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Objectives: To determine whether selected single nucleotide polymorphisms (SNPs) of genes encoding proteins responsible for the activation, transport, or metabolism of dabigatran and apixaban might be associated with a risk of gastrointestinal bleeding in a cohort of adult patients treated with these drugs. No previous study has focused specifically on the association with gastrointestinal bleeding., Materials and Methods: Ninety-one patients treated with dabigatran or apixaban were genotyped for selected polymorphisms. The following polymorphisms were studied: ABCB1 gene rs1045642, rs4148738, rs1128503 and rs2032582; CES1 gene rs2244613, rs8192935 and rs2244614; and SULT1A1 gene rs9282861 and SULT1A2 gene rs1136703. Two groups divided by particular drugs and genotypes were compared in terms of the presence (bleeding group) or absence (nonbleeding group) of gastrointestinal bleeding. The genotype distribution was expressed via dominant and recessive models., Results: In patients treated either with dabigatran or with apixaban, no evidence was found to support the association of gastrointestinal bleeding with any genotype for any of the studied SNPs., Conclusion: In both dabigatran- and apixaban-treated patients, no associations between the selected polymorphisms and gastrointestinal bleeding risk were found, however the results should be interpreted with caution because of the small cohort size.

Background: Carotid endarterectomy (CEA) after an unstable neurological presentation is still a controversial issue. The aim of this study was to evaluate outcomes of urgent (≤48 hr) CEA in patients with crescendo transient ischemic attack (cTIA) or stroke in evolution (SIE)., Methods: A retrospective analysis was performed using prospectively collected data from all consecutive neurologically unstable patients who underwent urgent CEA during the period from January 2013 to November 2018. End points were 30-day any stroke and death rate, symptomatic intracerebral hemorrhage (ICH), myocardial infarction (MI), surgical site bleeding requiring intervention, National Institutes of Health Stroke Scale (NIHSS) score variation, and functional outcome at 90 days assessed by the modified Rankin scale (mRS). Patients were evaluated according to clinical presentation (cTIA or SIE)., Results: A total of 46 neurologically unstable patients with cTIA (20 patients; 43.5%) and SIE (26 patients; 56.5%) were included. The 30-day risk of any stroke or death was 10.0% (2 of 20) in the cTIA group and 7.7% (2 of 26) in the SIE group. No symptomatic ICH or MI was detected after surgery in either study group. A total of 2 patients (4.3%; 1 cTIA, 1 SIE) underwent reoperation for surgical site bleeding. In patients with SIE, the mean NIHSS score on admission was 9.85 ± 5.12. Postoperatively, 22 (84.6%) of the 26 patients with SIE had clinical improvement of their neurological deficit, 3 (11.5%) patients had no change, and 1 (3.8%) patient died. On discharge, the mean NIHSS score was 4.31 ± 6.09 points and was significantly improved compared with NIHSS scores at admission (P < 0.001). At 3 months, 21 patients (80.8%) with SIE had a good clinical outcome (mRS ≤ 2)., Conclusions: Urgent CEA in neurologically unstable patients can be performed with acceptable perioperative risks. Moreover, in well-selected patients with SIE, urgent CEA may be associated with significantly improved final functional outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

An aggressive periaortic lymphoma could very rarely invade the aortic wall. We present a unique case of a patient with symptomatic thoracic aneurysm and imminent rupture due to the periaortic lymphoma, in which endovascular treatment using stent graft was applied. After stabilization of the aorta and histological confirmation of aggressive B-cell lymphoma by computed tomography-guided biopsy, the antilymphoma therapy was initiated. Despite the full treatment, the patient died 12 months later.

Background: The timing of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) is still a controversial issue. The aim of this study was to assess the safety of early carotid interventions in patients treated with thrombolysis for acute ischemic stroke., Methods: A retrospective analysis was performed using prospectively collected data from consecutive patients who underwent CEA for symptomatic internal carotid artery stenosis within 14 days after the index neurological event during the period from January 2013 to July 2016. Patients who had undergone IVT before CEA were identified. The primary outcome measures were any stroke and death rate at 30 days, symptomatic intracerebral hemorrhage and surgical site bleeding requiring intervention., Results: A total of 93 patients were included for the final analysis. Among these, 13 (14.0%) patients had undergone IVT before CEA while 80 (86.0%) patients had CEA only. The median time interval between IVT and CEA was 2 days (range: 0-13). A subgroup of 6 patients underwent CEA within 24 hours of administration of IVT. The 30-day combined stroke and death rate was 7.7% (1 of 13) among patients undergoing IVT before CEA and 5.0% (4 of 80) among those undergoing CEA only (P = 0.690). In the IVT group, there were no cerebral hemorrhages or significant surgical site bleeding events requiring reintervention., Conclusions: Our experience indicates that CEA performed early after IVT for acute ischemic stroke, aiming not only to reduce the risk of stroke recurrence but also to achieve neurological improvement by reperfusion of the ischemic penumbra, may be safe and can lead to favorable outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with an extremely poor prognosis. The best treatment approach in this setting is still unknown. The aim of our study was to evaluate the efficacy, safety, and outcomes of emergent surgical revascularization of acute extracranial ICA occlusion in patients with minor to severe ischemic stroke., Methods: A retrospective analysis was performed using prospectively collected data of consecutive patients who underwent carotid thromboendarterectomy for symptomatic acute ICA occlusion during the period from January 2013 to December 2015. Primary outcomes were disability at 90 days assessed by the modified Rankin Scale (mRS) and neurological deficit at discharge assessed using the National Institute of Health Stroke Scale (NIHSS). Secondary outcomes were the recanalization rate, 30-day overall mortality, and any intracerebral bleeding., Results: During the study period, a total of 6 patients (5 men and 1 woman) with a median age of 64 years (range: 58-84 years) underwent emergent reconstruction for acute symptomatic ICA occlusion within a median of 5.4 hours (range: 2.9-12.0 hours) after symptoms onset. The median presenting NIHSS score was 10.5 points (range: 4-21). Before surgery, 4 patients (66.7%) had been treated by systemic recombinant tissue plasminogen activator lysis. The median time interval between initiation of intravenous thrombolysis and carotid thromboendarterectomy was 117.5 minutes (range: 65-140 minutes). Patency of the ICA was achieved in all patients. On discharge, the median NIHSS score was 2 points (range: 0-11 points). There was no postoperative intracerebral hemorrhage and zero 30-day mortality rate. At 3 months, 5 patients (83.3%) had a good clinical outcome (mRS ≤ 2)., Conclusion: Patients presenting with minor to severe ischemic stroke syndromes due to isolated extracranial ICA occlusion may benefit from emergent carotid revascularization. Thorough preoperative neuroimaging is essential to aid in selecting eligible candidates for acute surgical intervention.

Purpose: To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality., Materials and Methods: We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients., Results: During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively., Conclusion: Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%., (© The Author(s) 2014.)

Background: People suffering from schizophrenia have a significantly shorter lifespan compared to the general population. The majority of deaths are caused by physical diseases, including cardiovascular events. The aim of this cross-sectional study was to predict the risk of premature cardiovascular mortality and assess the prevalence of cardiometabolic risk factors in a sample of Czech patients with schizophrenia and related psychoses., Subjects and Methods: We reviewed data from 129 subjects treated in an outpatient clinic that specialised in psychoses. The main collected variables included basic physical parameters (height, weight, waist circumference, blood pressure), smoking habits, laboratory data (glucose level, serum lipid level) and an electrocardiograph (ECG). We calculated the ten-year risk of fatal cardiovascular events using the Systematic Coronary Risk Evaluation (SCORE) chart., Results: The most prevalent risk factors were being overweight (70% of patients had a BMI over 25), dyslipidaemia (70% of patients) and smoking (43% of patients). According to the SCORE diagram, there was a high risk of fatal cardiovascular events over a ten-year period in 10% of the study group. The percentage was even higher (24%) when the latest European guidelines for cardiovascular disease prevention were used to calculate the risk., Conclusions: Our outcomes indicate even higher cardiometabolic morbidity rates in patients with psychoses than those referenced in the literature.

The aim of our study was to monitor a patient undergoing radical prostatectomy (RP) with an extraordinary large blood loss of 3600 ml. The perioperative bleeding was minimalized through an acute normovolemic hemodilution (ANH). During the procedure we monitored the patient's hemocoagulation profile. ANH is one of the possibilities for practical and pragmatic hemotherapy. It is a safe and effective method when facing massive blood loss or when it is necessary to temporarily replace or substitute the blood with a fluid during the operation (through a transfusion of allogeneic blood); and the patient benefits from the procedure. We argue that during ANH, the hypercoagulatory state appears in the patient--and even during the introduction of a combined solution of both crystalloids and colloids. In fact, during ANH it should not be recommended to provide a substitute for the patient's blood using only a single crystalloid solution alone (Tab. 2, Ref. 16).

Background: Breast cancer is the most common malignancy among women, and its timely diagnosis and treatment are of paramount importance, especially for vulnerable groups, such as low-income and uninsured women. Recent literature confirms that the method of breast cancer detection may be an important prognostic factor, but there are no studies that examine the method of breast cancer detection in low-income populations. We sought to analyze the determinants of method of detection (medical vs. self) in a cohort of low-income women with breast cancer receiving care through California's Breast and Cervical Cancer Treatment Program., Methods: This is a cross-sectional survey analysis of 921 low-income women interviewed within 6 months of definitive surgical treatment. The outcome analyzed was self vs. medical detection of breast cancer., Results: The mean age of the women was 53 years, with nearly 88% reporting an income of <$30,000 per year; 64% of women self-detected their breast cancer. Logistic regression analyses revealed that older women, Latinas, and women having any health insurance before diagnosis had lower odds of self-detecting their lesions., Conclusions: Patient age, ethnicity, and regular source of care were associated with method of breast cancer detection in a low-income underserved population. The rate of self-detection in our population correlates with the literature, but we need to improve efforts to increase mammography screening to ensure early detection of disease in this vulnerable group.

Objective: To analyze the relationship between patient satisfaction with surgical treatment and 4 consultation skills and processes of the surgeons (time spent, listens carefully, explains concepts in a way the patient can understand, and shows respect for what the patient has to say), controlling for a range of patient, surgeon, and treatment characteristics., Design: Cross-sectional survey., Setting: The Breast and Cervical Cancer Treatment Program for the state of California., Patients: A statewide sample of 789 low-income women who received treatment for breast cancer from February 1, 2003, through September 31, 2005., Main Outcome Measure: Satisfaction with surgical treatment., Results: Three of every 4 women reported being extremely satisfied with the treatment they received from their surgeon. African American women and those with arm swelling were less likely to be satisfied, whereas those reporting that the surgeon always spent enough time and explained concepts in a way they could understand were more likely to report greater satisfaction., Conclusion: Our findings highlight the importance of 2 relatively simple behaviors that surgeons can easily implement to increase patient satisfaction, which can be of potential benefit in the litigious world of today.

Aims: Psychiatric disorders and treatment with conventional antipsychotic medications have been associated with venous thromboembolism, but only a few data on recent antipsychotics such as olanzapine are available., Methods: We describe four subjects treated with olanzapine who developed venous thromboembolism, and were hospitalized at the University Hospital in Hradec Kralove during the period 2004-2006., Results: We found a combination of several clinical and laboratory risk factors in our patients., Conclusions: A cohort study or case-control studies are needed to better elucidate the possible role of olanzapine in etiopathogenesis of venous thromboembolism.

Unlabelled: LDL-apheresis is a very effective method in the treatment of resistant hypercholesterolemia when other therapies fail. To maximize the efficacy of the use of LDL-absorbers, we created a computerized model. The aim of this study is to verify it in clinical use., Patients and Methods: A therapeutic technique of immunoadsorption was used, applying a pair of Lipopak columns (Pocard, Russia). Plasma was separated by a continuous-flow plasma separator (Cobe Spectra, USA); adsorption was controlled by adsorption-desorption equipment Adasorb (Medicap, Germany). 494 LDL-apheresis procedures had been performed in nine patients with primary hypercholesterolemia in the earlier, initial study; 47 other procedures (202 therapeutic cycles) were used in this verification study. The program for procedure planning uses Microsoft Excel for Windows. Complex metabolism of the LDL-cholesterol was neglected (owing to the short-time period of the procedure) and the procedure calculated as continuous filtration. The input enterer into the program includes basic patient data (mass, height, sex and initial plasma LDL level in mmol/L)., Results: The results show a very good match between calculated levels and the real laboratory results in most procedures, but in some procedures we observed minor differences (0.05 mmol/L), which was caused by procedure adjustments due to technical reasons. However, some methodological and medical details must be carefully observed (initial cholesterol level, correct calculation of plasma volume, and the precise capacity of adsorbers that must not be overshot); as they influence the correct match between calculated and real results significantly., Conclusions: Although our software uses a fairly simplified model of the LDL-cholesterol kinetics during the LDL-apheresis, it is providing a great aid in the procedure planning. It is also suitable for practical use because it only requires a few commonly used and readily available input values.

Background: Surgery is a key modality in the treatment of breast cancer. The patient-physician interaction is a key determinant of a range of outcomes, but there is little work examining the surgeon-breast cancer patient interaction. We analyzed data from 240 women with a new breast cancer diagnosis to better understand this interaction and to delineate the patient, surgeon, and surgeon-patient interaction-level characteristics affecting this interaction., Methods: A cross-sectional survey was conducted in Los Angeles County of 240 women with a new breast cancer diagnosis aged>or=55 years. Women were asked to rate on a scale of 0 to 10 how helpful overall the way their surgeon discussed their breast cancer with them was. Logistic regression models were constructed to assess the relationship of patient, surgeon, and surgeon-patient interaction characteristics to the outcome variable., Results: Forty-four percent of women said that they found the way their surgeon discussed their breast cancer with them extremely helpful. Women with a higher level of perceived self-efficacy, a longer consultation time with the surgeon, a higher interactive information-giving score, and a higher participatory decision-making score had significantly higher odds of reporting the discussion to be "extremely helpful.", Conclusions: Our results indicate that strategies to improve the patient's perceived self-efficacy (preparing questions beforehand, practicing, watching a role model, and so on) will improve the surgeon-patient discussion. At a systems level, adequate time should be budgeted for the consultation, and we must ensure that adequate communication skills are imparted to surgeons during their educational training.

Patients who suffer from recurrent thromboembolic events often receive an inferior vena cava (IVC) filter. There are few data available regarding treatment of this patient population with catheterization interventions, especially catheter ablation. We report a case of cavotricuspid isthmus catheter ablation across an IVC filter.

Qualitiative research emphasizes identification, illumination, and understanding of phenomena, the meaning and theory behind which are unpresumed by the investigator. Although quantitative techniques are used to test predetermined hypotheses, qualitative techniques are used to generate hypotheses. Qualitative techniques have only begun to be used in medical research in the past decade but are especially useful in exploring content areas about which little is known and in eliciting and understanding the patient's perspective. Despite the aging of the United States population, the cancer illness experience has not been well studied in older patients. Because communication preferences, treatment decision-making styles, psychosocial issues, and the illness experience itself may be significantly different for older persons diagnosed with cancer than for younger persons, qualitative research techniques can be used to identify those differences critical to the effective health care of this burgeoning population.

Background: Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option., Objectives: To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence., Subjects: Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions., Measures: In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention., Results: The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600., Conclusions: The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.

Purpose: To identify and examine religious and spiritual coping strategies among elderly women with newly diagnosed breast cancer., Methods: A convenience sample of 33 women age 65 years was recruited within 6 months of diagnosis. Respondents participated in a structured interview with open-ended questions. Transcripts of the interviews were analysed independently by three researchers and themes were discussed until consensus was reached., Results: Participants' religious background was varied: 17 Protestant, five Catholic, six Jews, and four Other. There was great variation in the frequency of religious service attendance. Religious and/or spiritual belief either increased or stayed the same during the time of health crisis. Analysis of transcripts revealed three themes. Religious and spiritual faith provided respondents with the emotional support necessary to deal with their breast cancer (91%), with social support (70%), and with the ability to make meaning in their everyday life, particularly during their cancer experience (64%)., Conclusions: Religious and spiritual faith provides elderly women newly diagnosed with breast cancer with important tools for coping with their illness and should be recognized by diagnosing physicians. It may be important to encourage these patients to seek religious support and/or to reconnect with their religious community., (Copyright 1999 John Wiley & Sons, Ltd.)

Background: The purpose of this study was to assess the impact of an intervention to facilitate information giving to patients with chronic medical conditions on outcomes of care., Methods: A consecutive sample of 276 eligible patients with chronic medical conditions at a family medicine clinic was randomized to control and experimental interventions. A total of 205 completed the study. Experimental group patients received copies of their medical record progress notes, and they completed question lists for physician review, while control group patients received health education sheets and completed suggestion lists for improving clinic care. Self-reported physical functioning, global health, and patient satisfaction and adherence were measured at enrollment and after the interventions. Visit lengths and patient response to medical record sharing after the interventions were also measured., Results: After the intervention, experimental group patients reported 3.7% better overall physical functioning than did control patients (mean = 83.6, standard deviation [SD] = 17.6 vs mean = 79.9, SD = 25.3; P = .005 after adjusting for covariates). The experimental group was more satisfied with their physician's care (mean = 31.4, SD = 4.6 vs mean = 31.3, SD = 5.2; P = .045 after adjusting for covariates). They were also more interested in seeing their medical records than were control patients (mean = 12.0, SD = 2.8 vs mean = 11.2, SD = 2.8; P = .002 after adjusting for covariates). Experimental group patients also reported an 8.3% improvement in overall health status (postintervention mean = 3.0, SD = 1.1) compared with their pre-intervention health status (mean = 2.8, SD = 1.0; P =.001). Visit lengths for patients in the experimental group did not differ from those of the control group., Conclusions: A simple patient-centered intervention to facilitate information giving in the primary health care of patients with chronic medical conditions can improve self-reported health, physical functioning, and satisfaction with care.

Background: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain., Objective: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes., Design: A randomized controlled trial., Setting: Community-based sites., Patients: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment), Intervention: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations., Measurements: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery., Results: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated., Conclusions: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

Objective: To develop and validate a brief instrument--the Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI)--to measure older patients' self-efficacy in obtaining medical information and attention to their medical concerns from physicians., Design: Two consecutive validation surveys., Setting: Eleven senior multipurpose centers in Los Angeles County California., Population: A convenience sample of 163 community-dwelling older persons (Survey 1: n=59, mean age=77.1 years, 76.3% female; Survey 2: n=104, mean age=77.4 years, 57.7% female)., Measures: The 10-item PEPPI, subscales of the Patient Satisfaction Questionnaire, the Medical Outcomes Study (MOS) Coping Scale, the Mastery Scale, and global self-reported health and restricted activity days items., Results: The full 10-item and a 5-item short form of PEFPI demonstrated Cronbach's alphas of 0.91 and 0.83, respectively. PEPPI demonstrated discriminant and convergent validity as hypothesized, correlating negatively with avoidant coping (r=-.27, P=.001) and positively with active coping (r=.17, P=.03) and with patient satisfaction with physician interpersonal manner (r=.49, P < .0001) and communication (r=.51, P < .0001) (values from the overall sample). Further, in the second survey, PEPPI correlated positively with self-reported health (r=.42, P < .0001), education (r = .24, P=.01) and self-mastery (r=.29, P=.01) and negatively with restricted activity days (r=-.25, P=.01). PEPPI-5 demonstrated correlations similar in magnitude, direction, and statistical significance., Conclusion: In either the 5- or 10-item version, PEPPI is a valid and reliable measure of older patients' perceived self-efficacy in interacting with physicians. This instrument may be useful in measuring the impact of empowerment interventions to increase older patients' personal sense of effectiveness in obtaining needed health care.

Background: Long-term implantation of a left ventricular assist device (LVAD) may be a future alternative treatment for end-stage heart failure. The objective of the present study was to determine the hemodynamic effects of supine bicycle exercise and functional capacity during upright treadmill exercise in 10 patients after LVAD implantation placed for refractory heart failure as a bridge to cardiac transplantation., Methods and Results: With supine bicycle exercise, 46 +/- 25 days after device placement, heart and LVAD rates increased in parallel from 87 +/- 12 to 117 +/- 14 bpm and 82 +/- 18 to 107 +/- 21 bpm, respectively. Peak O2 consumption was 8.2 +/- 1.7 mL O2.kg-1.min-1. Fick Systemic blood flow rose from 5.0 +/- 1.2 to 7.8 +/- 2.5 L/min. Right atrial and pulmonary capillary wedge pressures increased from 6 +/- 4 and 5 +/- 3 mm Hg to 12 +/- 5 and 13 +/- 8 mm Hg, respectively. End-diastolic left ventricular dimension increased from 3.9 +/- 1.3 to 4.8 +/- 1.6 cm; however, right ventricular dimension decreased from 3.2 +/- 1.0 to 2.3 +/- 0.9 cm. With upright treadmill exercise, peak O2 consumption was 14.1 +/- 2.9 mL O2.kg-1.min-1., Conclusions: This study indicates that exercise during long-term LVAD support is safe and is not limited by right heart decompensation. It also justifies a larger study to examine how exercise after LVAD implantation compares with that after cardiac transplantation.

Background: comprehensive geriatric assessment (CGA) appears to be less effective when performed in outpatient clinics than in hospital settings. The effectiveness of outpatient CGA might be improved by selectively targeting frailer community-dwelling elderly people. The purpose of this study was to evaluate the clinical performance of rapidly-administered standard screening measures for geriatric syndromes in selecting community-dwelling older people for outpatient CGA., Methods: urban-dwelling older people were screened for CGA at community sites using a self-administered questionnaire containing standardized measures for each of four geriatric target conditions: depression, urinary incontinence, falls and functional impairment. The study sample included all 150 consecutive subjects who were screened, failed on one or more of the four target criteria and completed community-based, academically administered CGA. Diagnostic accuracy of the screening instruments was assessed using CGA diagnoses as the 'gold standard'. In addition, patients' potential for benefiting from CGA was determined by whether they received major medical recommendations for further evaluation or treatment., Results: after completing CGA, 60.2% of those failing on functional impairment, 53.5% of those failing on depression, 30.7% of those failing on falls and 92.7% of those on urinary incontinence, were confirmed as having these or highly related conditions as clinical problems. Overall, 81.3% of the subjects completing CGA received the least one major recommendations for further medical intervention; most of these recommendations (79.5%) were for a target-related condition and the further remainder (20.5%) addressed another significant medical condition., Conclusion: simple screening instruments used in community settings have variable degrees of accuracy, but may be markers for frailty and thus can identify older people likely to benefit from geriatric assessment.

Objectives: To evaluate the responses of primary care physicians and patients to recommendations from a community-based comprehensive geriatric assessment (CGA) program for management of four target conditions: falls, depression, urinary incontinence, and functional impairment., Design: Case series., Setting: Senior centers, meal sites, senior housing, and other community sites as screening locations; and a community-bases academic practice as the location for CGA., Participants: A total of 150 older patients living in the community who have one or more of the four target conditions and who received CGA., Measurements: Physician implementation and patient adherence rates were ascertained during a face-to-face structured interview with the patient 3 months after CGA., Results: Two hundred twelve of 528 (40%) CGA recommendations were clearly or possible related to the target or target-related conditions. Of these 212 recommendations, 59% required a physician's order for implementation. The remaining 41% were patient self-care recommendations. Overall physician implementation across conditions was 70%; implementation rates were highest for falls and lowest for functional impairment. Overall patient adherence rate was 85% for physician-implemented recommendations and 46% for self-care recommendations. Patient adherence to recommendations for counseling or support groups and exercise programs was particularly low., Conclusions: When examining the process of care of community-based CGA, patient as well as physician adherence must be considered. Although patient adherence to physician-initiated recommendations was high for all conditions, it varied substantially across target conditions and types of recommendations for self-care recommendations.

Background: In consultative models of Comprehensive Geriatric Assessment (CGA), lack of implementation of CGA recommendations is well documented and appears to be a potential explanation for negative findings. The purpose of this study is to identify patient determinants of adherence to recommendations received from a community-based CGA consultative model program., Methods: Subjects (N = 139) received self-care and/or physician-initiated CGA recommendations and were interviewed three months later to determine adherence with the most important recommendation, and health belief, communication, and social support factors associated with adherence. Independent variables were organized into the Andersen Behavioral Model for analysis., Results: At the bivariate level, one predisposing factor (intention) and six enabling factors (low difficulty level, high support, high utility, high self-efficacy, agreement on the importance of the recommendation and good specific communication about the recommendation) were significant determinants of adherence. Two functional health measures and seriousness of the target condition of the recommendation were significant need factors. In the final logistic regression model, one predisposing variable (intention), one enabling variable (utility), and one need factor (high functional status), and two interaction terms significantly predicted adherence., Conclusion: CGA recommendations that are seen as worthwhile, not too much trouble, and able to be accomplished are the most likely to be initiated. Older adults with relatively higher functional levels are also more likely to follow through with CGA recommendations even though their needs may be lower. We found the Andersen Behavioral Model useful in the analysis of factors associated with adherence behavior to consultative CGA recommendations.

Objective: To create a program to identify preventive needs for community-dwelling older persons and incorporate intervention strategies to improve implementation of these services., Design: Program development and case-series., Setting: Community-based meal sites, academically administered program., Participants: Persons 60 years of age or older attending meal sites and their primary care physicians., Measurements: Demographic characteristics, self reported preventive health behaviors and services, blood pressure measurement., Results: During the first 2 years of the program, 927 persons 60 years of age or older were screened. The most common physician-initiated preventive recommendations were: tetanus booster (72%), aspirin prophylaxis (68%), pneumonia vaccination (61%), and colorectal cancer screening (51%). The most common self-care recommendations have been: calcium supplementation (54% of women) and breast self examinations (51% of women). As part of the adherence intervention, we were able to complete health educator calls for 600 (65%) subjects. In addition, the physicians of 599 (65%) subjects were contacted either by telephone (n = 496) or by letter only (n = 97)., Conclusion: A community based preventive services program can identify large numbers of unmet preventive services needs, and a dual intervention strategy aimed at meeting these needs can be delivered successfully to the majority of participants. Implementation rates of specific recommendations and impacts on health outcomes remain to be determined.

Background: Comprehensive geriatric assessment (CGA) in outpatient settings has not been shown to be as effective in reducing mortality and improving health as in hospital settings; this difference has been attributed in part to a lack of direct control over recommendation implementation., Objective: To identify inhibiting and facilitating factors in physicians' compliance with consultative CGA recommendations, so that the effectiveness of outpatient CGA might be improved., Methods: A 49-item questionnaire was administered via the telephone to 87 eligible community primary care physicians in Los Angeles, Calif, whose patients had received consultative outpatient CGAs as part of a study of CGA (response rate, 96%). The questionnaire assessed physician compliance with CGA recommendations, reasons for implementing or not implementing the recommendations, and specific physician attitudes, perceptions, and characteristics. The focus of the interview was the CGA recommendation that was determined to be the "most important" by the evaluating geriatrician. Recommendations addressed geriatric syndromes, general medical problems, or psychiatric conditions., Results: Of the 87 physician respondents, 62 (71%) implemented the most important recommendation. In multivariate analysis, 4 variables were predictive of physician compliance: (1) a patient's request that the recommendation be implemented (odds ratio [OR], 10.8; 95% confidence interval [CI], 1.9-61.3; P = .007); (2) perceived legal liability resulting from nonimplementation of the recommendation (OR, 10.8; 95% CI, 1.1-108.2; P = .04); (3) female physician gender (OR, 9.6; 95% CI, 1.4-67.9; P = .04); and (4) perceived cost-effectiveness of the recommendation (OR, 7.0; 95% CI, 1.6-30.5; P = .01)., Conclusions: Patient behavior, which may be modifiable, was among the strongest determinants of physician compliance with recommended care. Specifically, when patients requested that a recommendation be implemented, physicians were highly likely to comply. Changing patient behavior within the physician-patient relationship as a way of effecting desired changes in physician health care practices merits further attention.

The purpose of this study was to determine if augmented hyperventilation produced via normoxic helium breathing would reduce exercise-induced hypoxemia (EIH). Seven highly trained endurance athletes with a mean maximum oxygen uptake of 65 ml.kg-1.min-1, performed two cycle ergometer tests to volitional exhaustion. During one of the tests the subjects breathed ambient air, while during the other they breathed normoxic helium (21% O2, 79% He). Mean maximum expired ventilation significantly (p < .05) increased from 139 L.min-1 during the ambient trial to 168 L.min-1 while breathing normoxic helium. Mean arterial oxygen saturation obtained at maximum exercise, however, was not significantly different for the two trials (ambient = 90%, helium = 89%). These results suggest that significantly augmenting exercise hyperventilation by 21% essentially had no effect on EIH in endurance athletes. Thus, the data do not support the hypothesis that inadequate hyperventilation is an important mechanism for arterial oxygen desaturation during graded exercise to exhaustion in highly trained individuals.

Purpose: The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence., Patients and Methods: One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients., Results: Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7)., Conclusions: These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".

Elderly people do use substances to alter mood and states of awareness. Detection is difficult because presenting symptoms are often those that are commonly associated with aging itself. All patients who present with symptoms of self-neglect, falls, cognitive and affective impairment, and social withdrawal should be screened for substance abuse. The CAGE and MAST, although not perfect, can be used. When abuse is found, the elderly should be treated as aggressively as their younger counterparts, with slow, careful detoxification and the use of some form of group therapy, such as AA.

Chemical dependence is a leading cause of morbidity and death in the United States. At least 20% of patients seen by primary care physicians in both the outpatient and inpatient setting are chemically dependent. Up to 90% of these patients go undiagnosed by their primary physicians. Chemical dependence is defined as a chronic, progressive illness characterized by the repeated and persistent use of alcohol or drugs despite negative health, family, work, financial, or legal consequences. Primary care physicians are in an ideal position to detect chemical dependence at its earliest stages, when irreversible medical consequences and death are most likely preventable. Alcohol is the most common drug of abuse. Improving the rate of recognition of chemical dependence depends on being familiar with the constellation of physical, mental, and social indicators. Early medical manifestations of alcoholism common in the primary care setting include: gastric complaints, elevated blood pressure, palpitations, traumatic injuries, headaches, impotence, and gout. Early psychosocial manifestations common in both alcohol and drug dependence include anxiety, depression, insomnia, persistent relationship conflicts, work or school problems, and financial or legal problems. Particularly useful laboratory indicators of alcoholism include elevated levels of GGT and MCV, both displaying high specificity, with the GGT level being the most sensitive. Similarly specific laboratory tests for drug dependence are not available. Any patient presenting with any of the above medical, psychosocial, or laboratory manifestations should be screened for chemical dependence. The CAGE questionnaire for alcoholism, a four-question test, is particularly well suited to the primary care setting, where it can be administered in fewer than 60 seconds. The CAGE has demonstrated high sensitivity (in the 80% range) and specificity (approximately 85%) for alcoholism. Comparably convenient instruments do not yet exist for drug dependence, although a 28-item instrument, the DAST (Drug Abuse Screening Test), has demonstrated high sensitivity and specificity for drug abuse.

Acetaldehyde has been used as a fluorescent dopant for two-dimensional imaging of the flame front in an internalcombustion-engine simulator. The molecule was excited with a XeCl-laser-light sheet at 308 nm, and broadband fluorescence centered at 400 nm was detected. In this way, the flame front could be marked by mapping regions of unburned gas. Also, the intake process into the engine could be followed.

Pregnant women were examined for chlamydia trachomatis-infection on a routine basis during a multicentric study in Vienna. Samples were taken from the cervix and fornix between the 30th and 34th week pregnancy. FTIC-conjugated monoclonal antibodies and immunofluorescence techniques were used to verify chlamydia trachomatis. Out of 1238 pregnant women, 101 (8.16%) were positive for chlamydia trachomatis. Since chlamydia infections can result in severe local or generalized complications and also spread to the newborn baby, screening investigations should be regularly performed during pregnancy and, if indicated, adequate treatment undertaken.

A unique case of Marfan's syndrome is presented in which the diagnosis was first established during early labor when the patient presented with chest pain, hypotension, and fetal distress as the earliest symptoms and signs. Prompt diagnosis in combination with correct medical and surgical therapy resulted in the survival of both the mother and infant.