The primary care physician and Alzheimer's disease: an international position paper

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Food sampling practice in the United Kingdom

As an integral part of the UK food surveillance scheme, routine food sampling is undertaken by officers at local councils. One of the main purposes of the food sampling programme is to detect food contaminants before they are sold to the public. This paper investigated the current UK food sampling activity undertaken by the local Environmental Health Departments and examined the effectiveness of the food programme. A national survey was undertaken by means of a questionnaire sent to 439 UK local authorities and a response rate of 39.2% (172 LAs) was achieved. Thirty-nine per cent of replies indicated that ensuring food safety and hygiene was the most important aim of sampling. Less than half of the returns suggested that their food programmes contributed to the prevention of foodborne illness. However, over three-quarters agreed that the current food sampling system could be improved upon. This study concluded that current UK food sampling is marginalized by financial constraints. In order to design an effective routine food programme, it should be based on an overall co-ordinated approach from local to European levels. Future work towards a statistically validated approach to the design will improve the effectiveness of food sampling programme.

The responsibilities and activities of internal medicine clerkship directors

PURPOSE

To characterize the responsibilities, activities, and scholarly productivity of internal medicine clerkship directors (CDs).

METHODS

In 1999, internal medicine CDs from 122 U.S. medical schools and one Canadian medical school were surveyed. The instrument asked about the CDs' demo-graphics, workloads, clerkship characteristics, and scholarly productivity.

RESULTS

The response rate was 89%; 72% of the respondents were men. Mean age was 45 years, mean time as CD was 6.5 years, and 58% of the CDs had completed fellowship training. The CDs spent 28% of their professional time on the clerkship, three half days weekly in clinic, and three months on inpatient services. The CDs had published a mean of 2.2 (range 0-20) articles and received a mean of 0.7 (range 0-4) grants. Similar factors were associated with publishing articles and receiving grants; gender (men), < or = three clinic half days weekly, fellowship training, having a faculty development program, teaching other courses, and discussing expectations with their department chairs. In a multivariate analysis, fellowship training, clinic half days, teaching other courses, and discussing expectations explained 22% of the variance for papers published. For grants received, a model with gender, clinic half days, a faculty development program, discussing expectations, and teaching other courses explained 35% of the variance.

CONCLUSIONS

An internal medicine CD invests significant effort administering the clerkship and contributing to clinical and educational activities. The factors associated with successful scholarship may be useful for fostering CDs' academic careers.

Identification of benzethonium chloride in commercial grapefruit seed extracts

Commercial grapefruit seed extracts (GSE) were extracted with chloroform. The solvent was evaporated, and the resulting solid was subsequently analyzed by high-performance liquid chromatography, electrospray ionization mass spectrometry, nuclear magnetic resonance (NMR) spectroscopy, and elemental analysis (by proton-induced X-ray emission [PIXE] analysis). The main constituent was identified as benzethonium chloride, a synthetic antimicrobial agent commonly used in cosmetics and other topical applications. This compound comprised 8.03% (n = 2) of the liquid GSE sample. Higher amounts of benzethonium chloride were found in powder GSE samples.

Fear of hypoglycaemia among insulin-treated Hong Kong Chinese patients: implications for diabetes patient education

This study investigated fear of hypoglycaemia among insulin-treated Chinese patients in Hong Kong. The study employed a cross-sectional descriptive design. Using structured-interviews, the authors collected data from 120 insulin-treated adults attending a diabetes centre. Results showed that although hypoglycaemic attacks were generally mild, they were common amongst one-third of patients. Fear was predominantly low, however 15% of respondents reported high fear. In addition, fear correlated positively with time since insulin-treatment, frequency of hospitalization due to hypoglycaemia, and frequency of hypoglycaemia affecting working life. Results also showed that although all respondents were insulin-treated, 40% had undesirable metabolic control. No statistically significant differences were found between the respondents' rating of adequacy of their diabetes knowledge among three groups of respondents who had completed, defaulted or were attending an education programme. Implications for diabetes patient education and further study are discussed.

Accuracy, precision and user-acceptability of self blood glucose monitoring machines

The performance of six self-monitoring blood glucose (SMBG) machines (Accutrend, Reflolux S, Companion 2, Glucometer GX, Glucometer IV and One Touch II) were examined using venous blood samples from 88 patients. Whole blood glucose (BG) values were measured by four machines from each brand. Machine-generated whole blood glucose (BG) values were corrected before comparison with laboratory plasma glucose values, measured by a glucose oxidase method. Based on error grid analysis, most of the corrected machine-generated BG values were clinically acceptable. Accutrend, Glucometer IV and Companion 2 showed the greatest consistency between machines of the same brand. Over 80% of corrected BG values generated by Glucometer IV fell within +/-10% of the reference values. One Touch II yielded the most reproducible results with a mean CV of 2.7% and was considered the most user friendly machine. More studies are required to examine the performance of these machines in the hands of patients.

Use of a single lumen endotracheal tube and continuous CO2 insufflation in transthoracic endoscopic sympathectomy

BACKGROUND

Transthoracic endoscopic sympathectomy (TES) is an accepted standard surgical treatment for palmar hyperhidrosis. For anesthetic management, a double lumen endobronchial tube is usually used to deflate the lung on the operative side. Recently we have applied continuous insufflation of carbon dioxide (CO2) into the pleural cavity to merely compress one lung while ventilating both lungs with a conventional single lumen endotracheal tube.

METHODS

We have studied 45 patients (ASA I and II) who underwent bilateral TES, Thirty-three were ventilated by single lumen tube and the other 12 by double lumen endobronchial tube with one lung ventilation. In both groups I and II, CO2 was insufflated slowly through the scope to a intrapleural pressure of 20 cm H2O. Both lungs were ventilated with peak pressure of less than 20 cmH2O at tidal volume of 5-12 ml/kg at 10-16 beats/min.

RESULTS

In these patients, no CO2 retention was noted. Oxygenation and cardiovascular stability were maintained and there were no complications. In the double lumen series, we found that oxygen saturation was less uniform and less stable than those in the single lumen series.

CONCLUSIONS

It is concluded that the use of single lumen endotracheal tube with continuous insufflation of CO2 in TES is easy, simple and safe.

Changes in acute myocardial infarction risk and patterns of practice for patients older and younger than 70 years, 1987-90

OBJECTIVE

To evaluate temporal changes in risk and patterns of hospital practice for acute myocardial infarction (AMI).

DESIGN/PATIENTS

Retrospective analysis of age-related medical therapy and outcome of 342 consecutive patients (132 at least 70 years old and 210 younger than 70) with AMI between July 1, 1989, and June 30, 1990, and comparison with data from two previous analyses of AMI practice in 1987 (n = 207) and 1988-89 (n = 402).

SETTING

Tertiary care medical centre.

INTERVENTIONS

No direct interventions; results of the two previous AMI practice pattern analyses, however, were propagated during the practice time of the most recent analysis.

RESULTS

In 1989-90, hospital mortality was higher (19%) among patients at least 70 years old compared with patients younger than 70 (8%) (P less than 0.01). Therapies proven by repeated clinical trials to be effective in reducing AMI risk were all used less frequently in patients aged at least 70 years: thrombolysis (20 versus 43%); beta-blockers (41 versus 62%); acetylsalicylic acid (71 versus 87%); and nitrates (86 versus 97%). Qualitatively, these age-specific patterns of AMI mortality and therapy were similar to previous studies. Quantitatively, however, comparing 1987 with 1989-90 demonstrated parallel and marked increases in the use of all proven medications in both age groups, ranging from 42 to 230% (P less than 0.01). There was also a significant overall decrease in mortality from the 1987 patient cohort (20%) to the 1989-90 cohort (13%) (P less than 0.05). The decrease in mortality was entirely due to decreased mortality within the group 70 years or older; 35% in 1987 versus 19% in 1989-90 (P less than 0.05). Mortality in the AMI patients younger than 70 years old remained unchanged from 1987 to 1989-90.

CONCLUSIONS

Pattern of practice analyses were associated with, and may have contributed to, improved patient care and outcomes in AMI. Increased use of effective AMI medical therapy had a greater benefit in elderly higher risk AMI patients than lower risk younger patients. Persisting age-specific differences in AMI therapy may respond to more direct quality improvement measures, such as critical path management.

Comparison of risk and patterns of practice in patients older and younger than 70 years with acute myocardial infarction in a two-year period (1987-1989)

To further evaluate contemporary risk and practice patterns in acute myocardial infarction (AMI), 402 consecutive patients with AMI between July 1, 1988, and June 30, 1989 were studied. The clinical investigations, medical therapy and outcome of patients aged greater than or equal to 70 years (n = 132; group 1) were compared with patients aged less than 70 years (n = 270; group 2). In group 1, 20% of patients had no typical cardiac pain versus 6% in group 2 (p less than 0.01). History of previous AMI, Q-wave AMI and peak creatine kinase were not different in the 2 groups. In-hospital mortality was markedly higher in group 1 (27%) than in group 2 (8%), p less than 0.01. Multivariate analysis revealed previous AMI, presentation without typical pain and age greater than or equal to 70 years to be independently associated with the greatest relative risk. Post-AMI exercise testing, ejection fraction calculations and coronary angiography were all performed less often (p less than 0.01); proven effective medical therapies, including thrombolysis, beta blockers, acetylsalicylic acid and nitrates were all used less frequently (p less than 0.01). The very high mortality and less aggressive management of elderly patients with AMI confirm similar data from our 1987 AMI patient cohort and other recently reported AMI patient outcome analyses. However, it remains uncertain why older patients with AMI are investigated and treated differently from younger patients. Further studies are warranted.

The use of methylmethacrylate in primary total knee replacements with large tibial defects

Bone defects in the tibial plateau present technical problems in primary knee replacement surgery. A variety of techniques is available to solve these problems. Of 59 patients treated with a cement fill and followed an average of 7.1 years (range, five to 11 years), there was only one failure requiring revision. Overall, knee scores averaged 78 points and roentgenogram scores averaged 85 points. Radiolucent lines were noted in 43 of the 59 patients, but none were progressive except in the one failure. There was no clinical correlation between the presence of radiolucent lines and clinical symptoms. Good long-term results might be expected from the cement fill when the bone defects are smaller than 20 mm and affect less than 50% of either plateau.

Revised Absolute Configurations of Latifolic Acid and the Pyrrolizidine Alkaloid Latifoline

The absolute stereochemistry of (+)- latifolk acid has been determined by single-crystal X-ray crystallographic analysis to be (2S,3R,4R)-3- hydroxy-2,4-dimethyl-5-oxotetrahydrofuran-3-carboxylic acid. The configuration of the three chiral centres is opposite to that presently recorded in the literature. Accordingly, the configuration of the pyrrolizidine alkaloid, latifoline, which includes a latifolic acid side chain, must be revised.

Transposition of Tn1000: in vivo properties

Transposition mediated by the Tn1000 transposase was investigated by using transposon variants carrying synthetic or wild-type termini but no intact Tn1000 genes. Transposon Tn1001, whose only homologies to Tn1000 are in its 38-base-pair terminal inverted repeats, transposed at the same rate as Tn1005, an artificial construct carrying wild-type Tn1000 termini and approximately 1 kilobase of flanking Tn1000 DNA at each end, when transposase was supplied in trans. The majority of the transpositions into pOX38 gave rise to cointegrates, but approximately 10% of the products expressed phenotypes of direct transpositions. The expression and temperature dependence of the tnpA gene product were examined by studying transposition of Tn1001 to bacteriophage lambda. The temperature optimum for transposition was 37 degrees C, and the transposase was stable for up to 2 h at this temperature.

Stress fracture as a cause of chronic pain following revision total hip arthroplasty. Report of two cases

Femoral stress fractures following revision total hip arthroplasty developed about a cortical window in two patients. These cases differ from previously reported fractures in that there was no significant trauma, the pain was gradual in onset, and there was no displacement at the fracture site. Tomograms and radionuclide bone scans were necessary to reveal the fracture. One femur healed with hip spica immobilization, while the other required bone grafting. Femoral stress fractures should be considered in the differential diagnosis of patients with thigh pain after revision total hip arthroplasty, particularly if a cortical window had been necessary.

Rotational isomerism about the 17(20)-bond of steroids and euphoids as shown by the crystal structures of euphol and tirucallol

The influence of configuration at C-20 on rotation about the 17(20)-bond in steroids and euphoids was examined by x-ray crystallographic studies of the C-20 epimers euphol and tirucallol. The H atom on C-20 was in back next to C-18 in the crystal structures of both of the compounds, and C-22 was found to be cis-oriented ("left-handed") to C-13 in euphol and trans-oriented to it ("right-handed") in tirucallol. The results, which are consistent with the known left-handed crystal structure of 24(25)-dihydroeuphol and right-handed crystal structure of cholesterol and other natural sterols, lend further credence to the earlier suggestion that rotational isomerism at the 17(20)-bond can arise in C-20 epimers and that there is preference for an arrangement with the 20-H atom adjacent to C-18.

Quinones and quinone methides. X. The crystal structure of a dimeric oxidation product from 2,4-Bis(1,1-dimethylethyl)-6-[(4-methoxyphenyl)methyl]phenol

The molecular structure of a minor oxidation product of the insect sterilant 2,4-bis(1,1-dimethylethyl) 6-[(4-methoxyphenyl)methyl]phenol has been established as (�)-cis-1,3,6,8-tetrakis(1,1-dimethyl-ethyl)-4b,9b-bis(4-methoxyphenyl)-4b,9b-dihydrobenzofuro[3,2-b]benzofuran by means of X-ray crystallographic analysis.

Diarylheptanoid and other phenolic constituents of Centrolobium species

The heartwood of a specimen of Centrolobium tomentosum Benth (Leguminosae) has given (–)-centrolobine (1a), (–)-de-O-methylcentrolobine (1b), (–)-centrolobol (2), piceatannol (3)and the isoflavone formononetin (4). The heartwood of a second Centrolobium species, which could not be identified further at the U.S. Forest Products Laboratory, yielded (+)-centrolobine, (+)-de-O-methylcentrolobine, (+)-centrolobol, formononetin, 4',7-dihydroxyflavanone (5), 3-hydroxy-9-methoxypterocarpan (6) and minor amounts of a new dihydric phenol. This was identified by n.m.r. and X-ray diffraction measurements as 2-(2'-hydroxy-4'-methoxyphenyl)benzofuran-6-ol (8).

New quinolinone and bis-quinolinone alkaloids from Euxylophora paraensis

Three quinolin-2-one alkaloids were isolated from the heartwood of Euxylophora paraensis andidentified by spectroscopic methods as 2,3,3-trimethyl-2,3,4,5-tetrahydrofurano[3,2-c]quinolin-4-one(2a), its N-methyl derivative (2b), and 3-(1,2-dimethyl-2-hydroxypropyl)-4-hydroxy-1-methylquinolin-2(1 H)-one (3). Four new dimers, E, F, G and B, were also isolated and identified as the bisquinolin-2-ones (5c), (5d), (6) and (9). The unsaturated dimer G and an isomer have been prepared by oxidationof paraensidimerin A and C.

The structures of paraensidimerin A and C, two bisquinolinone alkaloids from Euxylophora paraensis

Single-crystal X-ray diffraction studies and n.m.r. spectral measurements have now shown structure of paraensidimerin A, a bisquinolinone alkaloid from the heartwood of Euxylophora paraensis (Rutaceae), to be (6aα,7β,15β,16aα)-(�-6,6,9,15,18-pentamethyl-6,6a,7,9,15,16,16a,18-octahydro-7,15-methano-8H,17H-quino[3',4' :5',6'] pyrano[3',4':5,6] oxocino[3,2-c] quinoline-8,17-dione (8). Paraensidimerin C is a stereoisomer, (6aα,7β,15β,16aβ)-(�)-6,6,9,15,18-pentamethyl-9,15,16,16a,18-octahydro-7,15-methano-8H,17H-quino [3',4':5',6'] pyrano [3',4': 5,6] oxocino [3,2-quinoline-8,17-dione (9). Possible biosynthetic routes to these and other dimeric quinolinone alkaloids are suggested.

Quinones and quinone methides. VIII. Oxidation products of the screwworm chemosterilant, 2,4-Bis(1,1-dimethylethyl)-6-(4-methoxyphenylmethyl)phenol

The title compound is oxidized by silver oxide in acetone to a complex mixture of products, including the benzophenone derivative (7), a benzylic alcohol, isolated as its methyl ether (15), and two spiro cyclohexadienone benzopyran dimers (17) and (19). A colourless dimer was shown by single-crystal X-ray diffraction measurements to be a 2,3- dihydrobenzofuran derivative (22).

Quinones and quinone methides. IX. Oxidation of 2,4-Bis(1,1-dimethylethyl)-6-(4-methoxyphenylmethyl)phenol in alcoholic solvents: Monomeric products and the crystal structure of an unusual dimes, 2-[3,5-Bis(1,1-dimethylethyl)-2-{methoxy-(4-methoxyphenyl)methoxy} phenoxyl-1,5-bis(1,1-dimethylethyl)-3-[methoxy-(4-methoxyphenyl)methyl]benzene

Oxidation of the title benzylphenol (1) with silver oxide in alcoholic media forms benzylic ethers of type (5) in high yields; e.g. oxidation in methanol yields 2,4-bis(1,1-dimethylethyl)-6-[methoxy(4- methoxyphenyl)methyl]phenol(5a) together with an unusual dimer, the structure of which was shown by X-ray crystallographic analysis to be 2-[3,5-bis(1,1-dimethylethyl)-2-{methoxy(4-methoxyphenyl)- methoxy}phenoxy]-1,5-bis(1,1-dimethylethy)-3-[methoxy(4- methoxyphenyl)methyl]benzene (6). The benzylic ethers (5) are convenient intermediates for the syntheses of a variety of compounds related to (1).

New quinolinone alkaloids from the heartwood of, Euxylophora paraensis

The heartwood of Euxylophora paraensis Hub. (Rutaceae) has given N-methylflindersine (2),spectabiline (3), skimmianine (4) and two new alkaloids, identified from spectroscopic data as 4-hydroxy-2,2,6-trimethyl-3,4,5,6-tetrahydro-2H-pyrano[3,2-c]quinolin-5-one (5) and 4-(2,3-dihydroxy-3-methylbutoxy)-1-methylquinolin-2(1H)-one (6). Five new dimeric quinolinone alkaloids, C30H30N2O4, were isolated. The structure of one of these, paraensidimerin D, has now been shown by single-crystal X-ray diffraction methods to be (11), viz. (6aα,7α,14aα)-6,6,9,16- tetramethyl-7-(2-methylprop-1-enyl)-6,6a,7,9,14a,16-hexahydro-8H,15H- quino[3'',4'':5',6'] pyrano [2',3':4,5] pyrano-[3,2-c]quinoline-8,15- dione.

Quinones and quinone methides. VI. Reactions of 2-Arylmethyl- and 2-(1-Arylethyl)- 1,4-benzoquinones with 4-hydroxy-2H-1-benzopyran-2-one

In alcoholic potassium hydroxide 2-methoxy-5-(4-methoxyphenylmethyl)- 1,4-benzoquinone (I) reacts with 4-hydroxy-2H-1-benzopyran-2-one (7) to yield the quinol (8a). In pyridine, however,(1) tautomerizes to the ortho-quinone methide which combines with (7) to yield (17a). 2-(1- Arylethyl-1,4-benzoquinones yield quinols related to (8a) in both alcoholic potassium hydroxide and pyridine solutions; this indicates that quinones methides which might be formed from these quinones are relatively unreactive to nucleophiles.

Drowning and near-drowning involving children: a five-year total population study from the City and County of Honolulu

A study of all serious childhood immersion accidents (both drowned and near-drowned cases) is reported from Hawaii. This is a total population-based survey of 140 consecutive cases (0--15 years) occurring during the five-year period (1973--1977. Age-specific, sex-specific, and osmolality-specific (salt versus fresh water) data are presented both for survivors and fatalities. The overall annual drowning rate of 3.1 per 100,000 children at risk is low, for a water-oriented society. The survival rate following loss of consciousness in the water is 73 per cent. There is no evidence from this study that osmolality affected the probability of survival. The rank order of importance of drowning sites is swimming pools, surf, sheltered salt water bathing, domestic bath tubs, fresh water streams, salt water canals, and garden fish ponds. Specific accident rates, by sex, outcome, and site of immersion are also presented. No secular trend in the rate of drowning was observed in this study. Comparison with the only other available total population survey (Australia) of childhood immersions reveals common epidemiological and demographic patterns in modern urban societies and suggests that safety regulations play a role in reducing swimming accidents and fatalities in children.

Performance comparison of scene matching techniques

The problem of matching two images of the same scene, taken by different sensors under different viewing geometries, is a challenging problem in the field of image processing and pattern recognition. The scenes are usually transformed so drastically by the different viewing geometries and sensor characteristics that it is extremely difficult, if not impossible, to match the original images without the proper data processing. Geometric and intensity transformations must be performed to bring the matching elements and their intensity into a one-to-one correspondence. Objects of interest represented by subimages of one scene were located in the other using scene matching techniques with intensity difference and edge features as measurement features. Performance characteristics of the matches by these techniques are presented in terms of the probability of a match as a function of the probability of false fix.

Toxaphene insecticide: a complex biodegradable mixture

Adsorption and gas-liquid chromatography separate toxaphene into at least 175 polychlorinated 10-carbon compounds including Cl(6), Cl(7), Cl(8), Cl(9), and Cl(10) derivatives. One toxic component is 2,2,5-endo,6-exo,8,9,10-heptachlorobornane. Rats metabolically dechlorinate toxaphene, removing about half of the chlorine from the technical insecticide and from each of seven subfractions of varying composition and toxicity.