bluuebunny/crossref_metadata_2025 huggingface dataset:
International Diabetes Federation: a consensus on Type 2 diabetes prevention
Authors: Alberti K. G. M. M. , Zimmet P. , Shaw J.
Published: April 2007

Aims  Early intervention and avoidance or delay of progression to Type 2 diabetes is of enormous benefit to patients in terms of increasing life expectancy and quality of life, and potentially in economic terms for society and health‐care payers. To address the growing impact of Type 2 diabetes the International Diabetes Federation (IDF) Taskforce on Prevention and Epidemiology convened a consensus workshop in 2006. The primary goal of the workshop and this document was the prevention of Type 2 diabetes in both the developed and developing world. A second aim was to reduce the risk of cardiovascular disease in people who are identified as being at a higher risk of Type 2 diabetes.

The IDF plan for prevention of Type 2 diabetes is based on controlling modifiable risk factors and can be divided into two target groups:

People at high risk of developing Type 2 diabetes

The entire population.

Conclusions  In planning national measures for the prevention of Type 2 diabetes, both groups should be targeted simultaneously with lifestyle modification the primary goal through a stepwise approach. In addition, it is important that all activities are tailored to the specific local situation.

Further information on the prevention of diabetes can be found on the IDF website: http://www.idf.org/prevention.
Investigating Managers' Exploration and Exploitation Activities: The Influence of Top‐Down, Bottom‐Up, and Horizontal Knowledge Inflows*
Authors: Mom Tom J. M. , Van Den Bosch Frans A. J. , Volberda Henk W.
Published: April 2007

abstract This paper develops and tests hypotheses on the influence of managers' knowledge inflows on managers' exploration and exploitation activities. Based on a survey among managers of a leading electronics firm, the findings indicate, as expected, that top‐down knowledge inflows of managers positively relate to the extent to which these managers conduct exploitation activities, while they do not relate to managers' exploration activities. Furthermore, as expected, bottom‐up and horizontal knowledge inflows of managers positively relate to these managers' exploration activities, while they do not relate to managers' exploitation activities. We contribute to current literature on exploration and exploitation by focusing on the manager level of analysis, and by adding the importance of knowledge flow configurations to studies which investigate the impact of organizational factors on exploration and exploitation.
Differentiating Good Soldiers from Good Actors*
Authors: Snell Robin S. , Wong Yuk Lan
Published: April 2007

abstract  In a qualitative interview study, 20 Hong Kong Chinese informants were asked to report stories about colleagues who were either ‘good soldiers’ or ‘good actors’. In stories about good soldiers, informants attributed their colleagues' organizational citizenship behaviour (OCB) primarily to prosocial or pro‐organizational motives. Informants' stories about good actors broke down into three major subcategories of citizenship‐related impression management: OCB attributed primarily to impression management motives; alleged pseudo‐OCB concomitant with minimal compliance; and alleged pseudo‐OCB concomitant with counterproductive behaviour. When distinguishing good soldiers from good actors, informants adopted two criteria for attribution: wilful behavioural inconsistency, i.e. low generality of behaviour across contexts; and alleged false pretence, i.e. discrepancy between claims or allusions and actual deeds. Our findings partially supported a prior hypothesis from attribution theory, that consistency was a criterion for attribution, but indicated that consensus, i.e. correspondence between the focal colleague's behaviour and other employees' behaviour, failed to differentiate good soldiers from good actors. Informants generally regarded OCB as socially desirable only when it was attributed primarily to prosocial/pro‐organizational motives.
Young children's representations of peers’ distress: Associations to children's social functioning and acceptance of distressed peers
Authors: BENGTSSON HANS , PERSSON GUN E. B.
Published: April 2007

Children's mental representations of situations involving another child's distress were examined in two studies. Study 1 examined 3‐ to 7‐year‐old children's (n= 44) ideas about what victims and bystanders would think, feel and do in hypothetical situations. In Study 2, 7‐ to 8‐year‐olds (n= 40) described their own cognitive response to situations in which they were confronted with another's distress. In both studies, representational bias was examined in relation to children's display of prosocial and aggressive behavior and in relation to their acceptance of distressed peers. Although not entirely consistent, findings indicate that three types of representational biases are associated with low levels of considerate behavior and with relatively low acceptance of distressed peers: (a) mentally representing the victim's problem without giving thought to its implications for the victim, (b) significantly reducing the emotional significance of the problem and (c) exaggerating negative aspects of the problem.
Constructions of work stress and coping in a female‐ and a male‐dominated department
Authors: TORKELSON EVA , MUHONEN TUIJA , PEIRÓ JOSÉ MARIA
Published: April 2007

In the present study the nature of stress and coping was investigated and considered as socially constructed. Thirty small group interviews were performed using the Critical Incident Technique in one female‐ and one male‐dominated customer service department of a telecom company. The main themes about stress among both women and men were often expressed as collective phenomena and were connected to the organizational change and downsizing process, problems when carrying out the work and lack of autonomy. However, a striking difference between female and male interviews was found in the way that women to a greater extent expressed lack of autonomy and their working situation was described as strictly regulated. The findings illustrate that a traditional gender difference regarding autonomy could be found when comparing a female‐ and a male‐dominated department even though they were performing the same type of job. Both women and men portrayed coping as a mixture of collective and individual strategies. They often mentioned collective acceptance, resignation and hardening. There is a need for further research about women and men at work, taking into consideration the interpersonal context and the collective nature of stress and coping.
Estimation of premorbid cognitive function based on word knowledge: The Swedish Lexical Decision Test (SLDT)
Authors: ALMKVIST O. , ADVEEN M. , HENNING L. , TALLBERG I. M.
Published: April 2007

In clinical neuropsychology, the present status of a patient is evaluated in relation to the assumed premorbid status. However, in Sweden, existing methods to assess premorbid status are far from optimal. In the present study, the design and evaluation of a Swedish Lexical Decision Test (SLDT) for premorbid global cognitive function (i.e., premorbid intelligence) is described. The design was based on the empirical finding that, in general adult population, word knowledge is strongly associated with measures of global cognitive functioning. Linear stepwise regression analysis demonstrated that SLDT findings accounted for 48% of the variance of global cognitive function as assessed by the Full Scale Intelligence Quotient (FSIQ) from the Wechsler Adult Intelligence Scale Revised (WAIS‐R). Demographic variables alone accounted for 31% and a combination of SLDT results and demographics accounted for 60%. Psychometric properties are presented using data from 109 healthy individuals stratified according to age, gender, and level of education. In addition, a case of Alzheimer's disease is presented to illustrate the relationship between SLDT performance and cognitive function. Finally, the theoretical foundation for the relationship between word knowledge and global cognitive function is discussed.
Socio‐cognitive conflict, emotions and complexity of thought in real‐life morality
Authors: MYYRY LIISA , HELKAMA KLAUS
Published: April 2007

A new taxonomy of real‐life dilemmas was tested in two studies. In Study 1, 35 respondents assessed six types of real‐life dilemmas in terms of socio‐cognitive conflict. Support was found for a classification of dilemmas into three levels of socio‐cognitive conflict. In Study 2, 191 young women responded to measures of social perspective‐taking and emotional empathy and reported a real‐life moral dilemma as well as their feelings while making decisions about it. The dilemmas were classified into personal and impersonal and into three levels of socio‐cognitive conflict. Dependent variables were the integrative complexity of the arguments and the reported feelings (sympathy, upset, and remorse). Dispositional empathy and perspective taking predicted level of socio‐cognitive conflict and feelings of sympathy but not integrative complexity. Personal dilemmas aroused more feelings of upset than did impersonal ones. Low socio‐cognitive conflict dilemmas evoked less complex thinking and less intensive feelings of upset and sympathy than did moderate and high socio‐cognitive conflict dilemmas.
Cervical occlusion in women with cervical insufficiency: protocol for a randomised, controlled trial with cerclage, with and without cervical occlusion*
Authors: Secher NJ , McCormack CD , Weber T , Hein M , Helmig RB
Published: April 2007

Objective  To evaluate the effect of double cerclage compared with a single cerclage.

Design  Randomised, controlled multicentre trial.

Setting  Ten different countries are participating with both secondary and tertiary centres. The countries participating are Denmark, Sweden, Germany, United Kingdom, Spain, South Africa, Australia and India. This gives both a broad spectrum of diversity global and local. We expect a total of 242 women enrolled per year.

Population 

Prophylactic study:

History of cervical incompetence/insufficiency. (Delivery 15 to <36 weeks.)

Congenital short cervix (secondary to maternal administration of diethyl stilbestrol) or traumatic/surgical damage rendering the vaginal approach difficult (e.g. conisation).

Cervical suture applied in previous pregnancy, successful outcome.

Previous failed cerclage.

Therapeutic study:

Secondary cerclage: Short cervix, without the membranes being exposed to the vagina.

Tertiary cerclage: Short cervix, membranes exposed to the vagina.

Observational study: Eligible women who refuse to be randomised will participate in an observational study.

Repeat/requested cervical occlusion.

Methods  The women will be randomised between a single (vaginal or abdominal) and a double cerclage. The cervical cerclage (McDonald or Shirodkar) as well as the abdominal suture will be performed with the same material and technique normally used by the participating department. Those randomised to the double cerclage will have their external os closed with a continuous nylon 2‐0/3‐0 suture, in addition to the standard single cerclage. Local guidelines concerning antibiotics, Heparin, bed rest, tocolytics etc. are followed and recorded in the follow‐up form.

Main outcome measures  Primary endpoint is take home baby rate. The secondary endpoints are gestational age at delivery, incidence of preterm birth (<34+0 days) and number of days in neonatal unit.
Does methotrexate confer a significant advantage over misoprostol alone for early medical abortion? A retrospective analysis of 8678 abortions
Authors: Aldrich T , Winikoff B
Published: April 2007

Objective  The objective of this study was to compare efficacy for four medical abortion regimens used in one clinic setting: (1) misoprostol alone, (2) oral methotrexate + buccal misoprostol, (3) oral methotrexate + vaginal misoprostol, and (4) intramuscular methotrexate + vaginal misoprostol.

Design  Retrospective analysis of data from clinical records.

Setting  An anonymous women’s health centre in Latin America, providing medical abortion services since 2001 in a highly restrictive setting.

Population  A total of 8678 women with gestations <56 days, who sought a medical abortion between April 2002 and December 2004.

Methods  Chi‐square test was performed to compare patient characteristics by abortion outcome (success/failure). The impact of selected variables on method success was explored through logistic regression. A second regression analysis was conducted with a subsample (n= 4022), for which data on parity and previous abortion(s) were available.

Main outcome measure  Abortion outcome (success/failure) at 2‐week follow up.

Results  Success rates for the three methotrexate regimens ranged from 81.7 to 83.5% and did not differ significantly; misoprostol‐alone regimen had a success rate of 76.8%. Efficacy was significantly higher for the three combined methotrexate regimens compared with misoprostol alone and remained so in the multivariate model (OR = 1.35). In the final regression, lower gestational age, being nulliparous, and having no previous abortions were positively correlated with method success.

Conclusions  In this real‐use setting, methotrexate appears to confer a significant advantage over misoprostol alone for early medical abortion. This finding is important for settings where mifepristone remains unavailable. Additional factors such as gestational age limits and patient preference should be considered in regimen selection.
Short communication: Pregnancy outcome in Factor XI deficiency: incidence of miscarriage, antenatal and postnatal haemorrhage in 33 women with Factor XI deficiency
Authors: Myers B , Pavord S , Kean L , Hill M , Dolan G
Published: April 2007

Pregnancy complications in women with Factor XI deficiency were assessed in this retrospective analysis. All nonnulliparous women registered with Factor XI deficiency in the East Midlands region were included. Each woman was classified into ‘bleeder’ or ‘nonbleeder’. Rates of antenatal and postnatal bleeding and miscarriage rate were recorded. A total of 33 women had 105 pregnancies. Pregnancy and delivery was uneventful in 70% of the cases. Postpartum haemorrhage (PPH) appears increased in women with a ‘bleeding‘ phenotype with a highly significant difference between ‘bleeders’ and ‘nonbleeders’ (relative risk [RR] 7.2; CI 1.99–25.9). Miscarriage rate appeared unchanged. We conclude that PPH is increased in a subgroup with a bleeding phenotype. Larger studies are needed to define the underlying factors.
Neuropsychological outcome of children with asymmetric ventricles or unilateral mild ventriculomegaly identified in utero
Authors: Sadan S , Malinger G , Schweiger A , Lev D , Lerman‐Sagie T
Published: April 2007

Design  To assess the neuropsychological outcome of children with asymmetric ventricles and unilateral ventriculomegaly identified in utero.

Setting  Fetal neurology clinic.

Population  We assessed 21 children with asymmetric ventricles (group 1) and 20 children with unilateral ventriculomegaly (group 2) identified in utero and compared them with a group of 20 children with symmetric ventricles using a formal neuropsychological tool: the Bayley Scale of Infant Development II (BSID‐II).

Main outcome measures  The group of children with unilateral ventriculomegaly scored significantly lower than the control group on the mental developmental index (MDI) and on the behaviour rating scale (BRS) but not on the psychomotor index. The group of children with asymmetric ventricles did not differ significantly from the control group on either the MDI or psychomotor developmental index but differed from the latter on the BRS. Fifteen percent of the children in the asymmetric ventriculomegaly group performed two SDs below average compared with 4% of children in the asymmetrical ventricles group and none of the control.

Conclusion  Our results indicate that prenatally observed unilateral ventriculomegaly is a significant risk factor for developmental delay. The mental and motor outcome of children with asymmetric ventricles is similar to that of the control group, but these children are at a significant risk for behavioural abnormalities.
The impact of a trial of instrumental delivery in theatre on neonatal outcome
Authors: Olagundoye V , MacKenzie IZ
Published: April 2007

Objective  To observe the effect of a trial of instrumental delivery in theatre on outcome for mother and baby.

Design  A prospective observational study.

Methods  Relevant maternal and neonatal data were collected for all instrumental deliveries of singleton viable pregnancies delivered over a three month period.

Population  Two hundred and twenty nine consecutive deliveries conducted by ventouse or forceps because of fetal distress or dystocia.

Setting  The maternity unit of a teaching hospital delivering around 6000 women annually.

Main outcome measures  The decision‐to‐delivery intervals (DDI), mode of delivery and neonatal condition at birth.

Results  Sixty (26%) deliveries were managed as a trial in theatre, 46 (77%) because of prolonged second stage, with malposition being a factor in 39, and 14 (23%) because of fetal distress. The mean ± SD DDI for these 60 deliveries was 59.2 ± 20.4 minutes (median 58 minutes) compared with 21.2 ± 9.0 minutes (median 20 minutes) for 169 delivered in the labour room (P < 0.0001). Of these 169 deliveries, 168 were delivered within 46 minutes and 1 delivered by caesarean section at 60 minutes. Nine women (13%) ultimately delivered by caesarean section, eight following a trial in theatre; in seven, there was malposition. Deliveries following a trial had slightly less favourable cord blood gas results.

Conclusions  Trial of instrumental delivery takes two to three times longer than delivery in the labour room; fetal malposition was the major indication for the trial of instrumental delivery and reason for failed delivery. Adopting the recent guidelines of the Royal College of Obstetricians and Gynaecologists, at least 107 (47%) should have been managed as a trial in theatre. The added delay in delivery could be damaging to an already hypoxic fetus, and the use of a trial should be individually assessed.
The effect of hysterectomy or levonorgestrel‐releasing intrauterine system on sexual functioning among women with menorrhagia: a 5‐year randomised controlled trial
Authors: Halmesmäki K , Hurskainen R , Teperi J , Grenman S , Kivelä A , Kujansuu E , Tuppurainen M , Yliskoski M , Vuorma S , Paavonen J
Published: April 2007

Objective  To compare among women with menorrhagia the effect of hysterectomy or levonorgestrel‐releasing intrauterine system (LNG‐IUS) on sexual functioning .

Design  A randomised controlled trial.

Setting  Five university hospitals in Finland.

Sample  A total of 236 women, aged 35–49 years.

Methods  Of the women, 117 were treated by hysterectomy and 119 by LNG‐IUS.

Main outcome measures  Sexual functioning was evaluated by modified McCoy sexual scale at baseline and at 6 months, 12 months, and 5 years after initiation of treatment (hysterectomy or application of LNG‐IUS).

Results  Among women treated by hysterectomy, sexual satisfaction increased and sexual problems decreased. Among LNG‐IUS users, satisfaction with partner decreased. In addition to treatment modality (P= 0.02), estrogen therapy (P= 0.01), smoking (P= 0.001), night sweats (P= 0.03), vaginal dryness (P= 0.04), hot flushes (P= 0.01), and having someone to ask for advice (P= 0.03) and to share worries (P= 0.01) explained changes in sexual functioning.

Conclusions  Among women with menorrhagia, hysterectomy improves sexual functioning, whereas LNG‐IUS does not have such a positive effect.
Maximum Stresses in a Taper‐shanked Round‐ended Lug Loaded by an Oblique Concentrated Force*
Authors: Strozzi A. , Baldini A. , Giacopini M. , Rivasi S. , Rosi R.
Published: April 2007

Abstract:  In this study, the stress state in a round‐ended, taper‐shanked lug loaded by an oblique point force is investigated. Numerical, analytical and, partially, photoelastic studies were carried out. In the analytical model, the lug is modelled as a plane problem, and it is partially likened to a ring examined with a Michell‐type series solution; the differences in shape between lug and ring are overcome by endowing the series solution with degrees of freedom suitable for adapting the ring solution to the lug actual geometry. Three prompt access design charts are presented, which report the normalised stress concentration for three lug shank taper angles, for selection of five aspect ratios between bore radius and radius of the rounded extremity, and for load inclinations ranging from longitudinal to transverse directions.
A Review of Dynamic Fracture Studies in Functionally Graded Materials
Authors: Shukla A. , Jain N. , Chona R.
Published: April 2007

Abstract:  This article presents a review of dynamic fracture studies on functionally graded materials. A brief literature review on the fracture mechanics of graded materials is presented first. This is followed by a discussion on the higher‐order asymptotic analysis of the transient elastic field surrounding the tip of a dynamically growing crack in a functionally graded material. A comprehensive experimental study of dynamic crack growth in model functionally graded material using the optical method of reflection photoelasticity and high‐speed photography is then presented. The results are analysed to establish a generalised relationship between the crack velocity and the dynamic mode‐I stress intensity factor (SIF). This relationship is found to be unique and is distinctly different from that previously established for the matrix material (polyester). Finally, an innovative experimental procedure is used to demonstrate the necessity of employing a fully transient stress‐field representation in the analysis of optical data for an accurate prediction of the dynamic SIF history.
A Marine Propeller Aerodynamic Test Facility
Authors: Li H. H. , Davis K. R. , Davy M. H. , Green S. I.
Published: April 2007

Abstract:  Conventional propeller test facilities such as tow tanks, cavitation tunnels and the open sea have various limitations such as cost, accessibility, size and accuracy. An aerodynamic marine propeller test facility has been developed at the University of British Columbia to allow for performance evaluations of full‐size marine propellers in the highly controlled environment of a wind tunnel. Thorough static and dynamic calibrations of the test rig confirmed that the sensors have a highly linear response with essentially zero crosstalk between the thrust and torque signals. Performance curves acquired from a commercial 24 × 24 propeller show that the repeatability error of the torque and thrust measurements is <1%. The uncertainties of the advance ratio, torque coefficient, thrust coefficient, and efficiency are 0.2%, 0.5%, 0.1%, and 1%, respectively. Performance curves measured over a range of the Reynolds numbers show that Reynolds number independence is achieved for Reynolds numbers above approximately 5 × 105.
Comparing Oxygen Transfer Performance Between Three Membrane Oxygenators: Effect of Temperature Changes During Cardiopulmonary Bypass
Authors: Jegger David , Tevaearai Hendrik T. , Mallabiabarrena Iker , Horisberger Judith , Seigneul Isabelle , Von Segesser Ludwig K.
Published: April 2007

Abstract:  Recently, a new oxygenator (Dideco 903 [D903], Dideco, Mirandola, Italy) has been introduced to the perfusion community, and we set about testing its oxygen transfer performance and then comparing it to two other models. This evaluation was based on the comparison between oxygen transfer slope, gas phase arterial oxygen gradients, degree of blood shunting, maximum oxygen transfer, and diffusing capacity calculated for each membrane. Sixty patients were randomized into three groups of oxygenators (Dideco 703 [D703], Dideco; D903; and Quadrox, Jostra Medizintechnik AG, Hirrlingen, Germany) including 40/20 M/F of 68.6 ± 11.3 years old, with a body weight of 71.5 ± 12.1 kg, a body surface area (BSA) of 1.84 ± 0.3 m2, and a theoretical blood flow rate (index 2.4 times BSA) of 4.4 ± 0.7 L/min.

The maximum oxygen transfer (VO2) values were 313 mL O2/min (D703), 579 mL O2/min (D903), and 400 mL O2/min (Quadrox), with the D903 being the most superior (P < 0.05). Oxygen (O2) gradients were 320 mm Hg (D703), 235 mm Hg (D903), and 247 mm Hg (Quadrox), meaning D903 and Quadrox are more efficient versus the D703 (P < 0.05). Shunt fraction (Qs/Qt) and diffusing capacity (DmO2) were comparable (P = ns). Diffusing capacity values indexed to BSA (DmO2/m2) were 0.15 mL O2/min/mm Hg/m2 (D703), 0.2 mL O2/min/mm Hg/m2 (D903), and 0.18 mL O2/min/mm Hg/m2 (Quadrox) with D903 outperforming D703 (P < 0.0005). During hypothermia (32.0 ± 0.3°C), there was a lower absolute and relative VO2 for all three oxygenators (P = ns). The O2 gradients, DmO2 and DmO2/m2, were significantly lower for all oxygenators (P < 0.01). Also, Qs/Qt significantly rose for all oxygenators (P < 0.01).

The oxygen transfer curve is characteristic to each oxygenator type and represents a tool to quantify oxygenator performance. Using this parameter, we demonstrated significant differences among commercially available oxygenators. However, all three oxygenators are considered to meet the oxygen needs of the patients.
New Migraine and Pain Research
Authors: Hargreaves Richard
Published: April 2007

An understanding of the pathophysiology and pharmacology of migraine has been driven by astute clinical observations, elegant experimental medicine studies and importantly by the introduction of highly effective selective anti‐migraine agents such as the Triptan 5‐HT1B/1Dagonists. New investigational migraine therapies such CGRP antagonists target key components of the trigeminal sensory neuroinflammatory response and show promise for the future. Cutting edge molecular profiling studies looking at gene expression during chronic pain are now being used to reveal the cell biology of pain and new potential therapeutic targets. Translational neuroimaging research can link the laboratory and the clinic and is now being used to help understand the neural systems biology of migraine. Research into migraine has generated sophisticated hypotheses that encompass primary CNS dysfunction, trigeminovascular activation, pain perception and activation of associated neural circuits involved in affective functions providing a rich framework within which to design and test future migraine treatment strategies.
Ten Lessons on the Epidemiology of Migraine
Authors: Lipton Richard B. , Bigal Marcelo E.
Published: April 2007

The epidemiologic studies of the last 15 years have taught many lessons that will help define the clinical and research agenda in migraine for the next 15 years. Because the condition is common, disabling, and costly (Lesson 1) and because it has major comorbidities (Lesson 2), migraine is an important target for treatment. Because consultation, diagnosis, and effective treatment rates are low (Lessons 3 and 4) it is important to develop strategies for closing the gap between treatment available and treatment delivered in the primary care setting where the majority of patients seek care (Lesson 5 and 6). Strategies include public and provider education as well as the use of screening tools such as ID‐migraine to improve the recognition of migraine in primary care (Lesson 7). In addition, strategies that measure disability, with tools such as MIgraine Disability ASssessment, when coupled with treatment guidelines which consider illness severity in the selection of treatment provide great hope for improving patient outcomes (Lesson 8). Finally, the emerging evidence that migraine is progressive in a subgroup (Lesson 9) mandates the development of strategies to reduce the risk of progression by addressing modifiable risk factors and by assessing the effects of treatment on headache progression (Lesson 10).
The Convergence Hypothesis
Authors: Cady Roger K.
Published: April 2007

The Convergence Hypothesis postulates a single pathophysiological mechanism to explain the clinical spectrum of primary headaches seen in patients with migraine. The history and the scientific underpinnings of the Convergence Hypothesis are presented. Extrapolations from the Convergence Hypothesis are used to explore the evolution of episodic to chronic migraine and the development of common migraine co‐morbidities as a consequence of frequent migraine. A patient staging system is presented to illustrate this transformation process in migraine patients.
Depressive Symptoms and the Risk of Incident Delirium in Older Hospitalized Adults
Authors: McAvay Gail J. , Van Ness Peter H. , Bogardus Sidney T. , Zhang Ying , Leslie Douglas L. , Leo‐Summers Linda S. , Inouye Sharon K.
Published: April 2007

OBJECTIVES:To determine whether specific subsets of symptoms from the Geriatric Depression Scale (GDS), assessed at hospital admission, were associated with the incidence of delirium.

DESIGN:Secondary analysis of a prospective cohort study of patients from the Delirium Prevention Trial.

SETTING:General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998.

PARTICIPANTS:Four hundred sixteen patients aged 70 and older who were at intermediate or high risk for delirium and were not taking antidepressants at hospital admission.

MEASUREMENTS:Depressive symptoms were assessed GDS, and daily assessments of delirium were obtained using the Confusion Assessment Method.

RESULTS:Of the 416 patients in the analysis sample, 36 (8.6%) developed delirium within the first 5 days of hospitalization. Patients who developed delirium reported 5.7 depressive symptoms on average, whereas patients without delirium reported an average of 4.2 symptoms. Using a Cox proportional hazards model, it was found that depressive symptoms assessing dysphoric mood and hopelessness were predictive of incident delirium, controlling for measures of physical and mental health. In contrast, symptoms of withdrawal, apathy, and vigor were not significantly associated with delirium.

CONCLUSION:These findings suggest that assessing symptoms of dysphoric mood and hopelessness could help identify patients at risk for incident delirium. Future studies should evaluate whether nonpharmacological treatment for these symptoms reduces the risk of delirium.
Fall Prediction in Inpatients by Bedside Nurses Using the St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) Instrument: A Multicenter Study
Authors: Milisen Koen , Staelens Nele , Schwendimann René , De Paepe Leen , Verhaeghe Jeroen , Braes Tom , Boonen Steven , Pelemans Walter , Kressig Reto W. , Dejaeger Eddy
Published: April 2007

OBJECTIVES: To assess the predictive value of the St. Thomas's Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) instrument, a simple fall‐risk assessment tool, when administered at a patient's hospital bedside by nurses.

DESIGN: Prospective multicenter study.

SETTING: Six Belgian hospitals.

PARTICIPANTS: A total of 2,568 patients (mean age±standard deviation 67.2±18.4; 55.3% female) on four surgical (n=875, 34.1%), eight geriatric (n=687, 26.8%), and four general medical wards (n=1,006, 39.2%) were included in this study upon hospital admission. All patients were hospitalized for at least 48 hours.

MEASUREMENTS: Nurses completed the STRATIFY within 24 hours after admission of the patient. Falls were documented on a standardized incident report form.

RESULTS: The number of fallers was 136 (5.3%), accounting for 190 falls and an overall rate of 7.3 falls per 1,000 patient days for all hospitals. The STRATIFY showed good sensitivity (≥84%) and high negative predictive value (≥99%) for the total sample, for patients admitted to general medical and surgical wards, and for patients younger than 75, although it showed moderate (69%) to low (52%) sensitivity and high false‐negative rates (31–48%) for patients admitted to geriatric wards and for patients aged 75 and older.

CONCLUSION: Although the STRATIFY satisfactorily predicted the fall risk of patients admitted to general medical and surgical wards and patients younger than 75, it failed to predict the fall risk of patients admitted to geriatric wards and patients aged 75 and older (particularly those aged 75–84).
Access to Primary Care for Medicare Beneficiaries
Authors: Chou William C. , Cooney Leo M. , Van Ness Peter H. , Allore Heather G. , Gill Thomas M.
Published: April 2007

OBJECTIVES: To determine the acceptance rate of new Medicare patients by all primary care physicians. Among primary care physicians accepting new patients, to determine whether demographic and geographic factors are associated with the likelihood of accepting new Medicare patients.

DESIGN: Cross‐sectional.

SETTING: Primary care physicians drawn from a national sample.

PARTICIPANTS: Eight hundred forty‐eight primary care physicians.

MEASUREMENTS: Percentage of physicians accepting, not accepting, or conditionally accepting new Medicare patients.

RESULTS: Of the 848 primary care physicians contacted, only 58% unconditionally accepted all new Medicare patients; 20% accepted new patients but restricted new Medicare patients using policies of nonacceptance or conditional acceptance. Of the 665 physicians accepting new patients, those in the south and west were more likely not to accept new Medicare patients than those in the northeast, with multivariable odds ratios (ORs) of 2.79 (95% confidence interval (CI)=1.34–5.78) and 3.14 (95% CI=1.35–7.33), respectively. Similarly, family physicians were more likely than internists not to accept new Medicare patients (OR=2.36, 95% CI=1.39–3.99). Primary care physicians in the Midwest were more likely to conditionally accept new Medicare patients than those in the northeast (OR=4.84, 95% CI=1.32–17.76), and primary care physicians in metropolitan areas with a population less than 100,000 were more likely to conditionally accept new Medicare patients than those in areas with a population greater than 100,000 (OR=2.39, 95% CI=1.18–4.84).

CONCLUSION: Medicare beneficiaries' access to primary care is limited and varies significantly by region, population size, and type of provider.
Cumulative Index of Health Deficiencies as a Characteristic of Long Life
Authors: Kulminski Alexander M. , Ukraintseva Svetlana V. , Akushevich Igor V. , Arbeev Konstantin G. , Yashin Anatoli I.
Published: April 2007

OBJECTIVES: To describe the accumulation of aging‐associated health disorders using a cumulative measure known as a frailty index (FI) and to evaluate its ability to differentiate long‐ and short‐life phenotypes as well as the FI's connection to aging‐associated processes in older people.

DESIGN: Retrospective cross‐sectional and longitudinal studies.

SETTING: The National Long‐Term Care Survey (NLTCS) data that assessed health and functioning of U.S. older individuals (≥65) in 1982, 1984, 1989, 1994, and 1999 were analyzed. The NLTCS sample in each survey represents a mixture of longitudinal and cross‐sectional components.

PARTICIPANTS: Approximately 5,000 individuals in each survey.

MEASUREMENTS: A cumulative index of health and well‐being deficiencies (disabilities, signs, diseases) was calculated as a count of deficits observed in an individual divided by the total number of all considered deficits.

RESULTS: Men and women who died before the age of 75 and those who died after the age of 85 exhibited remarkably similar FI frequency patterns despite the 10‐year age difference between age profiles in these samples. Long life is consistently characterized in longitudinal analyses by lower FIs. FI dynamics are found to be strongly sex sensitive.

CONCLUSION: The FI appears to be a sensitive age‐independent indicator of sex‐specific physiological decline in aging individuals and a sex‐specific discriminator of survival chances. The FI is a promising characteristic suitable for improving sex‐sensitive forecasts of risks of adverse health outcomes in older people.
Geriatric Syndromes: Clinical, Research, and Policy Implications of a Core Geriatric Concept
Authors: Inouye Sharon K. , Studenski Stephanie , Tinetti Mary E. , Kuchel George A.
Published: April 2007

Geriatricians have embraced the term “geriatric syndrome,” using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes and proposes a balanced approach of developing preliminary criteria based on peer‐reviewed evidence. Based on a review of the literature, four shared risk factors—older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility—were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options, although given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more‐complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.
Cognitive Decline and Markers of Inflammation and Hemostasis: The Edinburgh Artery Study
Authors: Rafnsson Snorri B. , Deary Ian J. , Smith Felicity B. , Whiteman Martha C. , Rumley Ann , Lowe Gordon D. O. , Fowkes F. Gerald R.
Published: April 2007

OBJECTIVES: To determine whether circulating markers of activated inflammation and hemostasis are associated with cognitive decline in older people.

DESIGN: Prospective cohort study (Edinburgh Artery Study).

SETTING: Eleven general practices in Edinburgh, Scotland.

PARTICIPANTS: A sample of 452 men and women followed for 16 years.

MEASUREMENTS: Biomarker data were collected in 1987/88, and cognitive assessment was first conducted in 1998/99, when the mean age of the sample ± standard deviation was 73.1±5.0), and subsequently in 2002/03. Information was obtained on verbal declarative memory (Wechsler Logical Memory Test (LMT)), nonverbal reasoning (Raven's Standard Progressive Matrices), verbal fluency (Verbal Fluency Test), information processing speed (Wechsler Digit Symbol Test), and a general cognitive factor representing the variance common to the individual test scores.

RESULTS: In age‐adjusted analyses, plasma fibrinogen, interleukin‐6 (IL‐6), and intercellular adhesion molecule 1 (ICAM‐1) were negatively associated with performance on all cognitive measures in 2002/03 except the LMT (correlation coefficients from −0.10 to −0.24). In multivariate analyses controlling for demographic characteristics, depression, and cardiovascular morbidity and risk factors, fibrinogen independently predicted 4‐year decline in nonverbal reasoning (P<.05). Also, when cognitive change was estimated from peak prior level, IL‐6 turned out to be inversely related to decline in information processing speed (P<.05). Similarly, ICAM‐1 was associated with a greater decline in general cognitive ability (P<.05) and nonverbal ability (P<.05).

CONCLUSION: Systemic markers of inflammation and hemostasis are associated with a progressive decline in general and specific cognitive abilities in older people, independent of major vascular comorbidity.
Secondary Hyperparathyroidism Due to Hypovitaminosis D Affects Bone Mineral Density Response to Alendronate in Elderly Women with Osteoporosis: A Randomized Controlled Trial
Authors: Barone Antonella , Giusti Andrea , Pioli Giulio , Girasole Giuseppe , Razzano Monica , Pizzonia Monica , Palummeri Ernesto , Bianchi Gerolamo
Published: April 2007

OBJECTIVES: To determine whether secondary hyperparathyroidism (HPTH) due to hypovitaminosis D affects bone mineral density (BMD) response to alendronate (ALN) in elderly women with osteoporosis.

DESIGN: Randomized, controlled trial with 1‐year follow‐up.

SETTING: Two osteoporosis centers in northern Italy.

PARTICIPANTS: Community‐dwelling women aged 60 and older with a BMD T‐score below –2.5 and secondary HPTH with vitamin D insufficiency.

INTERVENTION: One hundred twenty subjects were randomly assigned to receive ALN 70 mg once a week alone or ALN 70 mg once a week plus calcitriol (1,25D3) 0.5 μg daily.

MEASUREMENTS: BMD measured using dual‐energy x‐ray absorptiometry at the lumbar spine (L1‐L4), femoral neck, and total hip and serum levels of intact PTH at baseline and 12 months.

RESULTS: After 1 year, BMD of the lumbar spine, femoral neck, and total hip significantly increased from baseline in both groups (P<.001). Patients allocated to ALN plus 1,25D3 demonstrated a significantly higher increase in lumbar spine BMD than those receiving ALN alone (mean percentage±standard deviation 6.8±4.6 vs 3.7±3.2, P<.001). Serum levels of PTH did not change significantly at 1 year in the ALN group (mean percentage, −3.7±27.1, P=.13) but decreased significantly in the ALN plus 1,25D3 group (−32.1±22.1, P<.001). At 12 months, subjects with normalized PTH independent of therapy allocation had a greater increase in lumbar spine BMD than those with persistent HPTH (6.5±4.6% vs 3.7±3.4%, P<.001). Lumbar spine BMD changes showed a significant negative correlation with PTH at 1 year (correlation coefficient (ρ) =−0.399, P<.001) and a positive correlation with PTH changes (i.e., baseline value – 1 year value; ρ=0.295, P=.005).

CONCLUSION: Persistence of secondary HPTH reduces BMD response to ALN in older women with osteoporosis.
Long‐Term Acute Care: A Review of the Literature
Authors: Eskildsen Manuel A.
Published: April 2007

Long‐term acute care (LTAC) represents a rapidly growing category of Medicare providers, but little is known about its quality, outcomes, and cost‐effectiveness. Its defining characteristic, as set by Medicare, is an average length of stay of greater than 25 days. Modern LTAC emerged in the early 1980s as a setting for the weaning of ventilator‐dependent patients. The industry has developed greatly in the last few years, with for‐profit corporations dominating the field, and as Medicare expenditures have grown, new payment systems have emerged to limit spiraling costs. Although LTAC is mainly known for providing chronic ventilator weaning, the case mix is varied. The majority of outcome studies in this setting have been done on pulmonary patients, with fewer data available on nonventilator patients. This article analyzes studies of LTAC that are currently available, discusses some of the public policy issues surrounding this level of care, and suggests a research agenda, including a role for the field of geriatrics.
The Right Ventricular Outflow Tract: The Road to Septal Pacing
Authors: MOND HARRY G. , HILLOCK RICHARD J. , STEVENSON IRENE H. , McGAVIGAN ANDREW D.
Published: April 2007

Background: Pacing from the right ventricular apex is associated with long‐term adverse effects on left ventricular function. This has fuelled interest in alternative pacing sites, especially the septal aspect of the right ventricular outflow tract (RVOT). However, it is a common perception that septal RVOT pacing is difficult to achieve.

Methods and Results: In this article, we will review the anatomy of the RVOT and discuss the importance of standard radiographic views and the 12‐lead electrocardiogram in aiding lead placement. We will also describe a method utilizing a novel stylet shape, whereby a conventional active‐fixation, stylet‐driven lead can be easily and reliably deployed onto the RVOT septum.
Cardiac Tamponade as Complication of Active‐Fixation Atrial Lead Perforations: Proposed Mechanism and Management Algorithm
Authors: GEYFMAN VITALY , STORM RANDLE H. , LICO SERRIE C. , OREN JESS W.
Published: April 2007

Background: Cardiac tamponade is a rare complication after implantation of dual chamber pacemaker or defibrillator systems. Its pathophysiology and optimal management are not currently well established.

Methods: Three cases of cardiac tamponade following successful implantation of transvenous dual chamber pacemakers with active‐fixation atrial leads were identified.

Results: All three patients with post‐implant cardiac tamponade were suspected to have the same etiology of bleeding into the pericardial space. This was due to protrusion of the helix of the active‐fixation atrial pacing lead through the atrial wall with subsequent abrasion of visceral pericardial layer and bleeding from the atrium through the perforation. In two patients, the perforation sites were visualized and repaired during open thoracotomy in the operating room. The third patient underwent lead repositioning under fluoroscopic guidance in the electrophysiology laboratory.

Conclusion: Based on the reviewed cases, we describe the pathophysiology of, and recommend a safe conservative algorithm for, the management of cardiac tamponade after successful transvenous lead implantation. Percutaneous pericardiocentesis with placement of the pericardial drain followed by lead repositioning under fluoroscopic guidance with surgical backup appears to be safe and effective.
Reverse Electrical Remodeling of the Atria Post Cardioversion in Patients Who Remain in Sinus Rhythm Assessed by Signal Averaging of the P‐Wave
Authors: CHALFOUN NAGIB , HARNICK DAVID , PE ELENA , UNDAVIA MANISH , MEHTA DAVENDRA , GOMES J. ANTHONY
Published: April 2007

Objectives: This study was designed to determine whether the signal‐averaged electrocardiogram of the P‐wave (SAPW) is an independent predictor of recurrence of atrial fibrillation (AF) post cardioversion (CV), and to assess atrial remodeling using SAPW.

Background: There are limited electrophysiologic data to predict the recurrence of AF post‐CV. The electrical remodeling that occurs post‐CV is poorly understood.

Methods: Sixty‐four patients with persistent AF undergoing CV were prospectively enrolled. SAPW parameters were measured the day of CV and repeated at 1 month. These SAPW parameters were compared to other baseline indices for the recurrence of AF.

Results: Sixty patients (94%) had successful CV. At 1 month, 22 (37%) maintained sinus rhythm (SR). The SAPW total duration decreased significantly in those who remained in SR (159 ms ± 19 to 146 ms ± 17; P < 0.0001). Only the duration of AF (46 ± 50 days vs 147 ± 227 days, P = 0.03) and the presence of left ventricular hypertrophy (LVH, 12% vs 65%, P = 0.0006) were significantly associated with recurrence of AF. Atrial size strongly correlated with the SAPW duration in patients who remained in SR (R2= 0.67, P = 0.003) but not in those who returned to AF (R2= 0.11, P = 0.65).

Conclusions: Atrial electrical reverse remodeling occurs in patients with AF who maintain SR post‐CV. This remodeling is likely inversely related to the duration of AF and LVH. SAPW duration does not predict recurrence of AF post‐CV.