Miracle-dz/UniFAR-FTUs huggingface dataset:
Dysphagia in Myæsthenia Gravis

PATIENTS with myaesthenia gravis presenting in the E.N. T. clinic as cases of dysphagia are not common and if the clinician is unfamiliar with the condition can very easily be misdiagnosed or dismissed as a functional disorder. In the first of the three cases described hereunder the diagnosis proved elusive not only in the E.N. T. clinic but also in medical, orthopaedic and psychiatric clinics. Yet it has been stated that the bulbar form of myaesthenia gravis with its typical fatigue palsy is readily identified, providing the right questions are asked (F. A. Elliott, 1956). Myaesthenia gravis occurs in both sexes but twice as commonly in the female; usually within the age range of 20-50 years, although F. B. Walsh in his series (1949) had patients as young as 3 years and as old as 75 years. Ophthalmoplegia, ptosis and weakness of the facial muscles are the most frequent and earliest symptoms and F. B. Walsh found the order of frequency of other symptoms was: weakness of the jaw muscles; dysphagia and dysarthria; weakness of the limbs and muscles of respiration. In Viets series (1942), approximately 20 per cent, suffered from dysphagia. Dysarthria and regurgitation of fluid through the nose are often associated with the dysphagia. Fluctuation of symptoms is common and occasionally remissions occur lasting for years. Respiratory distress in some instances is apoplectic in its appearance and respiratory failure is the common cause of death (F. B. Walsh, 1949). It has been suggested that myaesthenia gravis is an auto immune disease in which the thymus reacts to and against motor end plate proteins or other muscle tissue antigen (Simpson, i960). Myaesthenia gravis occasionally occurs as a complication of thyrotoxicosis or of malignant disease (particularly carcinoma of the bronchus).
Association of Traditional Cardiovascular Risk Factors With Development of Major and Minor Electrocardiographic Abnormalities: A Systematic Review

Electrocardiographic (ECG) abnormalities are prevalent in middle aged and are associated with risk of adverse cardiovascular events. It is unclear whether and to what extent traditional risk factors are associated with the development of ECG abnormalities. To determine whether traditional cardiovascular risk factors are associated with the presence or development of ECG abnormalities, we performed a systematic review of the English-language literature for cross-sectional and prospective studies examining associations between traditional cardiovascular risk factors and ECG abnormalities, including major and minor ECG abnormalities, isolated nonspecific ST-segment and T-wave abnormalities, other ST-segment and T-wave abnormalities, QT interval, Q waves, and QRS duration. Of the 202 papers initially identified, 19 were eligible for inclusion. We examined data analyzing risk factor associations with ECG abnormalities in individuals free of cardiovascular disease. For composite major or minor ECG abnormalities, black race, older age, higher blood pressure, use of antihypertensive medications, higher body mass index, diabetes, smoking, and evidence of left ventricular hypertrophy or higher left ventricular mass are the factors most commonly associated with prevalence and incidence. Risk factor associations differ somewhat according to types of specific ECG abnormalities. Because major and minor ECG abnormalities have important and independent prognostic significance, understanding the groups at risk for their development may inform prevention strategies focused on modifiable risk factors to reduce the burden of ECG abnormalities, which may in turn promote CVD prevention.
Treatment Is Indicated because of the Risk of Accelerated Atherosclerosis

It has been clear since shortly after the development of hemodialysis that morbidity and death due to cardiovascular disease were increased in patients with end-stage renal disease (ESRD) (1-6). Myocardial infarction, stroke, peripheral vascular disease, and sudden death (not explained by hyperkalemia) occur more frequently in dialysis patients compared to ageand gender-matched populations. Early disease and death associated with atherosclerosis are particularly prevalent when age is considered (1, 3 , 5 , 6). The increase in cardiovascular disease is more evident in Caucasians than in African-Americans ( 3 , 7). Since most of the early studies were performed when patients selected for dialysis were younger and did not have diabetes, these observations are especially significant because they could be partially obscured using data from today’s older dialysis popu-
Cardiac Manifestations of Sarcoidosis and Therapeutic Options

Sarcoidosis is a multisystem disorder of unknown etiology, characterized by granulomatous infiltration and the development of noncaseating granulomas in many organ systems. Although the lungs, eyes, and skin are most commonly affected, virtually any body organ can be involved. Clinical evidence of sarcoid heart disease (SHD) is seen only in 5% of patients and the disease may present with tachyarrhythmias, conduction disturbance, heart failure, or sudden cardiac death. SHD may present at any age and occurs in all ethnic groups. Cardiac involvement, although typically silent, is an important prognostic factor in sarcoidosis. Various diagnostic tests such as the electrocardiogram, two-dimensional echocardiography, cardiac magnetic resonance imaging, positron emission tomography scan, radionuclide scan, and a transvenous endomyocardial biopsy are available for the early detection of cardiac involvement in sarcoidosis. Given that early diagnosis and treatment may prevent substantial morbidity and mortality in patients with cardiac involvement, it remains important to screen patients with sarcoidosis and initiate early treatment with corticosteroids. Other immunosuppressive agents, antiarrhythmic drugs, placement of an automated implantable cardiac defibrillator, or surgical options such as a pericardial window, ventricular aneurysm repair and cardiac transplant, may also be required for the management of patients with SHD.
Improving access to psychological therapies for all adults

New psychological services are about to roll out across England. The National Institute for Health and Clinical Excellence clinical guidelines have led to government investment in the Improving Access to Psychological Therapies (IAPT) programme. New IAPT services should cut waiting times for psychological treatment of depression and anxiety disorders from months to days. They are intended to be available for all adults on the basis of need rather than age. It is not currently illegal for patients to be discriminated against by the National Health Service (NHS) because of their age. The government intends to introduce new legislation against age discrimination in the provision of goods, facilities and services by the NHS. Further investment and service development will be needed to counter existing age-related inequalities in mental health services
Editorial: Play and learn: potentials of game-based learning

Many of us have grown up playing games, and in primary education games have a high presence in nonformal and informal segments of our learning. Unfortunately, in formal education, games are still often seen just as an unserious activity, and the potentials of games for learning often stay undiscovered. Digital game-based learning is a novel approach in the area of universities and lifelong learning, and the search for new positioning of the universities in the changing setting of education; gaming is becoming a new form of interactive content, worthy of exploration. (http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8535.2007.00722.x/abstract)
Management of Hypercholesterolemia in Older Persons for the Prevention of Cardiovascular Disease

Multiple randomized, double-blind, placebo-controlled studies and observational studies have demonstrated that statins decrease mortality and major cardiovascular events in high-risk persons with hypercholesterolemia. The Heart Protection Study showed that statins decreased mortality and major cardiovascular events in high-risk persons regardless of the initial level of serum lipids, age, or gender. The updated National Cholesterol Education Program III guidelines state that in very high-risk patients, a serum low-density lipoprotein (LDL) cholesterol level of <70 mg/dL is a reasonable clinical strategy, regardless of age. When a high-risk person has hypertriglyceridemia or low serum high-density lipoprotein cholesterol, consideration can be given to combining a fibrate or nicotinic acid with an LDL cholesterol-lowering drug. For moderately high-risk persons, the serum LDL cholesterol should be lowered to <100 mg/dL. When LDL cholesterol-lowering drug therapy is used to treat high-risk persons or moderately high-risk persons, the serum LDL cholesterol should be reduced at least 30% to 40%. High-risk older persons should be treated with lipid-lowering drug therapy according to National Cholesterol Education Program III updated guidelines to decrease cardiovascular morbidity and mortality. The LDL cholesterol should be decreased to <160 mg/dL in persons at low risk for cardiovascular disease.
Anti-inflammatory Diets

Chronic disease is driven by inflammation. This article will provide an overview on how the balance of macronutrients and omega-6 and omega-3 fatty acids in the diet can alter the expression of inflammatory genes. In particular, how the balance of the protein to glycemic load of a meal can alter the generation of insulin and glucagon and the how the balance of omega-6 and omega-3 fatty acids can effect eicosanoid formation. Clinical results on the reduction of inflammation following anti-inflammatory diets are discussed as well as the molecular targets of anti-inflammatory nutrition. To overcome silent inflammation requires an anti-inflammatory diet (with omega-3s and polyphenols, in particular those of Maqui). The most important aspect of such an anti-inflammatory diet is the stabilization of insulin and reduced intake of omega-6 fatty acids. The ultimate treatment lies in reestablishing hormonal and genetic balance to generate satiety instead of constant hunger. Anti-inflammatory nutrition, balanced 40:30:30 with caloric restriction, should be considered as a form of gene silencing technology, in particular the silencing of the genes involved in the generation of silent inflammation. To this anti-inflammatory diet foundation supplemental omega-3 fatty acids at the level of 2–3 g of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) per day should be added. Finally, a diet rich in colorful, nonstarchy vegetables would contribute adequate amounts of polyphenols to help not only to inhibit nuclear factor (NF)-κB (primary molecular target of inflammation) but also activate AMP kinase. Understanding the impact of an anti-inflammatory diet on silent inflammation can elevate the diet from simply a source of calories to being on the cutting edge of gene-silencing technology.
Pulmonary Hypertension in Pregnancy

The presence of pulmonary arterial hypertension (PAH) in pregnancy is rare and signifies a high-risk pregnancy. Although the majority of mothers have knowledge of their condition before pregnancy, approximately one-third of patients are diagnosed during pregnancy. Termination of pregnancy should be discussed, and is often advised; however, a significant proportion of patients will choose to proceed with the pregnancy despite increased maternal and fetal mortality. Currently, most pregnant patients receive advanced therapy for treatment of PAH, particularly prostacyclin analogues. Particular attention is paid to volume status and blood loss and there has been a major trend toward delivery by cesarean section under controlled conditions involving an expert multidisciplinary team. The time of greatest maternal risk is in the first month after delivery. Transplantation of these patients in the nonpregnant state may be considered when those with idiopathic pulmonary hypertension have poor functional status despite optimal therapy and their projected 2-year survival is less than 50%. For patients with Eisenmenger syndrome, severe symptoms and an unacceptable quality of life may lead to transplantation.
The Effect of Cranberry Juice Consumption on the Recurrence of Urinary Tract Infection: Relationship to Baseline Risk Factors

ABSTRACT Objective: The objective of this study was to assess relationships between clinical predictors of urinary tract infection (UTI) and effects of cranberry juice consumption on recurrence in a post hoc analysis of a 24-week, randomized, double-blind, placebo-controlled, multicenter clinical trial in women with a recent history of UTI. Methods: Participants consumed a cranberry (n = 185) or placebo (n = 188) beverage (240 mL) daily. Odds ratios (OR) from 20 candidate predictor variables were evaluated in univariate analyses to assess clinical UTI incidence relationships in the placebo group. A multivariate logistic regression model was developed. The effects of cranberry juice consumption were evaluated in subsets categorized by the likelihood of a UTI event based on the prediction model. Results: In the placebo group, the final multivariate regression model identified four variables associated with the odds for having ≥ 1 UTI: intercourse frequency ≥ 1 time during the prior 4 weeks (OR: 2.36; 95% confidence interval [CI]: 0.98, 5.71; p = 0.057), use of vasectomy or hormonal methods for contraception (OR: 2.58; 95% CI: 1.20, 5.58; p = 0.016), most recent UTI < 90 days prior to screening (OR: 2.28; 95% CI; 1.12, 4.67; p = 0.024), and living in France compared with the United States (OR: 0.17; 95% CI: 0.04, 0.79; p = 0.024). Three propensity categories were investigated (24-week probability < 10%, 10%–21%, and > 21%). Incidence rate ratios for the cranberry vs placebo groups were 0.76 (95% CI: 0.22, 2.60; p = 0.663) for those with < 10% probability, 0.73 (95% CI: 0.35, 1.53; p = 0.064) for those with 10% to 21% probability, and 0.58 (95% CI: 0.35, 0.97; p = 0.039) for those with > 21% probability. Conclusions: Results suggest that clinical predictors identify women with low and high risk of clinical UTI recurrence, which may be useful for design of clinical studies evaluating preventive therapies.
Education, education, education: postgraduate assessments and the consultant contract

Recent changes in medical training have involved the introduction of a number of different tools for the assessment of trainees at all levels. These are completed by all doctors ranging from the level of foundation year 1 (FY1) trainees (previously pre-registration house officers) to final year specialty trainees (STs). While consultants are required to be an integral part of this assessment process, no formal time has been set aside and protected for these sessions. We propose the correct number of sessions for this activity be part of a new consultant contract, especially given the significant increase in the quantity of assessment and appraisals in the current training system. But how many hours are required?
Neurocognitive Predictors of Declining Financial Capacity in Persons with Mild Cognitive Impairment

ABSTRACT Objective: To identify cognitive predictors of declining financial capacity (FC) in persons with mild cognitive impairment (MCI). Methods: Participants were 66 cognitively normal older adults and 49 persons with MCI who completed neuropsychological testing and a performance measure of financial capacity (Financial Capacity Instrument; FCI) at baseline and two-year follow-up. We calculated two-year change scores for neuropsychological tests and FCI total score. We examined bivariate correlations between demographic/clinical variables and FCI change score, and between neuropsychological and FCI change scores. The five strongest bivariate correlates were entered into a linear regression analysis to identify longitudinal predictors of financial decline within group. Results: Persons with MCI showed significant decline on the FCI and most cognitive variables, while controls demonstrated relatively stable performance. For persons with MCI, education correlated with FCI change score. The top four cognitive variable-FCI change score correlations were written arithmetic, confrontation naming, immediate visual memory, and visual attention. In the regression model, written arithmetic was the primary predictor and visual memory and visual attention were secondary predictors of two-year FCI change scores. Conclusion: Semantic arithmetic knowledge, and to a lesser extent visual memory and attention, are key longitudinal cognitive predictors of financial skill decline in individuals with MCI. Clinical Implications: Clinicians should consider neurocognitive abilities of written arithmetic, visual memory, and processing speed in their assessments of financial capacity in person with MCI.
PRN Medication Administration in a Geriatric Psychiatric Hospital: Chart Review and Nursing Perspective

ABSTRACT Objective: To improve patient care/outcome, an evaluation was conducted of nursing procedures and protocols for pro re nata (PRN) medications. Methods: A 14-day chart review was conducted for 27 patients with mood and thought disorders (MTD) and for 24 patients with organic disorders (OD) at a geriatric psychiatric hospital, and a questionnaire was completed by 20 nurses. Results: 377 PRNs were administered to patients in the MTD and OD units (240 and 137, respectively). The majority of PRNs were administered during the evening shifts on the MTD unit and during the day shifts on the OD unit. Chart notes indicated the behavior requiring PRN administration was not always specifically described and therapeutic interventions were not often attempted before PRN administration. Inconsistency between chart notes and medication record books was noted in the majority of cases. It was often not known whether the PRN was initiated by the staff, patient, or family. PRNs were reported to be not effective in the majority of cases. Conclusions: Documentation was suboptimal and effectiveness was poor. Clinical Implications: It would be worthwhile to train all staff in a patient-centered or ecopsychosocial (i.e., non-pharmacological) model of care, which would provide staff alternatives to PRNs. In that context, it would be important to implement standards of practice into geriatric psychiatry inpatient settings for PRN administration and documentation.
Personality and its Relationship to Depression and Cognition in Older Adults: Implications for Practice

ABSTRACT Objectives: Personality is an important contributor to an individual’s mental health and is consistently linked to the two most prevalent mental health conditions among older adults: dementia and depression. This review summarizes the current findings on personality and its association with cognitive decline and depression, as well as treatment outcomes and possible intervention strategies. Methods: Literature searches were conducted in Web of Science, PubMed, and PsycINFO. Search terms included ‘personality traits,’ ‘depression,’ ‘treatment,’ and ‘older adults. ’ Results: Cognitive decline and depressive disorders are both associated with a common personality profile: high neuroticism, and low conscientiousness, extraversion, openness, and agreeableness. Across studies, the most consistent predictor of late-life depression, its course, and treatment outcomes is higher neuroticism. Conclusions: Personality traits are associated with cognitive decline, as well as the diagnosis and course of late-life depression in older adults. However, formal personality assessment is not typically incorporated in clients’ treatment plans, even though personality traits may influence treatment efficacy and outcomes. Clinical Implications: Formal assessment of personality traits may be beneficial in terms of treatment adherence and outcomes for older adults. Tailored interventions that specifically target the client’s strengths are likely to be well received by both clients and clinicians.
Clinical outcomes of drug‐eluting versus bare‐metal in‐stent restenosis

In‐stent restenosis (ISR) is a challenging syndrome that affects drug‐eluting stents and bare‐metal stents. However, data comparing the outcomes of drug‐eluting versus bare‐metal ISR are limited. Our objective was to evaluate the long‐term clinical outcomes of drug‐eluting versus bare‐metal ISR. Patients who underwent percutaneous coronary intervention at Cleveland Clinic for ISR from 05/1999 to 06/2007 were included. Unadjusted outcomes were tested using Kaplan‐Meier curves followed by multivariable adjusted Cox proportional hazards analyses. Twenty seven variables, including type of stent used to treat ISR and procedural date, were included. The primary end point was a composite of death, myocardial infarction (MI), or target lesion revascularization (TLR). The secondary endpoints were components of the primary endpoint. Of 931 patients identified, 225 had drug‐eluting ISR and 706 had bare‐metal ISR. There were 279 cumulative events for a median follow‐up of 3.2 years. The primary endpoint was not different between drug eluting and bare‐metal ISR (22% versus 33%, adjusted hazard ratio [HR] 1.14; 95% confidence interval [CI], 0.79–1.66; P = 0.49). The secondary endpoints of death (8% versus 16%, adjusted HR 1.05; 95% CI, 0.56–1.98; P = 0.88), MI (4% versus 5%, adjusted HR 1.48; 95% CI, 0.54–4.04; P = 0.45), and TLR (15% versus 16%, adjusted HR 1.30; 95% CI, 0.81–2.11; P = 0.28) were also not different. This study represents the largest analysis comparing drug‐eluting to bare‐metal ISR. On multivariable Cox proportional hazard analyses, drug‐eluting and bare‐metal ISR have similar long term outcomes. © 2009 Wiley‐Liss, Inc.
Psychotherapy Termination Practices with Older Adults: Impact of Patient and Therapist Characteristics

ABSTRACT Objectives: The aims of this study were to survey clinicians’ opinions regarding psychotherapy practices in mutual termination with a specified population (depressed older adult outpatients) and to examine the patient and therapist characteristics that may influence such practices. Methods: We surveyed psychologists’ (N = 96) psychotherapy termination practices, using a hypothetical depressed older adult as a referent, to assess consensus on the appropriateness of various guidelines to termination and to examine whether these differ as a function of patient and therapist characteristics. Results: Several practices were generally agreed to be “extremely appropriate” when terminating psychotherapy with older adults, including collaborating to determine the end date of treatment and discussing patient growth. Data also indicate that patient factors, such as personality pathology, and therapist factors, such as having an Integrative theoretical orientation were associated with differential endorsement of termination practices. Identification as a geropsychologist or working regularly with older adults were associated with a more cautious approach to termination. Conclusions: There is substantial consensus regarding many approaches to termination, but modifications might be appropriate depending on patient characteristics. Clinical Implications: Clinicians agree on a set of fundamental termination practices when working with older adults, but modify these based on orientation and diagnosis.