of those with CKD(cys), 60 (26%) developed mobility disability. Those with CKD(cys) had greater odds of mobility disability in the age- and sex-adjusted (odds ratio [OR] 1.91, 95% CI 1.32, 2.75) and fully adjusted (OR 1.55, 95% CI 1.05, 2.31) models compared with those without CKD(cys). In fully adjusted models, participants with CKD(cys) had greater gait speed declines than those without CKD(cys) (β = 0.07 [SE 0.02], p = .0022).

CONCLUSION

CKD(cys) was associated with higher odds of incident mobility disability and greater decline in gait speed, highlighting the loss of physical independence in elders with CKD.

Surface functionalization of Cu-Ni alloys via grafting of a bactericidal polymer for inhibiting biocorrosion by Desulfovibrio desulfuricans in anaerobic seawater

A novel surface modification technique was developed to provide a copper nickel alloy (M) surface with bactericidal and anticorrosion properties for inhibiting biocorrosion. 4-(chloromethyl)-phenyl tricholorosilane (CTS) was first coupled to the hydroxylated alloy surface to form a compact silane layer, as well as to confer the surface with chloromethyl functional groups. The latter allowed the coupling of 4-vinylpyridine (4VP) to generate the M-CTS-4VP surface with biocidal functionality. Subsequent surface graft polymerization of 4VP, in the presence of benzoyl peroxide (BPO) initiator, from the M-CTS-4VP surface produced the poly(4-vinylpyridine) (P(4VP)) grafted surface, or the M-CTS-P(4VP) surface. The pyridine nitrogen moieties on the M-CTS-P(4VP) surface were quaternized with hexylbromide to produce a high concentration of quaternary ammonium groups. Each surface functionalization step was ascertained by X-ray photoelectron spectroscopy (XPS) and static water contact angle measurements. The alloy with surface-quaternized pyridinium cation groups (N+) exhibited good bactericidal efficiency in a Desulfovibrio desulfuricans-inoculated seawater-based modified Barr's medium, as indicated by viable cell counts and fluorescence microscopy (FM) images of the surface. The anticorrosion capability of the organic layers was verified by the polarization curve and electrochemical impedance spectroscopy (EIS) measurements. In comparison, the pristine (surface hydroxylated) Cu-Ni alloy was found to be readily susceptible to biocorrosion under the same environment.

Bilateral Video-Assisted Thoracoscopic Thymectomy vs. Extended Transsternal Thymectomy in Myasthenia Gravis: A Prospective Study

The optimal approach to thymectomy remains controversial. This study is designed to prospectively compare the results between bilateral video-assisted thoracoscopic thymectomy (BVTx) and extended transsternal thymectomy (ETTx) in patients with myasthenia gravis (MG) without thymoma. Fifteen patients who had undergone BVTx and 16 patients who had undergone ETTx were compared for age, gender, severity of disease, preoperative duration of disease, operative time, intraoperative blood loss, postoperative complications, hospital stay, duration of chest tube drainage, thymic histopathology, pain perception by visual analog scale (VAS), remission and improvement rate, period of follow-up, and activities of daily living (ADL). Fisher's exact test, t test and paired t test were used for statistical analysis. BVTx had longer operative time and less intraoperative blood loss than that of the ETTx. Their remission rates and their degree of postoperative ADL improvement were not significantly different. However, the lowering of VAS was significantly greater in the sternotomy group at 3 months. All other parameters were not significantly different. No mortality was noted in the series. We consider BVTx as an effective alternative procedure to the transsternal approach for patients with nonthymomatous MG. As more and more people care about cosmetics, BVTx could become the future trend.

Apolipoprotein E in Taiwan Chinese patients with dementia

To clarify whether Alzheimer's disease (AD) and vascular dementia (VaD) share the same risk factors in Taiwan Chinese patients. Using the criteria of the NINCDS- ADRDA and NINDS-AIREN, 154 AD patients, 30 VaD patients, and 112 controls were enrolled. Their apolipoprotein E (ApoE) genes, extracted from peripheral blood leukocytes, were analyzed. The epsilon4 allele frequency was significantly higher in AD patients than in the control group. The odds ratio of carrying at least one copy of the epsilon4 allele in AD patients is 2.7 compared with control subjects. There was no significant difference between the VaD patients and the control subjects in their ApoE epsilon4 or epsilon2 allele frequency. The present study demonstrates a strong association between the ApoE epsilon4 allele and AD, but not between the ApoE epsilon4 allele and VaD. This suggests that AD and VaD do not share the same pathogenesis and deserve further investigation.

Glucose/lipid mixed substrates as a means of controlling the properties of medium chain length poly(hydroxyalkanoates)

Glucose-triacylglycerol (TAG) mixed substrates were used to modulate the physical and mechanical properties of medium-chain-length poly(hydroxyalkanoates) (mcl-PHAs). Pseudomonas resinovorans NRRL B-2649 grew and produced mcl-PHAs on glucose and TAGs (coconut oil, C; soybean oil, S) after 24 h in a shake flask culture. However, with the exception of coconut oil, maximum cell productivity was not reached in any of the cultures until 72 h post-inoculation. Here, 50:50 mixtures of glucose and coconut oil (glc/C) or glucose and soybean oil (glc/S) resulted in intermediate cell productivities with a maximum of 57% and 48% of the CDW at 72 h, respectively. In addition, mixed substrates resulted in mcl-PHAs with compositions that varied slightly over time. PHA-glc/C and PHA-glc/S were composed of 7 mol % and 8 mol % 3-hydroxydodecenoic acid (C(12:1)), respectively at 72 h. These concentrations were intermediate to the C(12:1) concentration of PHA-glc and respective PHA-TAG. Also, significant amounts of 3-hydroxytetradecanoic acid (C(14:0)), 3-hydroxytetradecenoic acid (C(14:1)), and 3-hydroxytetradecadienoic acid (C(14:2)) were present in PHA-glc/C and PHA-glc/S, which were derived from the respective TAG, as glucose resulted in almost no C(14:)(X) monomers. The molar masses of each of the polymers remained relatively constant between 24 and 96 h. At 72 h, the number-average molar masses (M(n)) of PHA-glc/C and PHA-glc/S were 178,000 and 163,000 g/mol, respectively, which were also intermediate to the M(n) of PHA-glc (225,000 g/mol) and the respective PHA-TAG (PHA-C = 153,000 g/mol; PHA-S = 75,000 g/mol). These physical differences caused variations in the mechanical properties of mcl-PHA films, thus providing a new and effective method of modifying their properties.

Neuropsychiatric symptoms of Alzheimer's disease differ in Chinese and American patients

BACKGROUND

The prevalence of Alzheimer's disease is similar across ethnic groups. To our knowledge, no comparison of behavioral symptoms has been addressed.

OBJECTIVE

This cross-sectional, retrospective, descriptive study compares neuropsychiatric symptoms of Chinese subjects with Alzheimer's disease (AD) at tertiary care centers in Taiwan and Hong Kong against Caucasian subjects in Los Angeles, California. We compared the frequency and severity of symptoms and caregiver responses to neuropsychiatric symptoms of AD using the Neuropsychiatric Inventory (NPI). We hypothesized that Chinese patients do not seek care unless they have high severity of neuropsychiatric symptoms and that Caucasian Americans do not wait for behavioral disturbances to develop before coming to medical attention.

RESULTS

The Caucasian sample had the highest mean educational level and mildest Clinical Dementia Rating (CDR) scale distributions of all four groups. Older age and lower educational levels contributed to higher CDR scale scores, which in turn correlated with higher total NPI scores. Only one of the Chinese samples had a higher frequency of severe neuropsychiatric symptoms than the Caucasian sample. Chinese caregivers reported anxiety and delusions more frequently (58.1%) than Caucasians (37.3% and 39.6%; chi(2), p < 0.01 and p < 0.05, respectively). Caucasians reported appetite changes (47.3%) and apathy (59.2%) more frequently than the Chinese samples (chi(2), p < 0.05 and p < 0.01, respectively). Caregivers at all four centers were distressed by behaviors qualified as severe.

CONCLUSION

We found support for our hypothesis, in that Chinese subjects presented during a more severe stage of dementia than American subjects, but the delay in seeking care could not be correlated with significant differences in neuropsychiatric profiles of the demented subjects. Other barriers to dementia care warrant investigation.

Rehabilitation fees, length of stay and efficiency for hospitalized stroke patients: a preliminary study based on function-related groups

The purpose of this study was to examine the relationships between severity of disability and factors such as rehabilitation fees, length of stay and efficiency for hospitalized stroke patients. One hundred and seven first-time stroke patients were studied consecutively for this study. They were recruited from a rehabilitation ward in a university medical center during 1997. Functional ability was evaluated using the Functional Independence Measure (FIM) instrument on admission and discharge. Stroke patients who presented with similar degrees of disability were put together using the admission FIM score (FIM Function-Related Groups, FIM-FRGs) for further analysis. Twenty-eight (26.2%) patients examined were categorized as severely disabled (scored 18-36), 48 (44.8%) moderately disabled (scored 37-72) and 31 (29.0%) mildly disabled (scored 73-126). The average expense on rehabilitation fees, for the average rehabilitation length of stay (LOSR) of 34.7 +/- 16.7 days, was NT$ 27,645 +/- 13,812. The FIM score improved from 56.8 +/- 24.2 on admission to 76.6 +/- 26.2 at discharge, with a rehabilitation efficiency index (EIR) of 0.7 +/- 0.7. Further analysis indicated that there were significant differences among the three disability groups on rehabilitation fees and LOSR while EIR was unaffected. The findings of this study suggest that FIM-FRGs can differentiate different rehabilitation needs in terms of rehabilitation fees and LOSR; therefore, a prospective case payment system based on FIM-FRGs is suggested for stroke rehabilitation reimbursement scheme in the future.

Alzheimer's disease: scintigraphic appearance of Tc-99m HMPAO brain spect

To investigate the value of Tc-99m hexamethylpropylene amine oxime (Tc-99m HMPAO) single photon emission computed tomography (SPECT) as a diagnostic test for Alzheimer's disease.

METHODS AND PATIENTS

Tc-99m HMPAO SPECT was performed on 140 patients and 20 controls. A final diagnosis was established for 115 patients, 58 of whom had Alzheimer's disease. The probability of AD was determined for seven scintigraphic patterns. The probability of Alzheimer's disease was 14% for patients with memory loss and normal perfusion. For patients with abnormal perfusion patterns, the probability of Alzheimer's disease was 87% with bilateral temporoparietal defects, 73% with bilateral temporoparietal defects plus additional defects, 62% with a unilateral temporoparietal defect, 33% with a frontal defect only, 0% with other large defects, and 0% with multiple small cortical defects. In 115 patients with the complaint of memory loss or cognitive abnormalities, bilateral temporoparietal hypoperfusion with or without additional hypoperfusion was more frequent than other scintigraphic patterns in patients with Alzheimer's disease. Tc-99m HMPAO SPECT offers the clinician the possibility of differentiating dementias on the basis of differences in perfusion patterns.

Apolipoprotein E polymorphism and Alzheimer's disease

We aimed to determine the association and related factors of the apolipoprotein E (ApoE) genotype and Alzheimer's disease (AD) in Taiwan. We examined ApoE genotypes in 50 Chinese patients with AD and 50 age- and sex-matched controls. The patients met the criteria of probable AD of the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and AD of the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV). There were 28 females and 22 males in the case and control groups. The mean age of onset of AD was 72. 62 years. The average interval between onset and research was 3.85 years. The frequency of ApoE epsilon 4 in the AD group was significantly higher than that in the controls (0.13 versus 0.02, p < 0.05). The odds ratio for AD in individuals with at least one ApoE epsilon 4 allele was 6.0 (95% CI 1.34 to 55.3, p < 0.001). The linear trend for AD in proportion to alleles of ApoE epsilon 4 was significant (chi 2 = 8.3, p = 0.004). The risk of ApoE epsilon 4 allele for the late-onset AD patients, males, or those who received less education was higher than that for the early-onset AD patients, females, or those who had received more education. The sensitivity of the epsilon 4 allele was 24%, the specificity 96%, the positive predictive value 86%, and the negative predictive value 56%. Our results supported that the ApoE epsilon 4 allele is related to AD in Taiwan. In addition, sex and education may play important roles in the presence of ApoE epsilon 4 allele. The epsilon 4 allele seemed helpful as an adjunct for diagnostic testing of AD.

Behavioral disorders and caregivers' reaction in Taiwanese patients with Alzheimer's disease

OBJECTIVES

To evaluate the applicability of the Chinese version of the Neuropsychiatric Inventory Scale (NPI), and to explore the neuropsychiatric manifestations of Taiwanese patients with Alzheimer's disease (AD) and caregiver distress.

METHOD

The Mini-Mental State Examination (MMSE) was administered to 95 patients with AD, and their caregivers were interviewed with the NPI. To assess the test-retest reliability of the Chinese version of the NPI, 86 caregivers underwent a second NPI 3 weeks later.

RESULTS

The Cronbach's alpha coefficient of the Chinese version of the NPI was .76. The test-retest reliabilities of frequency, severity, and caregiver burden scores were significantly correlated; overall correlations were .85 for frequency (p < .001), .82 for severity (p < .001), and .79 (p < .001) for distress. Factor analysis was carried out, and three groups, "mood and psychosis," "psychomotor regulation," and "social engagement," were found. Aberrant motor behavior was the most frequently recorded behavior; euphoria was the least. There was no significant correlation between the patient's MMSE and the caregiver distress score, except for aberrant motor activity (r = -.23, p = .03). The symptoms most frequently reported to be severely distressing to caregivers were aberrant motor activity, anxiety, agitation, and delusions.

CONCLUSIONS

These results indicate that the NPI is a reliable tool to assess behavioral disturbance and caregiver distress in Taiwanese AD patients. These findings also confirm the high prevalence of psychopathology among AD patients and the marked distress produced by many of these behaviors.

Factors influencing functional independence outcome in stroke patients after rehabilitation

The purpose of this study was to identify predictive variables relevant to functional independence outcomes for stroke patients following rehabilitation therapy. We prospectively studied 150 stroke patients consecutively admitted to the inpatient rehabilitation department of a university hospital from January 1 to December 31, 1997. Functional ability was assessed with the Functional Independence Measure (FIM) instrument on admission, on discharge of inpatient rehabilitation program, and at the 6 months follow-up visit after discharge. Severity of stroke was determined by using the Canadian Neurological Scale (CNS) on admission. In addition, major medical and sociodemographic factors were documented during hospitalization as independent variables. Of the 142 subjects surveyed, 23 (16.2%) stroke patients achieved functional independence at home when re-visited. Univariate test and multiple logistic regression analyses indicated that the significant factors affecting functional independence included age of onset, occupation, prior heart problems, the presence of medical complications, bilateral hemiplegia, and the functional ability (FIM score) and the severity of stroke (CNS score) on admission. The results of this study suggest that the admission CNS and FIM scores are useful in the prediction of functional independence outcome for stroke survivors following rehabilitation therapy.