159 BARRIERS AND FACILITATORS TO IMPLEMENTING NON-PHARMACOLOGICAL STRATEGIES TO MANAGE RESPONSIVE BEHAVIOURS OF NURSING HOME RESIDENTS WITH DEMENTIA

Background

Many nursing home residents with dementia exhibit responsive behaviours including agitation and aggression. Psychotropic drugs are often prescribed to manage responsive behaviours but increase the rate of falls, strokes and death in residents with dementia. Therefore, the aim of this research is to conceptualise the barriers and facilitators to implementing non-pharmacological strategies to manage responsive behaviours.

Methods

Twenty-five interviews were conducted with nursing home managers, nurses and healthcare assistants from twenty-one private and voluntary nursing homes. Reflexive thematic analysis was used to conceptualise the barriers and facilitators to implementing non-pharmacological strategies to manage responsive behaviours. Ethical approval was obtained from the University Research Ethics Committee (Ref. FHMREC20091). All participants provided written informed consent.

Results

Three themes were constructed conceptualising the barriers and facilitators to taking a non-pharmacological approach to manage responsive behaviours. Strong leadership, specialised training in gerontology or dementia care and retention of staff long term supported the development of trusting relationships with residents. Treating residents with dementia with love and respect while providing meaningful activities enhanced resident’s self-esteem, facilitating a non-pharmacological approach to managing responsive behaviours. In addition, the engagement of families in residents’ care was found to be a powerful facilitator. However, sub-optimal teamwork between nurses and healthcare assistants and a lack of multidisciplinary collaboration posed barriers to taking a non-pharmacological approach to behaviour management. Furthermore, most healthcare assistants perceived that they were not valued, this also had a detrimental impact on residents’ care.

Conclusion

Conceptualisation of the barriers and facilitators to taking a non-pharmacological approach to manage responsive behaviours enables formulation of recommendations to address these barriers. These recommendations will assist in the development of dementia policy including the national dementia strategy, to implement sustainable non-pharmacological strategies to manage responsive behaviours of nursing home residents with dementia.

A refined risk stratification scheme for clinical stage 1 NSGCT based on evaluation of both embryonal predominance and lymphovascular invasion

BACKGROUND

Active surveillance is an increasingly accepted approach for managing patients with germ-cell tumors (GCTs) after an orchiectomy. Here we investigate a time-to-relapse stratification scheme for clinical stage 1 (CS1) nonseminoma GCT (NSGCT) patients according to factors associated with relapse and identify a group of patients with a lower frequency and longer time-to-relapse who may require an alternative surveillance strategy.

PATIENTS AND METHODS

We analyzed 266 CS1 GCT patients from the IRB-approved DFCI GCT database that exclusively underwent surveillance following orchiectomy from 1997 to 2013. We stratified NSGCT patients according to predominance of embryonal carcinoma (EmbP) and lymphovascular invasion (LVI), using a 0, 1, and 2 scoring system. Cox regression and conditional risk analysis were used to compare each NSGCT group to patients in the seminomatous germ-cell tumor (SGCT) category. Median time-to-relapse values were then calculated among those patients who underwent relapse. Relapse-free survival curves were generated using the Kaplan-Meier method.

RESULTS

Fifty (37%) NSGCT and 20 (15%) SGCT patients relapsed. The median time-to-relapse was 11.5 versus 6.3 months for the SGCT and NSGCT groups, respectively. For NSGCT patients, relapse rates were higher and median time-to-relapse faster with increasing number of risk factors (RFs). Relapse rates (%) and median time-to-relapse (months) were 25%/8.5 months, 41%/6.8 months and 78%/3.8 months for RF0, RF1 and RF2, respectively. We found a statistically significant difference between SGCT and patients with one or two RFs (P < 0.001) but not between SGCT and NSGCT RF0 (P = 0.108).

CONCLUSION

NSGCT patients grouped by a risk score system based on EmbP and LVI yielded three groups with distinct relapse patterns -and patients with neither EmbP nor LVI appear to behave similar to SGCT.

High prevalence of subtle and severe menstrual disturbances in exercising women: confirmation using daily hormone measures

BACKGROUND

The identification of subtle menstrual cycle disturbances requires daily hormone assessments. In contrast, the identification of severe menstrual disturbances, such as amenorrhea and oligomenorrhea, can be established by clinical observation. The primary purpose of this study was to determine the frequency of subtle menstrual disturbances, defined as luteal phase defects (LPD) or anovulation, in exercising women, with menstrual cycles of 26-35 days, who engage in a variety of sports, both recreational and competitive. Secondly, the prevalence of oligomenorrhea and amenorrhea was also determined via measurement of daily urinary ovarian steroids rather than self report alone.

METHODS

Menstrual status was documented by daily measurements of estrone and pregnanediol glucuronide and luteinizing hormone across two to three consecutive cycles and subsequently categorized as ovulatory (Ovul), LPD, anovulatory (Anov), oligomenorrheic (Oligo) and amenorrheic (Amen) in sedentary (Sed) and exercising (Ex) women.

RESULTS

Sed (n = 20) and Ex women (n = 67) were of similar (P > 0.05) age (26.3 +/- 0.8 years), weight (59.3 +/- 1.8 kg), body mass index (22.0 +/- 0.6 kg/m2), age of menarche (12.8 +/- 0.3 years) and gynecological maturity (13.4 +/- 0.9 years). The Sed group exercised less (P < 0.001) (96.7 +/- 39.1 versus 457.1 +/- 30.5 min/week) and had a lower peak oxygen uptake (34.4 +/- 1.4 versus 44.3 +/- 0.6 ml/kg/min) than the Ex group. Among the menstrual cycles studied in the Sed group, the prevalence of subtle menstrual disturbances was only 4.2% (2/48); 95.8% (46/48) of the observed menstrual cycles were ovulatory. This finding stands in stark contrast to that observed in the Ex group where only 50% (60/120) of the observed menstrual cycles were ovulatory and as many as 50% (60/120) were abnormal. Of the abnormal cycles in the Ex group, 29.2% (35/120) were classified as LPD (short, inadequate or both) and 20.8% (25/120) were classified as Anov. Among the cycles of Ex women with severe menstrual disturbances, 3.5% (3/86) of the cycles were Oligo and 33.7% (29/86) were Amen. No cycles of Sed women (0/20) displayed either Oligo or Amen.

CONCLUSIONS

This study suggests that approximately half of exercising women experience subtle menstrual disturbances, i.e. LPD and anovulation, and that one third of exercising women may be amenorrheic. Estimates of the prevalence of subtle menstrual disturbances in exercising women determined by the presence or absence of short or long cycles does not identify these disturbances. In light of known clinical consequences of menstrual disturbances, these findings underscore the lack of reliability of normal menstrual intervals and self report to infer menstrual status.

Spotlight on teenage pregnancy--defining the demographics and the family planning requirements

This study aims to provide a demographic analysis of teenage pregnancy and a needs-assessment for teenage family planning. A questionnaire was sent to all teenage mothers delivered in 2000 in Waterford Regional Hospital (WRH), and demographic analysis was performed. There were 118 teenage pregnancies, only 88% were primigravid, and 24% were aged <17 years. The response rate was 43%. The uptake of contraception before pregnancy was 74%, (42% using barrier methods only), and post-partum, the uptake was 98%, (12% barrier methods). The majority of teenagers (72%) prefer to attend the General Practitioner, preferably with an out-of-hours, weekday service. Teenage family planning is an area of need, particularly in the younger teen-years and following a pregnancy. We have shown how this can be addressed.

Reintroduction of the greater bilby, Macrotis lagotis (Reid) (Marsupialia : Thylacomyidae), to northern South Australia: survival, ecology and notes on reintroduction protocols

Nine bilbies were reintroduced to a 14-km2 reserve free of rabbits, cats and foxes in South Australia in April 2000. The survival, growth and ecology of the population were studied for 17 months after release by means of radio-tracking and trapping. Reproduction was continuous over the study period, with juveniles successfully recruited into the population. Home-range size of female bilbies averaged 0.18 km2 and was significantly smaller than home ranges of males, which averaged 3.16 km2. Wild-born subadults had smaller home ranges than adults. While male home ranges, and male and female home ranges overlapped considerably, females appeared to maintain areas discrete from other adult females. Bilbies showed a significant preference for dune habitat. As swale habitat appears too hard for burrow construction and males moved greater distances from diurnal burrows than females, males are likely to access food reserves that are under-used by females. Both males and females reused at least 30% of their burrows, and females displayed long-term site fidelity. The release was considered successful and suggests that despite historical damage from rabbits and stock, bilbies are able to successfully recolonise parts of their former range in arid South Australia once rabbits, cats and foxes are removed.

Ulcerative pododermatitis in a cat associated with Anatrichosoma sp

A 9-year-old castrated male Chartreaux cat was presented for an ulcerative pododermatitis of all 4 paws. A clinical exam was inconclusive and supportive therapy did not improve the condition. Histologic examination revealed an ulcerative and eosinophilic dermatitis associated with epidermal and dermal nematodes and ova consistent with the aphasmid Anatrichosoma sp. Treatment with ivermectin completely resolved the skin lesions. Anatrichosomiasis should be included in the differential diagnosis of ulcerative pododermatitis in cats, at least in the southwestern United States.

Evidence that interleukin-1beta and reactive oxygen species production play a pivotal role in stress-induced impairment of LTP in the rat dentate gyrus

Long-term potentiation (LTP) in both area CA1 and the dentate gyrus is attenuated by stress and the evidence is consistent with the view that this is a consequence of increased activation of glucocorticoid receptors, in the hippocampus, following the stress-induced increase in circulating corticosterone. It has been shown that expression of the pro-inflammatory cytokine, interleukin-1beta (IL-1beta), is increased in hippocampus in response to stress; this finding together with the observation that IL-1beta exerts an inhibitory effect on LTP, suggests that IL-1beta may play a key role in mediating this inhibitory effect of stress on LTP. In this study, we explore this possibility and report that stress is also associated with increased reactive oxygen species production. The evidence presented supports the view that this is secondary to the stress-induced increase in IL-1beta concentration, as IL-1beta increased activity of superoxide dismutase and increased reactive oxygen species accumulation in hippocampus in vitro. We report that the inhibitory effect of stress on LTP is mimicked by H2O2, which increases reactive oxygen species accumulation, and by IL-1beta, the effect of which is overcome by the antioxidant, phenylarsine oxide. The hypothesis that the stress-induced increase in reactive oxygen species production may underlie the suppression of LTP is further supported by the finding that the effect of stress is abrogated by dietary manipulation with antioxidant vitamins E and C.

The inhibitory effect of interleukin-1beta on long-term potentiation is coupled with increased activity of stress-activated protein kinases

Long-term potentiation (LTP) in perforant path-granule cell synapses is decreased in aged rats, stressed rats, and rats injected intracerebroventricularly with the proinflammatory cytokine interleukin-1beta (IL-1beta). One factor that is common to these experimental conditions is an increase in the concentration of IL-1beta in the dentate gyrus, suggesting a causal relationship between the compromise in LTP and increased IL-1beta concentration. In this study, we have investigated the downstream consequences of an increase in IL-1beta concentration and report that the reduced LTP in rats injected intracerebroventricularly with IL-1beta was accompanied by a decrease in KCl-stimulated glutamate release in synaptosomes prepared from dentate gyrus, although unstimulated glutamate release was increased. These changes were paralleled by increased activity of the stress-activated kinases, c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase. Intracerebroventricular injection of IL-1beta increased reactive oxygen species production in hippocampal tissue, whereas IL-1beta and H(2)O(2) increased activities of both JNK and p38 in vitro. Dietary manipulation with antioxidant vitamins E and C blocked the increase in reactive oxygen species production, the stimulation of JNK and p38 activity, the attenuation of glutamate release, and the IL-1beta-induced inhibitory of LTP. We propose that IL-1beta stimulates activity of stress-activated kinases, which in turn may inhibit glutamate release and result in compromised LTP and that these actions are a consequence of increased production of reactive oxygen species.

Age-related impairment in LTP is accompanied by enhanced activity of stress-activated protein kinases: analysis of underlying mechanisms

The age-related impairment in long-term potentiation in the rat dentate gyrus is coupled with an increase in the proinflammatory cytokine, interleukin-1beta (IL-1beta). It is possible that this increase in IL-1beta might be a consequence of the age-related increase in reactive oxygen species production in hippocampal tissue. In this study we set out to identify the underlying cause of the age-related increase in reactive oxygen species production and to establish whether any consequences of such a change might impact on the ability of aged rats to sustain long-term potentiation (LTP). We report that there was an age-related increase in the activity of superoxide dismutase but no parallel increases in activities of glutathione peroxidase or catalase, while age-related decreases in the concentration of the scavengers, vitamins E and C and glutathione were also observed. We propose that these compromises in antioxidative strategies may result in an increase in reactive oxygen species production. The data described indicate that IL-1beta and H2O2 increase the activity of two stress-activated mitogen-activated protein kinases, c-Jun NH2-terminal kinase (JNK) and p38 in vitro, while age-related increases in both kinases were observed. We propose that the endogenous increase in these parameters which occurs with age induces the increase in activity of the stress-activated kinases, which in turn impacts on the ability of the aged rat to sustain LTP.

Infection by Rhodococcus equi in a patient with AIDS: histological appearance mimicking Whipple's disease and Mycobacterium avium-intracellulare infection

Rhodococcus equi pneumonia with systemic dissemination is being reported increasingly in immunocompromised patients. This is the first case report of disseminated R equi infection with biopsy documented involvement of the large intestine. The patient was a 46 year old male with AIDS who was diagnosed with cavitating pneumonia involving the left lower lobe. R equi was isolated in culture from the blood and lung biopsies. Subsequently, the patient developed anaemia, diarrhoea, and occult blood in the stool. Colonoscopy revealed several colonic polyps. Histological examination of the colon biopsies showed extensive submucosal histiocytic infiltration with numerous Gram positive coccobacilli and PAS positive material in the histiocytes. Electron microscopy showed variably shaped intrahistiocytic organisms which were morphologically consistent with R equi in the specimen. Disseminated R equi infection may involve the lower gastrointestinal tract and produce inflammatory polyps with foamy macrophages which histologically resemble those seen in Whipple's disease and Mycobacterium avium-intracellulare infection.

Dietary antioxidant supplementation reverses age-related neuronal changes

Evidence suggests that reactive oxygen species in brain may play a role in the development of age-related neuronal impairments, and that the increase in the concentration of the proinflammatory cytokine, interleukin-1beta (IL-1beta), in aged brain tissue, may also be a contributory factor. In this study, we have analyzed changes in enzymatic and nonenzymatic antioxidant levels, in parallel with interleukin-1beta concentration, in cortical tissue prepared from young and aged rats. We report that there was an age-related increase in the activity of superoxide dismutase without concomitant changes in the activity of catalase or glutathione peroxidase and an age-related decrease in the concentrations of alpha-tocopherol and ascorbate. These observations, coupled with age-related increases in lipid peroxidation and interleukin-1beta concentration, are consistent with a compromised antioxidant defense in cortex of aged rats, a proposal supported by the finding that these changes were not observed in cortical tissue prepared from rats fed on a diet supplemented with alpha-tocopherol and ascorbate for 12 weeks.

Prevention of subsequent urinary tract infections in women by the use of anti-adherence antimicrobial agents: a double-blind comparison of enoxacin with co-trimoxazole

A prospective, double-blinded crossover study was carried out to test whether a brief course of antibiotic therapy could eliminate bacteria adherent to uroepithelial cells and thus prolong the interval between urinary tract infections (UTIs). Thirty-two women with frequent Gram-negative urinary tract infections were randomized to receive either co-trimoxazole or enoxacin twice a day for 10 days to treat their UTI. Their urines were collected for 30 days after the onset of their UTI and quantitatively analyzed for bacteria, antibiotics, and bacteria adherent to uroepithelial cells (UECs). A subsequent infection caused the patient to be treated with the alternative antibiotic. A third infection terminated the study. Both regimens were indistinguishable in the rate of elimination of bacteria and in their inhibition of bacterial adherence to UECs for up to five days after stopping treatment. The interval between infections was inversely correlated with the number of adherent bacteria per UEC 30 days after the onset of the first UTI. Both regimens were equally effective in preventing subsequent UTI and the effect of 10 days therapy on the inhibition of bacterial adherence to UEC's did not extend beyond five days after stopping treatment.

Disseminated cutaneous and meningeal sporotrichosis in an AIDS patient

We report the first proven case of Sporothrix meningoencephalitis in an AIDS patient. The patient had dramatic, wide-spread ulcerative and infiltrative disease with progressive meningoencephalitis in spite of amphotericin and itraconazole therapy. Sporothrix was cultured from premortem cerebrospinal fluid and seen in the meninges and in brain vessels at autopsy.

Different distributions of dystrophin and related proteins at nerve-muscle junctions

The distributions of dystrophin, 'dystrophin-related protein' (DRP) and beta-spectrin were compared with that of acetylcholine receptors (AChRs) at rat nerve-muscle junctions (NMJs) using immunofluorescence techniques. In sections, monoclonal antibodies (MAbs) to dystrophin and beta-spectrin labelled the entire sarcolemma but were concentrated at the NMJs while those to DRP labelled only NMJs. In permeabilized muscle fibres, DRP was precisely co-localized with the AChRs, whereas the zone of high density labelling of dystrophin and beta-spectrin extended 0.3-0.4 microns beyond the AChRs. Within the NMJ, the labelling of DRP appeared as a series of interconnecting lines similar to that of AChRs. However, labelling of dystrophin and beta-spectrin was consistently more punctate. These data suggest DRP is more closely associated with AChRs than are dystrophin or beta-spectrin.

Dystrophin or a "related protein" in Duchenne muscular dystrophy?

Previously we have shown low levels of dystrophin immunoreactivity in muscle from patients with DMD. According to the "frame-shift hypothesis" DMD muscle should not synthesize any dystrophin through to the C-terminus and it has been suggested that the protein detected is not dystrophin, but a related autosomal homologue. We have labelled serial sections of DMD muscle with specific monoclonal antibodies to the amino, rod and C-terminal domains of dystrophin and find labelling on the same individual fibres, allowing us to conclude that the protein detected is Xp21-encoded dystrophin. This has an impact on the interpretation of myoblast transfer experiments. The abundance (on blots) of "C-terminal dystrophin" appears lower than "rod dystrophin" in both BMD and DMD.

Dystrophin in skeletal muscle. I. Western blot analysis using a monoclonal antibody

The value of analysing dystrophin on Western blots of skeletal muscle for the differential diagnosis of Xp21 muscular dystrophies is now fairly well established. Here we describe a sensitive system based on monoclonal antibodies to dystrophin. The specificity of the antibodies was established and experiments were undertaken to identify the source of dystrophin-related protein bands which were detected on blots of normal skeletal muscle. These investigations formed a necessary preliminary study to the application of the assay to samples of muscle obtained at biopsy from patients with Duchenne and Becker muscular dystrophy.

The surgical pathology of ainhum (dactylolysis spontanea)

Ainhum (dactylolysis spontanea) is a poorly understood disease characterized by spontaneous autoamputation of the fifth toe. Its incidence is highest among blacks and in the tropical and subtropical climates. The present study is the first to present certain gross and semimicroscopic findings. Moreover, scanning electron microscopic and histochemical data are presented and these reportings are believed to be unique. Hyperkeratosis and parakeratosis, together with elongation of the epidermal rete pegs and acanthosis, are observed and these findings are associated with the presence of numerous fibroblasts and wound repair phenomena. The leukocytic infiltrate is identified as being principally of T lymphocyte type, suggesting the existence of an unknown immunologic response. Relevant intraoperative data, radiographs, and light microscopy, as well as transmission electron microscopy, have been reported in this study. The spontaneous amputation of the fifth toe, designated as dactylolysis spontanea, has no known etiology, and no treatment short of amputation. The worldwide incidence of this condition is rare. Two cases have been observed at the Baltimore Veterans Administration Medical Center in the last 5 years. One patient is in an early stage of the disease. The present study involves the single instance in which amputation was elected as the treatment of choice. Because the occurrence of ainhum (dactylolysis spontanea) is rare, discussion of the disease is lacking in medical literature. It is the intent of the present study to be the definitive analysis of clinical, surgical, and surgical-pathologic data of this rare disease. Unique applications of semimicroscopic, histochemical, and light microscopic findings, as well as transmission and electron microscopy, will be presented. Speculation as to the implications of immunologic and/or wound repair responses as implicated in ainhum needs to be explored.