Evaluation of an advance care planning training program for practice professionals in Japan incorporating shared decision making skills training: a prospective study of a curricular intervention

BACKGROUND

We developed a novel training program for health care professionals that incorporated shared decision making (SDM) skills training into an advance care planning (ACP) training course, the first in Japan. This study aimed to assess the training program's impact on health care professionals' knowledge, skill, attitudes, and confidence to initiate ACP.

METHODS

Using the novel Japanese educational program, we evaluated the effect of 8-month programs conducted eight community training sites of professionals who can practice ACP in a local area in Aichi Prefecture (the Aichi ACP Project). SDM skills training was provided during the workshops conducted in the ACP training course, and the participants' satisfaction and understanding of the training were assessed. After the completion of two workshops, information on SDM skill results from the training and submitted assignments were collected anonymously from the training sites.

RESULT

A total of 404 participants completed all education programs. After the first workshop, at least 95% of trainees stated that they were satisfied with the training and that it was useful for ACP practice. The evaluation of the results between the first and second workshops indicated improvement in SDM skills on some items of the SDM measures. In the second workshop, at least 90% of participants submitted implementation reports, and after the second workshop, a survey of confidence in ACP practice was administered, with responses indicating improvement. There were high levels of interest in education related to the ACP practices of oneself and others.

CONCLUSIONS

This educational program can be an effective for developing professionals who can practice ACP with SDM skills.

Adapting the patient and physician versions of the 9-item shared decision making questionnaire for other healthcare providers in Japan

BACKGROUND

In Japan, the number of older people with various health problems and difficulties in living is increasing. In order to practice patient-centered care for them, not only medical professionals but also multidisciplinary teams including care professionals and patients need to practice shared decision making (SDM) in the context of long-term care. For this reason, a measure of SDM in consultations with healthcare professionals (HCPs) other than physicians is needed. Therefore, this study aimed at adapting the patient and physician versions of the 9-item Shared Decision Making Questionnaire (SDM-Q-9, SDM-Q-Doc) for consultations with HCPs other than physicians in Japan.

METHODS

A pair of SDM measures that can be used by HCPs other than physicians, "Care SDM-Questionnaire for care receivers (SDM-C-patient)" and "Care SDM-Questionnaire for care providers (SDM-C-provider)" were prepared based on the Japanese versions of the SDM-Q-9 and SDM-Q-Doc. The internal consistency and conceptual structure of these measures were tested by secondary analysis of data from 496 participants from a workshop on SDM for different HCPs. Measurement invariance were tested by multigroup confirmatory factor analysis (CFA) for the patient (SDM-C-patient and SDM-Q-9) and provider (SDM-C-provider vs. SDM-Q-Doc) versions.

RESULTS

Both the Japanese SDM-C-patient and SDM-C-provider demonstrated high internal consistencies (Cronbach's α coefficient was 0.90 and McDonald's ω coefficient was 0.90 for both measures). CFA showed one-factor structures for both measures and original measures for physicians. Moreover, multigroup CFA showed configural and metric invariance between the novel care measures and original physician's measures.

CONCLUSIONS

Thus, the novel SDM measures for care providers in Japan as well as the original physician's measures could be used in training setting. As these measures were tested only in a training setting, their reliability and validity as new measures for care should be tested in a clinical setting in future.

Job satisfaction among physicians providing health care to the elderly in Japan: a qualitative study

BACKGROUND

Physicians' job satisfaction plays an important role in service delivery. Japan is a country with a higher number of elderly people and their medical care is a crucial issue. To date, no study has been conducted on the job satisfaction of geriatricians serving the elderly in Japan. This study aims to explore the job satisfaction and motivation of physicians providing health care to the elderly working at different hospitals in Japan.

METHODS

In-depth interview of 23 geriatric physicians was conducted and data were coded and analysed. Qualitative content analysis was conducted to identify the response themes.

RESULTS

Three major themes emerged from the analysis and they are: satisfaction as a primary care provider, career development, and suitable communication with patients. Geriatric physicians enjoy their work with inter-professional collaboration and are satisfied to provide primary health care to elderly people. Geriatrics is a very promising career to them and they enjoy the communication and empathetic doctor-patient relationship in their service.

CONCLUSIONS

Japanese physicians providing health care to the elderly are enjoying their work due to a suitable environment, multi-professional collaboration, work-life balance, and patient-doctor relationship.

[Malignant lymphoma with IgG4-related disease arising in a very elderly man]

IgG4-related disease (IgG4-RD) which is characterized by an autoimmune abnormality and elevated serum IgG4 level often presents as swelling, nodules, and the thickening of multiple organs. It typically occurs in middle-aged to elderly patients, but its pathogenesis remains unclear. Lymphadenopathy is frequently seen in IgG4-RD, which clinically requires a differential diagnosis from malignant lymphoma. We herein report a case of malignant lymphoma with IgG4-RD arising in a very elderly man.An 85-year old man with a 6-year history of autoimmune pancreatitis was diagnosed as IgG4-related hypophysitis 13 months prior to admission. Hydrocortisone was prescribed for secondary adrenal insufficiency after this presentation. At 9 months before admission, he began to suffer from central diabetes insipidus, and desmopressin was also prescribed at that time. However, 9 months later, he presented with fever, weight loss, and systemic lymphadenopathy while demonstrating elastic hardness, flexibility, and no tenderness. A pathologic specimen obtained from a right axillary lymph node biopsy revealed diffuse large B cell lymphoma. Considering his age and performance status, palliative therapy was chosen, and thus prednisolone was administered. He was transferred to another hospital to receive palliative care on the 55^th day after hospitalization.We should consider the clinical course, pathological findings, serum IgG4 level, and other involved organs in order to differentiate malignant lymphoma from IgG4-related lymphadenopathy. To our knowledge, this case is the oldest known patient to have ever been reported. Both IgG4-RD and malignant lymphoma are frequently seen in elderly people, therefore, we should deepen our knowledge of these diseases.

Relationship between blood coagulability and sense of burden among caregivers of patients with dementia

AIM

This study aimed to examine the relationship between blood coagulability and sense of burden among caregivers of patients with senile dementia of the Alzheimer type.

METHODS

A cross-sectional study was carried out involving healthy older caregivers who lived with their patients with senile dementia of the Alzheimer type. We evaluated the Zarit Burden Interview score, levels of von Willebrand factor antigen, D-dimer, thrombin-antithrombin III complex, tissue plasminogen activator/plasminogen activator inhibitor type 1 complex, number of chronic diseases, body mass index and number of medications. A linear regression model was used to estimate adjusted associations.

RESULTS

Thrombin-antithrombin III complex levels were higher in female caregivers than in male caregivers (P = 0.07). Headaches were significantly more frequent in female caregivers than in male caregivers, as assessed by a visual analog scale (P < 0.01). The number of chronic diseases and body mass index were positively associated with levels of tissue plasminogen activator/plasminogen activator inhibitor type 1 complex (P < 0.05). Similarly, the number of medications was positively associated with levels of D-dimer (P < 0.05). However, the Zarit Burden Interview score was not associated with blood coagulability (P > 0.05).

CONCLUSIONS

The present study found that the number of chronic diseases and body mass index were associated with blood coagulability, and that female caregivers were more prone to headaches and higher blood coagulability than male caregivers. These findings highlight the essential nature of health management during caregiving. The impact of caregiver burden on blood coagulability is likely to differ depending on the long-term or short-term psychological stress associated with caregiving conditions. Geriatr Gerontol Int 2019; 19: 804-808.

WITHDRAWN: Psychotherapy for depression among incurable cancer patients

BACKGROUND

The most common psychiatric diagnosis among cancer patients is depression; this diagnosis is even more common among patients with advanced cancer. Psychotherapy is a patient-preferred and promising strategy for treating depression among cancer patients. Several systematic reviews have investigated the effectiveness of psychological treatment for depression among cancer patients. However, the findings are conflicting, and no review has focused on depression among patients with incurable cancer.

OBJECTIVES

To investigate the effects of psychotherapy for treating depression among patients with advanced cancer by conducting a systematic review of randomized controlled trials (RCTs).

SEARCH METHODS

We searched the Cochrane Pain, Palliative and Supportive Care Group Register, The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and PsycINFO databases in September 2005.

SELECTION CRITERIA

All relevant RCTs comparing any kind of psychotherapy with conventional treatment for adult patients with advanced cancer were eligible for inclusion. Two independent review authors identified relevant studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the original reports using standardized data extraction forms. Two independent review authors also assessed the methodological quality of the selected studies according to the recommendations of a previous systematic review of psychological therapies for cancer patients that utilized ten internal validity indicators. The primary outcome was the standardized mean difference (SMD) of change between the baseline and immediate post-treatment scores.

MAIN RESULTS

We identified a total of ten RCTs (total of 780 participants); data from six studies were used for meta-analyses (292 patients in the psychotherapy arm and 225 patients in the control arm). Among these six studies, four studies used supportive psychotherapy, one adopted cognitive behavioural therapy, and one adopted problem-solving therapy. When compared with treatment as usual, psychotherapy was associated with a significant decrease in depression score (SMD = -0.44, 95% confidence interval [CI] = -0.08 to -0.80). None of the studies focused on patients with clinically diagnosed depression.

AUTHORS' CONCLUSIONS

Evidence from RCTs of moderate quality suggest that psychotherapy is useful for treating depressive states in advanced cancer patients. However, no evidence supports the effectiveness of psychotherapy for patients with clinically diagnosed depression.

Impaired Autonomic Nervous System Activity During Sleep in Family Caregivers of Ambulatory Dementia Patients in Japan

The number of dementia patients requiring care is rapidly increasing in Japan. Consequently, a large percentage of family members, including spouses and children of those with dementia, are assuming the role of primary caregiver. Many caregivers develop health problems including sleep disorders. Some report poor quality of sleep even when sleep duration is normal. In the present study, we used actigraphy and heart rate variability spectral analysis to assess autonomic nervous system activity and quality of sleep in family caregivers of people with ambulatory dementia. The 20 caregivers who participated in our study exhibited significantly higher levels of sympathetic nervous system activity during sleep than noncaregivers. This abnormal activity was most prominent during the first half of the sleep period and was not related to overall sleep duration. We propose that relaxation is inhibited during the first half of the sleep period in this caregiver population. This may be due to increased stress, as caregivers of people with ambulatory dementia may worry about their patients waking and wandering at night, potentially injuring themselves. Our findings indicate a need for increased support for caregivers of people with dementia, including the assessment and treatment of sleep disorders.

Development of a Portable Acceleration Monitor Device and its clinical application for the Quantitative Gait Assessment of the Elderly

In this study, a handy gait assessment system with a tri-axial accelerometer has been developed and its application for a quantitative assessment of gait in the elderly was examined. This assessment system consists of a portable acceleration monitor device and PC analysis software. This portable device was fixed to the lower front of the subject, and the subject was asked to walk around a test course at a voluntary speed. The activities performed on the test course include standing up, normal walking, fast walking, and walking over a barrier. Gaits in 402 elderly people were measured three times every three months. These subjects were under nursing health services, such as expert place nursing, walking training, power rehabilitation, fall prevention training, and pool training. The measured acceleration was converted into relative velocity and relative displacement of the center of gravity of the subject. Four evaluation indices, i.e., physical activity, stability, symmetry, and average speed were calculated. The results reveal that both the physical activity and average speed decreased after six months under nursing services.

The effect of age and exercise training on insulin sensitivity, fat and muscle tissue cytokine profiles and body composition of old and young Standardbred mares

This study tested the hypothesis that old and young mares exhibit different endocrine responses to a frequently sampled intravenous glucose tolerance test (FSIGT) and different cytokine profiles in blood, adipose and muscle tissues. It was also hypothesised that exercise training alters endocrine and tissue cytokine profiles. Pilot data from 15 mixed background horses indicated tissue differences in cytokine profiles. For the main study, six old (22.0±0.7 years) and six young (7.3±0.6 years; mean±SE) unfit Standardbred mares were tested pre- and post-training. Exercise training occurred three days/week for 15 weeks at ~60% maximum heart rate. Plasma insulin and glucose concentrations were measured via radioimmunoassay and enzyme-electrode interface, respectively. Samples of blood, middle gluteal muscle (RM), and subcutaneous adipose tissue from the neck (NF) were collected pre- and post-training for mRNA quantification. Minimal model analysis of FSIGT, repeated measures ANOVA and Pearson Product Moment were used to analyse data. The null hypothesis was rejected when P≤l0.10. Post-training, old and young mares improved insulin sensitivity (SI) (P=0.08, P=0.01, respectively) and disposition index (P=0.04, P<0.001, respectively), but acute insulin response to glucose increased in young mares only (P=0.02). Old mares exhibited lower (P=0.06) average relative quantity (RQ) of tumour necrosis factor-alpha in NF compared to RM. Old mares showed greater RQ of interleukin-6 (IL-6) in NF compared to young (P=0.08). A negative correlation was observed between SI and IL-6 in NF post-training (P=0.07, R=-0.54), and a positive correlation occurred between SI and monocyte chemotactic protein-1 in NF post-training (P=0.08, R=0.53). Exercise training improved pancreatic beta cell function and insulin sensitivity in old and young horses. Cytokines associated with glucose metabolism may have varied roles in different tissues.

Comparative analysis of exit interviews and direct clinical observations in pediatric ambulatory care services in Afghanistan

OBJECTIVE

To assess the receiver operating curves (ROCs) for counseling in the management of common childhood diseases comparing direct observations with exit interviews.

DESIGN

Eight thousand six hundred and fifty-nine randomly selected new outpatient consultations of sick children under 5 years were assessed by observation using a standardized checklist and an exit interview with their parent/guardian, taken between 2005 and 2007 from 948 health facilities in Afghanistan. The observation checklist was used as a 'gold standard' for counseling provided.

MAIN MEASURE

Sensitivity, specificity and ROCs were estimated for five counseling items, including explanations of: a working diagnosis; what to do at home; possible adverse reactions to medicine; signs that require a return to the health facility; and a time to return.

RESULTS

The prevalence of counseling items was relatively low (ranging from 8 to 80%), but generally increasing each year. Exit interviews had relatively low levels of sensitivity for the counseling items, ranging from 33 to 88%, with higher levels of specificity (ranging from 63 to 91%), whereas the ROCs ranged from 61 to 77%. Although ROCs varied significantly from year to year (P < 0.002 for each item), there was little difference based on the sex or type of the health provider.

CONCLUSIONS

Exit interviews did not provide reliable measurements of provider performance compared with direct observations. Observations identified low prevalence of counseling tasks though increasing over time. The differences between observation and exit interviews identified significant gaps in communication, suggesting that exit interviews are of low accuracy and should not be used alone.

Psychotherapy for depression among incurable cancer patients

BACKGROUND

The most common psychiatric diagnosis among cancer patients is depression; this diagnosis is even more common among patients with advanced cancer. Psychotherapy is a patient-preferred and promising strategy for treating depression among cancer patients. Several systematic reviews have investigated the effectiveness of psychological treatment for depression among cancer patients. However, the findings are conflicting, and no review has focused on depression among patients with incurable cancer.

OBJECTIVES

To investigate the effects of psychotherapy for treating depression among patients with advanced cancer by conducting a systematic review of randomized controlled trials (RCTs).

SEARCH STRATEGY

We searched the Cochrane Pain, Palliative and Supportive Care Group Register, The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and PsycINFO databases in September 2005.

SELECTION CRITERIA

All relevant RCTs comparing any kind of psychotherapy with conventional treatment for adult patients with advanced cancer were eligible for inclusion. Two independent review authors identified relevant studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the original reports using standardized data extraction forms. Two independent review authors also assessed the methodological quality of the selected studies according to the recommendations of a previous systematic review of psychological therapies for cancer patients that utilized ten internal validity indicators. The primary outcome was the standardized mean difference (SMD) of change between the baseline and immediate post-treatment scores.

MAIN RESULTS

We identified a total of ten RCTs (total of 780 participants); data from six studies were used for meta-analyses (292 patients in the psychotherapy arm and 225 patients in the control arm). Among these six studies, four studies used supportive psychotherapy, one adopted cognitive behavioural therapy, and one adopted problem-solving therapy. When compared with treatment as usual, psychotherapy was associated with a significant decrease in depression score (SMD = -0.44, 95% confidence interval [CI] = -0.08 to -0.80). None of the studies focused on patients with clinically diagnosed depression.

AUTHORS' CONCLUSIONS

Evidence from RCTs of moderate quality suggest that psychotherapy is useful for treating depressive states in advanced cancer patients. However, no evidence supports the effectiveness of psychotherapy for patients with clinically diagnosed depression.

Attitudes toward disclosing the diagnosis of dementia in Japan

BACKGROUND

The rapid increase in the elderly population in Japan has triggered a debate on whether or not patients with dementia should be informed of their diagnosis. The purpose of the present study was to investigate the attitudes of people in a large city in Japan toward the disclosure of a diagnosis of dementia.

METHODS

In Study 1, 2000 residents aged 40-64 and 5000 residents aged 65 and over were sampled randomly, and a structured questionnaire was sent to them by mail. In Study 2, we administered a structured interview-based questionnaire to 3949 randomly enrolled residents of Nagoya City aged 45 and over whose family member had been certified as needing long-term care.

RESULTS

In Study 1, 79.8% of the younger respondents (n = 710) stated that they would prefer the disclosure of a hypothetical diagnosis of dementia, as did 75.5% of the older respondents (n = 2162). Furthermore, 85.1% (n = 749) of the younger respondents and 82.5% (n = 2181) of the older respondents stated that they would prefer that the patient be told his or her hypothetical diagnosis of dementia. In Study 2, in the case of care recipients without dementia, 68.3% (n = 650) of their family members preferred disclosure of a hypothetical diagnosis of dementia. Among the families of care recipients who had dementia, 58.4% (n = 301) of family members preferred disclosure.

CONCLUSIONS

The present survey of caregivers and non-caregivers in an urban city of Japan demonstrated that the desire for disclosure of a diagnosis of dementia is relatively high.

Which two questions of Mini-Mental State Examination (MMSE) should we start from?

The MMSE is a simple and commonly used instrument to evaluate cognitive impairment. With the aim of enabling the examiner to skip a large portion of the MMSE when screening subjects with lower possibility of cognitive impairment, we examined the internal distribution of the MMSE scores among 792 older adults visiting a teaching hospital, a long-term care hospital, nursing homes, and a geriatric clinic. The correlation coefficients between the summed scores of any two items of MMSE and the total score were compared. A receiver operating characteristic (ROC) curve was drawn to show the sensitivity and the specificity of predicting cognitive impairment, which was defined by the total MMSE score being less than 24. The mean MMSE score was 20.5 +/- 6.9 (+/-S.D.). A good predictor for cognitive impairment was the summed scores of the time orientation and serial sevens with a sensitivity of 98.2% and a specificity of 69.2% if cut-off was set at 7/7+. This finding appears to help streamline the screening process for cognitive impairment in general elderly population.

The pleasurable recreational activities among community-dwelling older adults

This study aimed to clarify what pleasurable recreational activities older adults like to participate in, and to investigate the relationship between those activities and quality of life (QOL). Questionnaires were delivered to older residents (65 years and above) in a Japanese rural area. The residents' background information, the amount of pleasure for various activities, and the QOL were surveyed. The QOL was evaluated by the revised Philadelphia Geriatric Center (PGC) morale scale. The amount of pleasure taken in a majority of the activities, such as conversation with family or neighbors showed a significant association with the happiness score, but only a few activities showed significant association between the revised PGC morale scale and the amount of pleasure. The multiple regression analyses indicated that the amount of pleasure in exercise, the difficulty in managing finances, and amount of pleasure taken in watching TV were significant variables for predicting the happiness score. The results indicated that the amount of pleasure older adults experienced when engaging in activities such as conversation with family or neighbors showed significant association with the older adults' happiness. These results may be helpful in understanding contributions of various activities to the perception of pleasure in older adults.

Behavioral, psychological and physical symptoms in group homes for older adults with dementia

BACKGROUND

Despite the recent dissemination of group homes in Japan for older adults with dementia, the behavioral and psychological features of the residents remain unknown. To clarify the association of such features with the levels of difficulty encountered by caregivers in coping with these symptoms, we have conducted a survey to compare the frequencies of the symptoms among group homes, nursing homes and a long-term care hospital.

METHODS

Five hundred and eighty-six older adults aged 65 years or more were sampled. Data were consecutively collected from questionnaires given to the caregivers. The questionnaire included basic activities of daily living, the Mini-mental State Examination, frequencies of behavioral, psychological and physical symptoms, and the levels of difficulty in coping with the symptoms.

RESULTS

In group homes, requests to go home, urinary incontinence and frequent complaining were the most commonly observed symptoms. The symptoms associated with disorientation, anxiety and depression were frequently observed in all three care settings. Most of the symptoms were more frequently observed in group homes than in the other two care settings. However, the levels of difficulty in coping with most of the symptoms were the highest in the long-term care hospital, followed in order by the group homes and nursing homes. In group homes, inappropriate sexual behavior was the symptom creating the most stress for the caregivers, followed by verbal and nonverbal abuse and changeable mood.

CONCLUSIONS

The symptomatic traits of residents in group homes were clarified in the present study. These findings could be helpful in considering desirable placement or the improvement of eligible service provision for older adults with dementia in care facilities.

A comparison of depressive mood of older adults in a community, nursing homes, and a geriatric hospital: factor analysis of Geriatric Depression Scale

The Geriatric Depression Scale (GDS)-15 was used in 607 adults aged 65+ years living in a community, nursing homes, and a general hospital to explore characteristics of depressive mood in different care settings. Factor analysis of GDS-15 extracted 4 factors labeled unhappiness, apathy and anxiety, loss of hope and morale, and energy loss. The scale scores labeled unhappiness, apathy and anxiety, and loss of hope and morale were negatively correlated with the Barthel Index and the Mini-Mental State Examination scores. The results classified the depressive patterns into 2 types, one fitting the nursing home residents and the other fitting the hospital patients. The dominant factors of the nursing-home type were unhappiness and loss of hope and morale, and the hospital type was highly related with apathy and anxiety. The results indicate an extended utility of the GDS-15 for a deeper understanding of depressive mood in various care settings.

Predictive Model for Assessing Cognitive Impairment by Quantitative Electroencephalography

OBJECTIVE

To assess the utility of quantitative electroencephalographic analysis as an indicator of cognitive impairment, we examined the correlation between Mini-Mental State Examination (MMSE) scores and quantitative electroencephalographic (QEEG) power values in elderly patients and constructed a regression model to predict MMSE scores.

BACKGROUND

Because of the growing number of elderly individuals with cognitive deficits, there is an increasing need for simple and objective methods with which to evaluate cognitive function. Although QEEG is reportedly a useful method for this purpose, few researchers have constructed a QEEG-based model for predicting the degree of cognitive impairment in clinical settings.

METHOD

We evaluated brain function using QEEG in 44 elderly patients with memory complaints and compared the results with their MMSE scores.

RESULTS

In the correlation analysis, no significant correlation was found between MMSE scores and QEEG power values. However, a regression model created using relative QEEG and gender for predicting MMSE scores had an adjusted R2 of 0.471.

CONCLUSIONS

This finding suggests that QEEG analysis may be a useful indicator of cognitive decline in patients with memory complaints.

Influence of behavioral and psychological symptoms of dementia (BPSD) and environment of care on caregivers' burden

With increasing population of older adults in need of care, caregiver's burden is becoming a major concern. We investigated the relative contributions of BPSD of care recipients, caregiver's background and the care environment to caregiver's burden assessed by using Zarit burden interview (ZBI). Among BPSD, inability of finding the way home, inability of managing money and fecal incontinence were the most difficult symptoms to cope with. A path analysis, by which we constructed a network model to clarify the contributions of the factors examined to the caregiver's burden, indicated that the severity of dementia, the feeling of "would rather die than be in the same condition" and the physical pain of the caregivers showed great direct influences on the score of the ZBI. In conclusion, we clarified kinetic and dynamic interactions of factors affecting caregiver's burden by using a path analysis. The model indicates that the caregiver's burden can be affected not merely by the illness of the care recipients but by the caregiver's background and the care environment.

Smell identification test as an indicator for cognitive impairment in Alzheimer's disease

OBJECTIVES

The aim of the present study was to assess olfactory dysfunction in patients with Alzheimer's disease (AD) and to compare utility of the olfactory tests as possible clinical markers.

METHODS

Two olfactory identification tests (The Cross-Cultural Smell Identification Test [CC-SIT] and the Picture-based Smell Identification Test [P-SIT]) and the Mini Mental State Examination (MMSE) were administered to patients with AD and age-matched controls. Apolipoprotein E (Apo E) genotypes of patients with AD were identified.

RESULTS

Patients with AD had significantly lower olfactory identification scores than age-matched non-demented elderly subjects in both olfactory assessments. In the AD group, the coefficient of correlation between the MMSE scores and the P-SIT scores was higher than that between the MMSE scores and the CC-SIT scores. Receiver operating curve (ROC) analyses for both tests indicated that the P-SIT discriminated AD patients from controls more reliably than did the CC-SIT. Within AD patients, those who were carrying one or two ApoE epsilon4 alleles had a higher coefficient of correlation between the MMSE scores and the P-SIT scores than patients without the ApoE epsilon4 allele.

CONCLUSIONS

The results suggest that a short and simple non-lexical olfactory identification test can be useful as a clinical marker of AD appropriate for Japanese elderly population.

The relationship between functional disability and depressive mood in Japanese older adult inpatients

Depression is commonly found in older adult patients and is often associated with handicaps. The authors administered the Comprehensive Geriatric Assessment (CGA), including basic activities of daily living (BADL), instrumental activities of daily living (IADL), Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS)-15, and a socioenvironmental questionnaire to 198 patients who were admitted to Nagoya University Hospital, to examine the relationship between depressive mood and various physical and socioenvironmental outcomes. The overall GDS-15 score was correlated with the BADL and IADL. The factor analysis extracted 4 factors from the GDS-15 subscales. The factors labeled "loss of morale and hope" and "memory loss and reduction of social activity" were highly correlated with both ADLs, social variables, and the MMSE score. The results reveal that factor analysis of GDS-15 will help in understanding the etiology of depressive mood, thereby contributing to better therapeutic approaches.

[Long-term prognosis and satisfaction after percutaneous endoscopic gastrostomy in a general hospital]

Although percutaneous endoscopic gastrotomy (PEG) has been widely acknowledged as a safer method for enteral feeding, its long-term impact on prognosis and quality of life (QOL) in elderly patients is not sufficiently understood. Regarding the indications of PEG, there still exist issues to be studied due to lack of convincing evidence for reduction of expected complications such as aspiration pneumonia or for improvement of prognosis in patients with severe dementia. In this study we investigated the survival rate after PEG placement and family satisfaction retrospectively in 78 elderly inpatients who underwent PEG, by sending questionnaires to the patients or their caregivers. The results of 68 cases (88%) recovered showed that the 1-year survival rate was 64.0%, and the 2-year survival rate was 55.5%. Fifty-three percent of families of patients showed overall satisfaction regarding the induction of PEG. The survival rate was relatively higher than that from previously reported studies. The differences we observed may be attributed to variations in patients' backgrounds (clinical, socio-economic, cultural) in therapeutic interventions. We recognized the importance of clarifying factors which would affect the prognosis and QOL in elderly patients who undergo PEG. The indication for PEG can be made based on comprehensive assessment of the relevant factors in individual cases, taking patient's or caregiver's wishes into consideration.

Discovery of novel antifungal (1,3)-beta-D-glucan synthase inhibitors

The increasing incidence of life-threatening fungal infections has driven the search for new, broad-spectrum fungicidal agents that can be used for treatment and prophylaxis in immunocompromised patients. Natural-product inhibitors of cell wall (1,3)-beta-D-glucan synthase such as lipopeptide pneumocandins and echinocandins as well as the glycolipid papulacandins have been evaluated as potential therapeutics for the last two decades. As a result, MK-0991 (caspofungin acetate; Cancidas), a semisynthetic analogue of pneumocandin B(o), is being developed as a broad-spectrum parenteral agent for the treatment of aspergillosis and candidiasis. This and other lipopeptide antifungal agents have limited oral bioavailability. Thus, we have sought new chemical structures with the mode of action of lipopeptide antifungal agents but with the potential for oral absorption. Results of natural-product screening by a series of newly developed methods has led to the identification of four acidic terpenoid (1,3)-beta-D-glucan synthase inhibitors. Of the four compounds, the in vitro antifungal activity of one, enfumafungin, is comparable to that of L-733560, a close analogue of MK-0991. Like the lipopeptides, enfumafungin specifically inhibits glucan synthesis in whole cells and in (1,3)-beta-D-glucan synthase assays, alters the morphologies of yeasts and molds, and produces a unique response in Saccharomyces cerevisiae strains with point mutations in FKS1, the gene which encodes the large subunit of glucan synthase.

Geranylgeranyltransferase I of Candida albicans: null mutants or enzyme inhibitors produce unexpected phenotypes

Geranylgeranyltransferase I (GGTase I) catalyzes the transfer of a prenyl group from geranylgeranyl diphosphate to the carboxy-terminal cysteine of proteins with a motif referred to as a CaaX box (C, cysteine; a, usually aliphatic amino acid; X, usually L). The alpha and beta subunits of GGTase I from Saccharomyces cerevisiae are encoded by RAM2 and CDC43, respectively, and each is essential for viability. We are evaluating GGTase I as a potential target for antimycotic therapy of the related yeast, Candida albicans, which is the major human pathogen for disseminated fungal infections. Recently we cloned CaCDC43, the C. albicans homolog of S. cerevisiae CDC43. To study its role in C. albicans, both alleles were sequentially disrupted in strain CAI4. Null Cacdc43 mutants were viable despite the lack of detectable GGTase I activity but were morphologically abnormal. The subcellular distribution of two GGTase I substrates, Rho1p and Cdc42p, was shifted from the membranous fraction to the cytosolic fraction in the cdc43 mutants, and levels of these two proteins were elevated compared to those in the parent strain. Two compounds that are potent GGTase I inhibitors in vitro but that have poor antifungal activity, J-109,390 and L-269,289, caused similar changes in the distribution and quantity of the substrate. The lethality of an S. cerevisiae cdc43 mutant can be suppressed by simultaneous overexpression of RHO1 and CDC42 on high-copy-number plasmids (Y. Ohya et al., Mol. Biol. Cell 4:1017, 1991; C. A. Trueblood, Y. Ohya, and J. Rine, Mol. Cell. Biol. 13:4260, 1993). Prenylation presumably occurs by farnesyltransferase (FTase). We hypothesize that Cdc42p and Rho1p of C. albicans can be prenylated by FTase when GGTase I is absent or limiting and that elevation of these two substrates enables them to compete with FTase substrates for prenylation and thus allows sustained growth.

Hyalodendrosides A and B, antifungal triterpenoid glycosides from a lignicolous hyphomycete, Hyalodendron species

Two antifungal triterpenoid glycosides, hyalodendrosides A and B (1 and 2), were isolated from a solid matrix fermentation of a lignicolous hyphomycete, Hyalodendron sp. Their structures were determined based upon extensive examination of spectral parameters, particularly NMR and MS data. Both compounds have beta-linked glucose moieties. Compounds 1 and 2 show weak to moderate antifungal activity against some clinically relevant fungi.

Identification of the FKS1 gene of Candida albicans as the essential target of 1,3-beta-D-glucan synthase inhibitors

Pneumocandins and echinocandins are fungicidal antibiotics, currently in clinical development, that inhibit 1,3-beta-D-glucan synthase (GS) in several human fungal pathogens. We have identified a gene from the diploid organism Candida albicans that encodes a target of these inhibitors. A 2.1-kb portion of this gene, designated CaFKS1, has significant homology to the Saccharomyces cerevisiae FKS1 and FKS2 genes, which encode partially functionally redundant subunits of GS. To evaluate the role of CaFkslp in susceptibility to echinocandins, we disrupted CaFKS1 on one homolog each of the spontaneous pneumocandin-resistant C. albicans mutants CAI4R1, NR2, NR3, and NR4. These mutants had been selected previously on agar plates containing the pneumocandin L-733,560. The clones derived from this transformation were either resistant (Ech[r]) or fully sensitive (Ech[s]) to inhibition by L-733,560 in both liquid broth microdilution and in vitro GS assays. The site of plasmid insertion in the transformants was mapped by Southern blot analysis, using restriction site polymorphisms in the CaFKS1 gene to distinguish between the two alleles (designated CaFKS1h and CaFKS1b). For strains CAI4R1 and NR2, the CaFKS1b allele was disrupted in each Ech(r) transformant; for strain NR4, CaFKS1h was disrupted in each Ech(r) transformant. We conclude that (i) strains CAI4R1, NR2, and NR4 are heterozygous for a dominant or semidominant pneumocandin resistance mutation at CaFKS1, (ii) drug resistance mutations can occur in either CaFKS1 allele, and (iii) CaFks1p is a target of the echinocandins. For transformants of strain NR3, all the clones we analyzed were uniformly Ech(r), and only the CaFKS1h allele, either in disrupted or wild-type form, was detected on genomic Southern blots. We believe gene conversion at the CaFKS1 locus may have produced two Cafks1h alleles that each contain an Ech(r) mutation. Transformants derived from the mutants were analyzed for susceptibility to pneumocandin treatment in a mouse model of disseminated candidiasis. Strains heterozygous for the resistant allele (i.e., C. albicans CAI4R1, NR2, and NR4) were moderately resistant to treatment, while strains without a functional Ech(s) allele (i.e., strain NR3 and derivatives of strain CAI4R1 with the disruption plasmid integrated in the Ech[s] allele) displayed strong in vivo echinocandin resistance. Finally, we were unable to inactivate both alleles at CaFKS1 by two-step integrative disruption, suggesting that CaFks1p is likely to be an essential protein in C. albicans.

Oral administration of propentofylline, a stimulator of nerve growth factor (NGF) synthesis, recovers cholinergic neuronal dysfunction induced by the infusion of anti-NGF antibody into the rat septum

We have reported that the continuous infusion of anti-nerve growth factor (NGF) monoclonal antibody into the septum of rats produces an impairment of memory and a decrease in choline acetyltransferase (ChAT) and cholinesterase (ChE) activities in the hippocampus. Propentofylline, a xanthine derivative, has potent stimulatory effects on NGF synthesis/secretion in mouse astrocytes in vitro. To investigate the pharmacological effects of propentofylline in vivo, we induced amnesia in rats by infusing anti-NGF antibody into the septum for 16 days. One group of rats was given no further treatment, while the other group was treated with propentofylline orally once a day for 19 days, commencing 3 days before the implantation of the mini-osmotic pump, and continuing throughout the period during which the animals performed the behavioral tasks. In the treated amnesic rats, learning and memory in the 3 tasks and ChAT and ChE activity were reduced compared to values in control rats. The administration of propentofylline recovered the decreased learning capacity and the deficit in cholinergic marker enzyme activity. These results suggest that the use of NGF stimulators may provide a new approach to the treatment of dementia.

Propentofylline prevents neuronal dysfunction induced by infusion of anti-nerve growth factor antibody into the rat septum

We have reported that the continuous infusion of anti-nerve growth factor (NGF) monoclonal antibody into the septum of rats produces neuronal dysfunction in the cholinergic system. Propentofylline has potent stimulatory effects on NGF synthesis/secretion in mouse astrocytes in vitro. To investigate the pharmacological effects of propentofylline, we used an animal model of dementia in which anti-NGF antibody was infused into the septum for 16 days via a mini-osmotic pump. The rats were treated with propentofylline orally once a day throughout the period during which performance in learning and memory tasks was observed. In the vehicle-treated dementia rats, learning and memory ability and choline acetyltransferase and cholinesterase activity were reduced compared to values in the control rats. The administration of propentofylline prevented the decreased learning capacity and the deficit in cholinergic marker enzyme activities. These results suggest that the use of NGF stimulators may provide a new approach to the treatment of dementia.

Increased antifungal activity of L-733,560, a water-soluble, semisynthetic pneumocandin, is due to enhanced inhibition of cell wall synthesis

The pneumocandins are natural lipopeptide products of the echinocandin class which inhibit the synthesis of 1,3-beta-D-glucan in susceptible fungi. The lack of a corresponding pathway in mammalian hosts makes this mode of action an attractive one for treating systemic infections. Substitution by an aminoethyl ether at the hemiaminal and dehydration and reduction of the glutamine of pneumocandin B0 produced a semisynthetic compound (L-733,560) with intrinsic water solubility, significantly increased potency, and a broader antifungal spectrum. To evaluate the mechanism for the improved antifungal efficacy, we determined that L-733,560 was a more potent inhibitor of glucan synthase activity in vitro, did not affect the other membrane-bound enzymes tested, conferred susceptibility to lysis in the absence of osmotic support, and did not disrupt currents in liposomal bilayers or 86Rb+ fluxes from liposomes. In Aspergillus species L-733,560 also produced the same morphological alterations as pneumocandin B0. A stereoisomer of L-733,560 with poor antifungal activity was a weak inhibitor of glucan synthase. All of these results support the notion that the enhanced antifungal activity of L-733,560 is achieved by superior inhibition of glucan synthesis and not by nonspecific membrane effects or a second mode of action.

Morphological effects of lipopeptides against Aspergillus fumigatus correlate with activities against (1,3)-beta-D-glucan synthase

The lipopeptide antifungal agents, echinocandins, papulacandins, and pneumocandins, kill Candida albicans by inhibiting glucan synthesis. For this fungus, there is a good correlation of in vitro enzyme inhibition with in vitro assays of MICs. Semisynthetic lipopeptides such as cilofungin, LY303366, L-693,989, and L-733,560 have activity in vivo against Aspergillus infections but appear to be inactive in broth dilution in vitro tests (MICs, > 128 micrograms/ml). To understand how compounds which lack activity in vitro can have good in vivo activity, we monitored the effect of pneumocandins on the morphology of Aspergillus fumigatus and A, flavus strains by light microscopy and electron microscopy and related the changes in growth to inhibition of glucan synthesis. Pneumocandin B0 caused profound changes in hyphal growth; light micrographs showed abnormally swollen germ tubes, highly branched hyphal tips, and many cells with distended balloon shapes. Aspergillus electron micrographs confirmed that lipopeptides produce changes in cell walls; drug-treated germlings showed very stubby growth with thick walls and a conspicuous dark outer layer which was much thicker in the subapical regions. The rest of the hyphal tip ultrastructure was unaffected by the drug, indicating considerable specificity for the primary target. The drug-induced growth alteration produced very compact clumps in broth dilution wells, making it possible to score the morphological effect macroscopically. The morphological changes could be assayed quantitatively by using conventional broth microdilution susceptibility assay conditions. We defined the endpoint as the lowest concentration required to produce the morphological effect and called it the minimum effective concentration to distinguish it from the no-growth endpoints used in MIC determinations. The minimum effective concentration assay was related to inhibition of glucan synthase activity in vitro and may provide a starting point for development of susceptibility testing methods for lipopeptides.

Pharmacokinetics of L-671,329 in rhesus monkeys and DBA/2 mice

The time course of plasma drug levels and urinary recovery for two lipopeptide antifungal antibiotics, L-671,329 and cilofungin, were measured in male rhesus monkeys (Macaca mulatta) and in female DBA/2 mice. The antibiotics were administered intravenously at 10 mg/kg of body weight in phosphate-buffered saline-26% polyethylene glycol for the rhesus monkeys and in 5% dimethyl sulfoxide for the mice. Plasma and urine drug concentrations were determined by high-pressure liquid chromatography and/or a microbiological assay versus Aspergillus niger, and pharmacokinetic parameters were determined for both species. In each of the two rhesus crossover tests as well as in the mouse studies, the pharmacokinetics of the two compounds were similar; however, a marked difference was evident between species. The half-lives of L-671,329 and cilofungin in plasma were 39 and 34 min in the mice and averaged 1.8 and 2 h in the rhesus monkeys, respectively. In mice and rhesus monkeys, urinary recovery was less than 4% for both compounds.

Restricticin, a novel glycine-containing antifungal agent

Restricticin (1) is a naturally-occurring antifungal agent which contains triene, pyran and glycine ester functionalities and is unrelated to any previously known family of natural products. This unstable compound, as well as its corresponding N,N-dimethyl derivative (2), have been produced and isolated from both solid and liquid fermentations of Penicillium restrictum. The desglycyl hydrolysis product, restrictinol (3), was produced via the hydrolysis of pure restricticin and as an artifact of the isolation of restricticin.

L-657,398, a novel antifungal agent: fermentation, isolation, structural elucidation and biological properties

L-657,398 is a broad spectrum antifungal agent isolated from solid fermentation or from the mycelium of the liquid fermentation of Aspergillus ochraceus. Structurally, the compound is a novel pyrollidine related to anisomycin.