Developing a Quality Improvement Implementation Taxonomy for Organizational Employee Wellness Initiatives

BACKGROUND

Standardized taxonomies (STs) facilitate knowledge representation and semantic interoperability within health care provision and research. However, a gap exists in capturing knowledge representation to classify, quantify, qualify, and codify the intersection of evidence and quality improvement (QI) implementation. This interprofessional case report leverages a novel semantic and ontological approach to bridge this gap.

OBJECTIVES

This report had two objectives. First, it aimed to synthesize implementation barrier and facilitator data from employee wellness QI initiatives across Veteran Affairs health care systems through a semantic and ontological approach. Second, it introduced an original framework of this use-case-based taxonomy on implementation barriers and facilitators within a QI process.

METHODS

We synthesized terms from combined datasets of all-site implementation barriers and facilitators through QI cause-and-effect analysis and qualitative thematic analysis. We developed the Quality Improvement and Implementation Taxonomy (QIIT) classification scheme to categorize synthesized terms and structure. This framework employed a semantic and ontological approach. It was built upon existing terms and models from the QI Plan, Do, Study, Act phases, the Consolidated Framework for Implementation Research domains, and the fishbone cause-and-effect categories.

RESULTS

The QIIT followed a hierarchical and relational classification scheme. Its taxonomy was linked to four QI Phases, five Implementing Domains, and six Conceptual Determinants modified by customizable Descriptors and Binary or Likert Attribute Scales.

CONCLUSION

This case report introduces a novel approach to standardize the process and taxonomy to describe evidence translation to QI implementation barriers and facilitators. This classification scheme reduces redundancy and allows semantic agreements on concepts and ontological knowledge representation. Integrating existing taxonomies and models enhances the efficiency of reusing well-developed taxonomies and relationship modeling among constructs. Ultimately, employing STs helps generate comparable and sharable QI evaluations for forecast, leading to sustainable implementation with clinically informed innovative solutions.

Developing a Quality Improvement Implementation Taxonomy for Organizational Employee Wellness Initiatives

BACKGROUND

Standardized taxonomies (STs) facilitate knowledge representation and semantic interoperability within health care provision and research. However, a gap exists in capturing knowledge representation to classify, quantify, qualify, and codify the intersection of evidence and quality improvement (QI) implementation. This interprofessional case report leverages a novel semantic and ontological approach to bridge this gap.

OBJECTIVES

This report had two objectives. First, it aimed to synthesize implementation barrier and facilitator data from employee wellness QI initiatives across Veteran Affairs health care systems through a semantic and ontological approach. Second, it introduced an original framework of this use-case-based taxonomy on implementation barriers and facilitators within a QI process.

METHODS

We synthesized terms from combined datasets of all-site implementation barriers and facilitators through QI cause-and-effect analysis and qualitative thematic analysis. We developed the Quality Improvement and Implementation Taxonomy (QIIT) classification scheme to categorize synthesized terms and structure. This framework employed a semantic and ontological approach. It was built upon existing terms and models from the QI Plan, Do, Study, Act phases, the Consolidated Framework for Implementation Research domains, and the fishbone cause-and-effect categories.

RESULTS

The QIIT followed a hierarchical and relational classification scheme. Its taxonomy was linked to four QI Phases, five Implementing Domains, and six Conceptual Determinants modified by customizable Descriptors and Binary or Likert Attribute Scales.

CONCLUSION

This case report introduces a novel approach to standardize the process and taxonomy to describe evidence translation to QI implementation barriers and facilitators. This classification scheme reduces redundancy and allows semantic agreements on concepts and ontological knowledge representation. Integrating existing taxonomies and models enhances the efficiency of reusing well-developed taxonomies and relationship modeling among constructs. Ultimately, employing STs helps generate comparable and sharable QI evaluations for forecast, leading to sustainable implementation with clinically informed innovative solutions.

The role of sleep duration in suicide risk among sexual and gender minority adolescents

BACKGROUND

Short sleep duration is linked with suicide risk in adolescence. Sexual and gender minority (SGM) adolescents experience substantially increased risk for suicide compared to their non-SGM peers.

METHODS

We investigated the role of sleep duration in SGM adolescent suicide risk using population-based, cross-sectional data from the 2022 Minnesota Student Survey (MSS; N = 85,610, Mage = 14.8). Adolescents reported average school-night sleep duration; those reporting <6 h were classified as having very short sleep duration. The MSS additionally assessed past-year suicidal ideation and suicide attempt. Mediation analyses assessed the role of sleep duration in explaining associations between SGM identity and suicide risk. Further, to examine intervention mechanisms, among SGM adolescents (n = 20,171, 23.6%), a logistic regression model assessed associations among demographic factors, perceived parental care, and very short sleep duration.

RESULTS

As compared to non-SGM adolescents, SGM adolescents reported substantially higher prevalence of past-year suicidal ideation and suicide attempt and 2.6× higher prevalence of very short sleep duration (all p < 0.001). Mediation analyses demonstrated that very short sleep duration partially mediated the pathway between SGM identity and past-year suicidal ideation (15.5% mediated) and suicide attempt (17.2% mediated). Among SGM adolescents, a striking positive dose-response relationship was observed between level of perceived parental care and very short sleep duration. As perceived parental care decreased, so too did hours of sleep.

DISCUSSION

Sleep duration is a crucial and understudied mechanism underlying suicide risk disparities affecting SGM adolescents. Family-based interventions may improve SGM adolescent sleep and reduce suicide risk.

A systematic review of the geospatial barriers to antiretroviral initiation, adherence and viral suppression among people living with HIV

Background With the emergence of antiretroviral therapy (ART), Treatment as Prevention (TasP) has become the cornerstone of both HIV clinical care and HIV prevention. However, despite the efficacy of treatment-based programs and policies, structural barriers to ART initiation, adherence and viral suppression have the potential to reduce TasP effectiveness. These barriers have been studied using Geographic Information Systems (GIS). While previous reviews have examined the use of GIS for HIV testing - an essential antecedent to clinical care - to date, no reviews have summarised the research with respect to other ART-related outcomes.

METHODS

Therefore, the present review leveraged the PubMed database to identify studies that leveraged GIS to examine the barriers to ART initiation, adherence and viral suppression, with the overall goal of understanding how GIS has been used (and might continue to be used) to better study TasP outcomes. Joanna Briggs Institute criteria were used for the critical appraisal of included studies.

RESULTS

In total, 33 relevant studies were identified, excluding those not utilising explicit GIS methodology or not examining TasP-related outcomes.

CONCLUSIONS

Findings highlight geospatial variation in ART success and inequitable distribution of HIV care in racially segregated, economically disadvantaged, and, by some accounts, increasingly rural areas - particularly in the United States. Furthermore, this review highlights the utility and current limitations of using GIS to monitor health outcomes related to ART and the need for careful planning of resources with respect to the geospatial movement and location of people living with HIV (PLWH).

Preliminary Impact of the weCare Social Media Intervention to Support Health for Young Men Who Have Sex with Men and Transgender Women with HIV

Young racial/ethnic minority men who have sex with men (MSM) and transgender women with HIV often have poor health outcomes. They also utilize a wide array of social media. Accordingly, we developed and implemented weCare, a social media intervention utilizing Facebook, texting, and GPS-based mobile social and sexual networking applications to improve HIV-related care engagement and health outcomes. We compared viral load suppression and clinic appointment attendance among 91 participants during the 12-month period before and after weCare implementation. McNemar's chi-square test analyses were conducted comparing the pre- and postintervention difference using paired data. Since February 2016, intervention staff and 91 intervention participants (79.1% African American and 13.2% Latino, mean age = 25) exchanged 13,830 messages during 3,758 conversations (average: 41.3 conversations per participant) across a variety of topics, including appointment reminders, medication adherence, problem solving, and reducing barriers. There were significant reductions in missed HIV care appointments (68.0% vs. 53.3%, p = 0.04) and increases in viral load suppression (61.3% vs. 88.8%, p < 0.0001) 12 months postimplementation. Our results highlight the initial success of weCare in improving care engagement and viral suppression. Social media is an important tool, especially for young MSM and transgender women, to support individual- (e.g., viral suppression) and community- (e.g., reduced transmission efficiency) level health. It may also be a useful tool for improving engagement with biomedical HIV prevention tools (e.g., PrEP use).

Opiate Injection-associated Infective Endocarditis in the Southeastern United States

BACKGROUND

Opiate pain reliever (OPR) misuse by injection is increasing in the United States. Infective endocarditis (IE), a devastating complication of injection OPR use, has been understudied.

METHODS

We conducted a retrospective chart review of IE cases at an academic tertiary care hospital in North Carolina. Hospital admissions from 2009-2014 were screened for cases of definite IE. Subjects reporting injection drug use (IDU) were classified as IDU-IE, and compared to those without reported IDU, classified as No IDU-IE. Rates of IDU-IE and No IDU-IE, patient demographics, microbiologic data and outcomes were compared between the groups.

RESULTS

A total of 127 incident admissions for IE were identified, 48 (37.8%) were classified as IDU-IE and 79 (62.2%) as No IDU-IE. IDU-IE cases increased from 14% of hospitalizations for IE in 2009 to 56% in 2014; reporting of OPR injection increased in 2012 and continued through the study period. IDU-IE subjects were younger (32.6 ± 11.7 versus 54.4 ± 13.1, P < 0.0001), more likely to be single (n = 33 [68.8%] versus n = 23 [29.1%], P < 0.0001) and to reside in rural communities (n = 36 [75.0%] versus n = 25 [31.6%], P < 0.0001) than No IDU-IE subjects. Hospital length of stay (26 days versus 12 days, P < 0.0001) and intensive care unit length of stay (2 days versus 1 day, P = 0.04) were longer for IDU-IE patients and hospital mortality did not differ (10.4% IDU-IE versus 8.9% No IDU-IE, P = 0.77).

CONCLUSIONS

IDU-IE rates increased over time, and OPR injection use in rural communities appears to be a major contributor. Interventions to reduce IDU-IE and OPR misuse are needed to halt this growing epidemic in at-risk rural communities.

weCARE: A Social Media-Based Intervention Designed to Increase HIV Care Linkage, Retention, and Health Outcomes for Racially and Ethnically Diverse Young MSM

Estimates suggest that only about 30% of all individuals living with HIV in the U.S. have achieved viral suppression. Men who have sex with men (MSM), particularly racial/ethnic minority young MSM, are at increased risk for HIV infection and may have even lower viral suppression rates. HIV testing rates among MSM are low, and when tested, racial/ethnic minority young MSM have disproportionately lower rates of retention in care and viral suppression compared to other subgroups. This article describes the design and development of weCare, our social media-based intervention to improve care linkage and retention and health outcomes among racially and ethnically diverse MSM, ages 13-34, living with HIV that will be implemented and evaluated beginning in late 2016. The intervention harnesses established social media that MSM between these ages commonly use, including Facebook, text messaging, and established GPS-based mobile applications (apps). We are using community-based participatory research (CBPR) to enhance the quality and validity of weCare, equitably involving community members, organization representatives, healthcare providers, clinic staff, and academic researchers.

A comparison of administrative and physiologic predictive models in determining risk adjusted mortality rates in critically ill patients

Background

Hospitals are increasingly compared based on clinical outcomes adjusted for severity of illness. Multiple methods exist to adjust for differences between patients. The challenge for consumers of this information, both the public and healthcare providers, is interpreting differences in risk adjustment models particularly when models differ in their use of administrative and physiologic data. We set to examine how administrative and physiologic models compare to each when applied to critically ill patients.

Methods

We prospectively abstracted variables for a physiologic and administrative model of mortality from two intensive care units in the United States. Predicted mortality was compared through the Pearsons Product coefficient and Bland-Altman analysis. A subgroup of patients admitted directly from the emergency department was analyzed to remove potential confounding changes in condition prior to ICU admission.

Results

We included 556 patients from two academic medical centers in this analysis. The administrative model and physiologic models predicted mortalities for the combined cohort were 15.3% (95% CI 13.7%, 16.8%) and 24.6% (95% CI 22.7%, 26.5%) (t-test p-value<0.001). The r² for these models was 0.297. The Bland-Atlman plot suggests that at low predicted mortality there was good agreement; however, as mortality increased the models diverged. Similar results were found when analyzing a subgroup of patients admitted directly from the emergency department. When comparing the two hospitals, there was a statistical difference when using the administrative model but not the physiologic model. Unexplained mortality, defined as those patients who died who had a predicted mortality less than 10%, was a rare event by either model.

Conclusions

In conclusion, while it has been shown that administrative models provide estimates of mortality that are similar to physiologic models in non-critically ill patients with pneumonia, our results suggest this finding can not be applied globally to patients admitted to intensive care units. As patients and providers increasingly use publicly reported information in making health care decisions and referrals, it is critical that the provided information be understood. Our results suggest that severity of illness may influence the mortality index in administrative models. We suggest that when interpreting “report cards” or metrics, health care providers determine how the risk adjustment was made and compares to other risk adjustment models.

Imaging as a strategy for premortem diagnosis and staging of tauopathies

Alzheimer's disease is diagnosed by postmortem detection of pathological lesions that accumulate in specific brain regions. Although the presence of both beta-amyloid plaques and tau-bearing neurofibrillary lesions defines Alzheimer's disease, the distribution of neurofibrillary lesions alone correlates strongly with neurodegeneration and cognitive decline. A whole-brain imaging test capable of detecting these lesions in premortem cases could have great potential for staging and differentially diagnosing Alzheimer's disease. Here we discuss the challenges in developing a whole-brain imaging approach for detection of this intracellular target.

A multicenter, randomized, placebo controlled, multiple-dose, safety and pharmacokinetic study of AIT-082 (Neotrofin) in mild Alzheimer's disease patients

A phase 1, randomized, double-blind, placebo-controlled, dose escalation study of the purine derivative, AIT-082 (Neotrofin, NeoTherapeutics) was conducted in mild Alzheimer's disease (AD) patients to evaluate multiple-dose safety, tolerability, and pharmacokinetics. Possible short-term effects of AIT-082 on cognition and memory were preliminarily investigated. AIT-082 is currently being developed as a potential treatment for Alzheimer's disease and other neurological disorders. Pre-clinical studies indicate that AIT-082 has memory enhancing properties, stimulates neuritogenesis and the production of neurotrophic factors. Patients received an oral dose of AIT-082 or placebo daily for one week. Thirty-six AD patients were divided into three dose cohorts; each dose cohort consisted of twelve patients with 8 patients randomized to AIT-082 and 4 to placebo. The 3 doses of AIT-082 evaluated in this study were 100 mg/day, 500 mg/day, and 2,000 mg/day. There were no serious adverse events at any dose and the drug was well tolerated without significant side effects. AIT-082 was orally and rapidly absorbed, resulting in peak serum concentrations within 2 hours with an elimination half-life of approximately 20 hours. Higher doses resulted in corresponding increases in peak concentrations and areas under the curve (AUC). There was an approximate 2-fold accumulation in AIT-082 with daily dosing (as reflected by the AUC) at steady state. There were no significant differences by treatment arm on the clinical or neuropsychological evaluations. AIT-082 was rapidly absorbed by the oral route with a half-life suitable for dosing once or twice daily. No problems with tolerability or safety were found. AIT-082 appears suitable for testing in larger clinical trials for the treatment of AD and other neurologic disorders.

Influence of the probiotic strain Bacillus cereus var. toyoi on the development of enterobacterial growth and on selected parameters of bacterial metabolism in digesta samples of piglets

The effect of the probiotic strain Bacillus cereus var. toyoi on enterobacterial growth and selected metabolic parameters in digesta samples from piglets before and shortly after weaning was studied. Growth capacities of enterobacteria in digesta samples were significantly reduced, but no correlation was found between enterobacterial growth and concentrations of short-chain fatty acids and lactic acid, which are often influenced by other probiotic preparations. Tendencies for higher amounts of short-chain fatty acids were only recorded in digesta samples from the end of the jejunum, caecum and colon from piglets receiving probiotic-supplemented feed. Lactic acid concentrations were reduced by the presence of B. cereus var. toyoi in feed in the first segment of the jejunum during the suckling period, while samples of the lower parts displayed an increased amount 4 days after weaning. Microbial activity of taurocholine deconjugating enzymes was significantly reduced in jejunum digesta from probiotic-fed piglets. There are strong indications that the early uptake of already modified microbial populations from faeces of the mother sow aids modification of intestinal microbial communities and their metabolic activities in piglets.

The prothrombotic effects of leptin possible implications for the risk of cardiovascular disease in obesity

Human obesity is associated with leptin resistance, elevated leptin levels in the circulation, and increased risk of arterial and venous thrombotic disease. Our studies suggest that elevated leptin levels may directly promote arterial thrombosis in vivo. We found that leptin-deficient ob/ob mice had prolonged times to thrombosis after arterial injury with ferric chloride and that exogenously administered leptin corrected their phenotype in a dose-dependent manner. These effects appear to result from a direct, receptor-mediated effect of leptin on platelets, because leptin stimulated the aggregation of murine (wild-type and ob/ob) and human platelets, but it had no effect on platelets from leptin receptor-deficient db/db mice. Moreover, db/db mice had an attenuated thrombotic response to ferric chloride injury (indistinguishable from that of the ob/ob mice), which was unaffected by exogenous leptin. Our results raise the possibility that elevated plasma levels of leptin may contribute to the risk of atherothrombotic complications in human obesity.

Interobserver disagreements on clinical dementia rating assessment: interpretation and implications for training

The Clinical Dementia Rating (CDR) is a widely used semiobjective instrument for staging dementia severity. A global CDR score is reported that is derived from individual scores in six domains. In this study, we examined both agreement and disagreement, among raters and with a gold standard, to identify domain-specific and global dementia severity level ratings that would most benefit from further training or greater emphasis in future training. We found that raters-in-training experienced the most difficulty with rating normal and questionable dementia. They also had the most trouble scoring the memory domain. When they disagreed with the gold standard, they nearly always gave higher ratings. A third, extremely experienced group of raters were uniform in their high levels of agreement on each domain and the global CDR and tended to give lower ratings if they disagreed with the gold standard. Analysis of the agreement and disagreement patterns suggested that greater emphasis on the memory, home and hobbies, and orientation domains during CDR training, and increasing the information provided for the judgment and problem solving domain on the standardized CDR worksheets, could improve the consistency of raters and increase the efficiency with which they are trained to use the CDR.

Treatment of agitation in AD: a randomized, placebo-controlled clinical trial

BACKGROUND

Treatment of agitation is a crucial problem in the care of patients with AD. Although antipsychotic and antidepressant medications and behavior management techniques (BMT) have each been used to treat agitation, clinical trials of these treatments have been characterized by small sample sizes and uncontrolled treatment designs.

OBJECTIVE

To compare haloperidol, trazodone, and BMT with placebo in the treatment of agitation in AD outpatients.

METHODS

A total of 149 patients with AD and their caregivers participated in a randomized, placebo-controlled, multicenter trial. Blind assessment was conducted at baseline and after 16 weeks of treatment. The three active treatments were haloperidol, trazodone, and BMT. The Alzheimer's Disease Cooperative Study Clinical Global Impression of Change was the primary outcome measure. Secondary outcomes included patient agitation, cognition, and function, and caregiver burden.

RESULTS

Thirty-four percent of subjects improved relative to baseline. No significant differences on outcome were obtained between haloperidol (mean dose, 1.8 mg/d), trazodone (mean dose, 200 mg/d), BMT, or placebo. Significantly fewer adverse events of bradykinesia and parkinsonian gait were evident in the BMT arm. No other significant difference in adverse events was seen. Symptoms did not respond differentially to the different treatments.

CONCLUSIONS

Comparable modest reductions in agitation occurred in patients receiving haloperidol, trazodone, BMT, and placebo. More effective pharmacologic, nonpharmacologic, and combination treatments are needed.

Small peptides Do not inhibit human non-pancreatic secretory phospholipase-A(2) (Type IIA)

Seven small peptides, that are among the most potent reported inhibitors of secreted mammalian phospholipases A(2), were found not to inhibit processing of a small phospholipid substrate by human non-pancreatic secretory phospholipase A(2) (type IIa), under conditions where certain non-peptides are potent inhibitors at nanomolar concentrations.

A randomized controlled trial of prednisone in Alzheimer's disease. Alzheimer's Disease Cooperative Study

BACKGROUND

Laboratory and epidemiologic studies suggest that anti-inflammatory/immunosuppressive therapy may be useful in the treatment of AD. In preliminary studies, a regimen of low to moderate dose prednisone was found to suppress peripheral inflammatory markers without adverse effects in subjects with AD.

METHODS

We conducted a randomized, placebo-controlled multicenter trial to determine whether prednisone treatment slowed the rate of cognitive decline in AD. The active treatment regimen consisted of an initial dose of 20 mg of prednisone daily for 4 weeks tapered to a maintenance dose of 10 mg daily for 1 year, followed by gradual withdrawal during an additional 16 weeks. The primary outcome measure was the 1-year change in the cognitive subscale of the AD Assessment Scale.

RESULTS

A total of 138 subjects were randomized to the drug and placebo groups. There was no difference in cognitive decline between the prednisone and placebo treatment groups in the primary intent-to-treat analysis, or in a secondary analysis considering completers only. Subjects treated with prednisone showed behavioral decline compared with those in the placebo group.

CONCLUSION

A low-dose regimen of prednisone is not useful in the treatment of AD.

Tunable terahertz radiation from Stark wave packets

We investigate the possibility that Stark wave packets can be used as a source of shaped terahertz radiation. Calculations for the sodium atom reveal that the frequency and intensity of the THz emission can be controlled over a broad range by varying the parameters of the excitation pulse.

Clinical dementia rating training and reliability in multicenter studies: the Alzheimer's Disease Cooperative Study experience

Global ratings of dementia severity are used increasingly in clinical trials of antidementia compounds. Such ratings are clinically relevant, but their reliability in multicenter settings has not been determined. To evaluate the reliability of one global scale, the Clinical Dementia Rating (CDR), 82 investigators of the multicenter Alzheimer's Disease Cooperative Study participated in a training and reliability protocol using videotaped assessments of subjects in various stages of Alzheimer's disease. Following training, overall agreement of the investigators with "gold standard" CDR scores was 83%. These results indicate that the training protocol is useful for establishing good levels of agreement in staging dementia severity and that the CDR can be standardized as a clinical global scale for multicenter studies of Alzheimer's disease.

A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer's disease. The Alzheimer's Disease Cooperative Study

BACKGROUND

There is evidence that medications or vitamins that increase the levels of brain catecholamines and protect against oxidative damage may reduce the neuronal damage and slow the progression of Alzheimer's disease.

METHODS

We conducted a double-blind, placebo-controlled, randomized, multicenter trial in patients with Alzheimer's disease of moderate severity. A total of 341 patients received the selective monoamine oxidase inhibitor selegiline (10 mg a day), alpha-tocopherol (vitamin E, 2000 IU a day), both selegiline and alpha-tocopherol, or placebo for two years. The primary outcome was the time to the occurrence of any of the following: death, institutionalization, loss of the ability to perform basic activities of daily living, or severe dementia (defined as a Clinical Dementia Rating of 3).

RESULTS

Despite random assignment, the baseline score on the Mini-Mental State Examination was higher in the placebo group than in the other three groups, and this variable was highly predictive of the primary outcome (P<0.001). In the unadjusted analyses, there was no statistically significant difference in the outcomes among the four groups. In analyses that included the base-line score on the Mini-Mental State Examination as a covariate, there were significant delays in the time to the primary outcome for the patients treated with selegiline (median time, 655 days; P=0.012), alpha-tocopherol (670 days, P=0.001) or combination therapy (585 days, P=0.049), as compared with the placebo group (440 days).

CONCLUSIONS

In patients with moderately severe impairment from Alzheimer's disease, treatment with selegiline or alpha-tocopherol slows the progression of disease.

A multicenter evaluation of new treatment efficacy instruments for Alzheimer's disease clinical trials: overview and general results. The Alzheimer's Disease Cooperative Study

Evaluating treatment efficacy in Alzheimer's disease (AD) clinical trials requires optimal assessment methods to determine the extent and clinical meaningfulness of potential therapeutic effects of pharmacologic agents. Development of improved outcome measures for AD clinical trials is a major objective of the Alzheimer's Disease Cooperative Study (ADCS), an NIA-sponsored, multisite clinical trials consortium. The ADCS Instrument Development Project evaluated the sensitivity, reliability and validity of new or improved measures in each of five assessment domains: (a) cognition (immediate and delayed memory, praxis, attention, and executive function); (b) clinical global change; (c) activities of daily living; (d) behavioral symptoms (agitation and other noncognitive symptoms); and (e) cognition in severely impaired patients. A total of 306 English-speaking subjects were enrolled in the study, including AD patients stratified by disease severity and cognitively normal, age-matched elderly subjects. Half were retested at 1 month and 2 months after baseline, and all received 6- and 12-month follow-up assessments. Spanish versions of these new measures are currently being evaluated. The development of this multisite study, the common methods and procedures, and a detailed description of the cohort are provided in this overview article. This multisite project demonstrates the feasibility of a consortium approach to instrument development. We were able to develop new instruments and efficiently evaluate their reliability and sensitivity to longitudinal change by capitalizing on the experience and patient resources of the participating ADCS research sites.

Assessing patterns of agitation in Alzheimer's disease patients with the Cohen-Mansfield Agitation Inventory. The Alzheimer's Disease Cooperative Study

As part of the effort of the NIA Alzheimer's disease cooperative study to develop improved instruments for quantifying effects in Alzheimer's disease (AD) clinical trials, patterns of agitated behaviors were evaluated with the Cohen-Mansfield Agitation Inventory (CMAI) in 241 AD patients and 64 healthy elderly controls with valid baseline assessment on the CMAI. The test-retest reliability of the CMAI over 1 month was good (r = 0.74 to 0.92). Physically and verbally nonaggressive behaviors were most often reported, whereas physically aggressive behaviors were rare. Frequency of agitated behaviors increased with dementia severity, especially for patients with a Mini-Mental Status Exam score of 0-4. Agitation tended to increase in the evening with dementia severity for the more impaired patients. Amount of agitation did increase after 12 months in all but controls and mildly demented patients. The CMAI shows promise for evaluating a unique aspect of behavior and may be useful in assessing the effects of cognitive enhancers and other types of psychotropic drugs on behavior in dementia patients.

The severe impairment battery: concurrent validity and the assessment of longitudinal change in Alzheimer's disease. The Alzheimer's Disease Cooperative Study

Measurement of cognitive dysfunction in the early stages of Alzheimer's disease (AD) has been well studied and there are many objective tests in use for this purpose. However, with the exception of clinical rating scales, such as the Clinical Dementia Rating Scale, Global Deterioration Scale, and Functional Assessment Staging, there are few objective measures of cognition in the more advanced stages of AD. Given a renewed interest in potential AD therapies, objective measures of mental functioning are needed to adequately assess change in more advanced AD patients. As part of an effort by the NIA-Alzheimer's Disease Cooperative Study to evaluate new measures of efficacy for their utility in treatment studies, the Severe Impairment Battery (SIB) was examined in a 1-year evaluation of change across a wide range of AD severity. The data suggest that the SIB is a reliable and valid measure of progression, particularly in persons with moderate to severe AD. The SIB may therefore be a useful outcome measure in clinical trials that include patients with more advanced stages of AD.

The Spanish Instrument Protocol: design and implementation of a study to evaluate treatment efficacy Instruments for Spanish-speaking patients with Alzheimer's disease. The Alzheimer's Disease Cooperative Study

Development of improved outcome measures for Alzheimer's disease (AD) clinical trials is a major objective of the Alzheimer's Disease Cooperative Study (ADCS), an NIA-sponsored, multisite clinical trials consortium. The ADCS is committed to recruiting and following minority patients in clinical trials. At present, a serious impediment to recruiting non-English-speaking minorities is the lack of instruments with adequate translation. Because Spanish is the second most commonly spoken language in the United States and because persons of Hispanic origin represent approximately 10% of the population, we conducted an instrument development protocol for Spanish-speaking patients. Evaluating treatment efficacy in Spanish-speaking AD patients requires the development of assessments that are comparable to those used for English-speaking participants in clinical trials. The ADCS Instrument Development Project evaluated the sensitivity, reliability, and validity of new or improved measures in each of five assessment domains: (a) cognition (immediate and delayed memory, praxis, attention, and executive function); (b) clinical global change; (c) activities of daily living; (d) behavioral symptoms (agitation and other noncognitive symptoms); and (e) cognition in severely impaired patients. These new treatment efficacy instruments were translated for Spanish speakers and a Spanish Instrument Study was conducted in parallel with the English version of the study. This report describes instrument translation, entry criteria, and recruitment procedures. In addition, the demographic and clinical characteristics of the cohort at baseline are presented and compared to the English-speaking cohort. Implications for the development of comparably sensitive Spanish language instruments are discussed.

Rationale and design of a multicenter study of selegiline and alpha-tocopherol in the treatment of Alzheimer disease using novel clinical outcomes. Alzheimer's Disease Cooperative Study

This report describes the rationale and design of a clinical trial using selegiline (10 mg/day) and alpha-tocopherol (2,000 IU/day) to slow the progression of dementia in Alzheimer disease (AD). This study was developed by the Alzheimer's Disease Cooperative Study (ADCS), a consortium of clinical research centers actively involved in AD research. The major goal of the consortium is to design and conduct clinical investigations leading to the development of treatments for AD. This study uses a randomized double-blind, placebo-controlled, 2 x 2 factorial, parallel group design to test two drugs for the treatment of AD. The primary outcome of the study is the time to reach any one of the following four endpoints: death, institutionalization, loss of two of three basic activities of daily living, and progression of Clinical Dementia Rating (CDR) stage from 2 to 3. Patients with moderately severe disease (CDR = 2) were enrolled and evaluated 10 times over a period of 2 years to determine if these agents reduce the time to reach any endpoint. A database from the Consortium to Establish a Registry for Alzheimer's Disease indicated adequate power analyses to observe a treatment effect on this clinically meaningful outcome measure. Recruitment and baseline characteristics of the population are provided. The rationale for the choice of a factorial design, the use of a novel, clinically meaningful endpoint, and the selection of a cohort of patients with AD of moderate severity are discussed.

The Chemistry of 5-Oxodihydroisoxazoles. XV. Reaction of Derived Ketenimines With Enamines and Enolates

Reaction of 2-heterocyclisoxazol-5(2H)-ones with bases leads to the formation of ketenimines, which react with nucleophiles in competition with intramolecular reactions. Such reactions in the presence of enamines, enamine anions or enolates are reported. Enamines undergo addition through carbon and nitrogen to the ketenimine in competition with direct addition-elimination to the isoxazolone. Enolates of imines or ketones add to the ketenimine to give a mixture of products: only the reaction with the enolate of cyclohexanone is sufficiently specific to provide a useful new synthetic procedure.

The (S)-enantiomer of 2-hydroxysaclofen is the active GABAB receptor antagonist in central and peripheral preparations

In the guinea-pig isolated ileum, (RS)-(+/-)-baclofen induced a depression of cholinergic twitch contractions, reversibly and competitively antagonised by (S)-2-hydroxysaclofen (pA2 = 5.2 +/- 0.2), but not by (R)-2-hyroxysaclofen. The depression of excitatory field potentials by baclofen ( 5 mu M) in rat CA1 hippocampal slices was antagonised by (S)-2-hydroxysaclofen (100 mu m) (pA2 = 4.3), whilst in rat neocortex, (S)-2-hyroxysaclofen (50-500 mu M) antagonised the baclofen (10 mu M)-induced suppression of spontaneous discharges, the (R)-enantiomer being inactive. These results show that (S)-2-hydroxysaclofen is the active antagonist at central and peripheral GABAB receptors.

The Chemistry of 5-Oxodihydroisoxasoles. XIV. Synthesis of 2-(1-Aryltetrazol-5-yl)propanoic Acids

A number of N-arylisoxazol-5(2H)-ones (aryl = phenyl, isoquinolin-1-yl, quinolin-2-yl, 2-phenylquinazolin-4-yl and benzothiazol-2-yl) have been reacted with lithium azide to give 2-(1-aryltetrazol-5-yl)acetic esters, which have been C- methylated and hydrolysed. The resulting 2-(1-aryltetrazol-5-yl) propanoic acids had low antiinflammatory activity, as judged by inhibition of synthesis of prostaglandin PGE2 or tumour necrosis factor α.

Mobile Fourier-transform infrared spectroscopy monitoring of air pollution

Fourier transform infrared spectroscopy is an efficient technique for the detection and quantification of molecules in gas mixtures. Measurement results from a mobile laboratory for ambient air analysis and for remote sensing of plume emission with the commercially available K300 spectrometer are reported. CO, CO(2), NO, NO(2), N(2)O, NH(3), CH(4), SO(2), H(2)O, HCl, and HCHO concentrations have been determined with good agreement with in situ results. The on-line multicomponent analysis software is based on line-by-line retrieval and least-squares fitting procedures, including the effects of multiple aerosol scattering and cloud and rain influences.

Identifying clues to infections in nursing home residents. The role of the nurses' aide

1. Hospitalized elderly are being discharged to nursing homes earlier and with conditions that previously would have merited prolonged stay in the acute care facility; nurses' aides (NAs) provide the vast majority of direct care to nursing home residents. 2. With this change in resident acuity, it is increasingly important for the NA to develop skills to recognize "clues" to potential problems (eg, early signs and symptoms of infection). The consequences of failing to recognize a resident problem promptly can often result in rapid progression of a condition such as an infection. 3. The challenge to improve the work environment of the nursing home so that it is conducive to improved NA performance will be of increasing importance as we move into the next century with more elderly people, fewer resources per capita, and increasing regulatory demands to reduce complications in residents and improve safety for care providers.

Cognitive performance of alcoholics: a longitudinal evaluation of the role of drinking history, depression, liver function, nutrition, and family history

To assess the role of drinking history, depression, liver function, nutrition, and family history on cognitive performance, 171 detoxified male alcoholics were administered a brief neuropsychological examination at admission and discharge from an inpatient treatment program and at a 3-month follow-up evaluation. Regression analyses showed that at admission, depression and liver function were significant predictors of neuropsychological performance, whereas at discharge 3 to 4 weeks later only age and an estimate of premorbid intelligence were significant predictors. At the 3-month follow-up, estimates of drinking following discharge and severity of depressive symptoms were major significant predictors of neuropsychological performance. Indices of drinking prior to admission to the treatment program, nutrition, and family history for alcoholism did not predict performance on any of the three test occasions. These findings indicate that in addition to the chronic neurotoxic effect of alcohol a number of different medical and psychiatric factors, as well as the acute effects of alcohol, contribute to the cognitive scores of patients at various points in the clinical course.

Reduced cerebral grey matter observed in alcoholics using magnetic resonance imaging

Twenty-eight chronic alcoholics and 36 age- and sex-matched non-alcoholic controls were examined with magnetic resonance imaging and brain morphometric analyses. Results confirmed large increases in subarachnoid cerebrospinal fluid (CSF) volume and mild ventricular enlargement in the alcoholics and revealed associated volume reductions of localized cortical and subcortical cerebral structures. Volume losses in the diencephalon, the caudate nucleus, dorsolateral frontal and parietal cortex, and mesial temporal lobe structures were the most prominent. Significant correlations between increments in cortical and ventricular CSF and decrements in the volume of cortical and subcortical grey matter were noted. Although there was little evidence for relationships between performance on neuropsychological tests and volume of grey matter structures, significant correlations between some cognitive measures and subcortical and cortical fluid volumes were found. The parallels between this pattern of affected structures and recent neuropathological findings are discussed.

Magnetic resonance imaging of alcoholic Korsakoff patients

Eight patients with alcoholic Korsakoff's syndrome were compared to age-matched groups of normal controls and nonamnesic chronic alcoholic patients using magnetic resonance imaging (MRI). Quantitative image-analytic techniques were used to estimate volumes of ventricular and cortical cerebrospinal fluid (CSF), as well as cortical and subcortical grey matter structures. For the nonamnesic alcoholics, these volume analyses revealed large CSF increases with some circumscribed decreases in grey-matter volumes. In contrast, alcoholic Korsakoff patients showed widespread reductions in grey matter volumes in addition to CSF increases, with greatest reductions observed in diencephalic structures. The volume losses that best differentiated the Korsakoff patients from the alcoholic controls included losses in anterior portions of the diencephalon, mesial temporal lobe structures, and the orbitofrontal cortices. These findings suggest that damage to structures other than the mesial thalamic nuclei, such as the hypothalamus and hippocampus, may contribute to the Korsakoff patients' amnesic symptoms.

Characterization of release of tumor necrosis factor, interleukin-1, and superoxide anion from equine white blood cells in response to endotoxin

Direct effects of endotoxin (lipopolysaccharide [LPS]) on equine WBC are known to stimulate the release of a variety of mediators including thromboxane, prostacyclin, and leukotrienes. In this study, 0.1 microgram of LPS/ml stimulated an early increase in tumor necrosis factor, succeeded by an increase in interleukin-1, but concentrations of LPS up to 5.0 micrograms/ml caused no significant increase in superoxide anion release. The concentration of LPS (0.1 microgram/ml) used in this experiment was in the range of concentrations measured in plasma of some horses with gastrointestinal problems. These results indicate that mediators released in response to low concentrations of LPS may be responsible for many of the LPS-induced pathophysiologic effects. This is indicated because concentrations of LPS detected in plasma of some horses with severe gastrointestinal problems are approximately 0.1 microgram/ml, a concentration that will stimulate cells to produce tumor necrosis factor, but will not stimulate any other measurable cytotoxic effect.

[Cysts of the thoracic canal. Apropos of a subclavicular site]

The authors report a case of cystic dilatation of the terminal portion of the thoracic duct which clinically corresponded to a swelling in the root of the left side of the neck. Pathogeny and evolutive mode of this exceptional affection are ill known. Echography and scanography show the cystic nature of the mass. Diagnosis is made by direct puncture which can prove the chylous nature of the content and permits the opacification of the cyst. Lymphography shows the type of junction with the thoracic duct.

Avoiding mental changes and falls in older Parkinson's patients

Falling occurs more often in patients with Parkinson's disease when there is inadequate--not excessive--effect of the antiparkinsonian agent. Thus, falling may be evidence of a need for increased dosage. Of PD patients participating in a study, 60% reported experiencing hallucinations, confusion, vivid dreams, or nightmares. Confusion (34%) was the most commonly reported mental complaint; 27% reported vivid dreams; 26%, hallucinations; and 20%, nightmares.