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Applications for surgical staplers continue to grow, due to the increase in minimally invasive surgical approaches, and range from vessel ligation to tissue transection and anastomoses. Complications associated with stapled tissue, such as bleeding or leaks, continue to be a concern for surgeons, as both can be associated with prolonged operative times and can contribute to postoperative morbidity and mortality. The goal of this retrospective study was to evaluate the performance of the da Vinci

The Sources of Discomfort Scale (SODS) assesses discomfort manifestations based on source of discomfort, thus making it both distinct from and complementary to pain assessments for persons with dementia. Sources were categorized as pertaining to physical discomfort, to body position, and to environmental sources. Body position sources of discomfort were related to poor functional status and to pain. The SODS scores were not related to cognitive functioning, and sources of discomfort other than those pertaining to body position were not correlated with pain. This paper demonstrates a direct and enhanced method to detect the manifestations of discomfort separately from pain indicators in a population with advanced dementia. The determination of the source of discomfort has direct implications for intervention.

OBJECTIVE: X-linked adrenoleukodystrophy (ALD) is a neurodegenerative disorder due to mutations in the peroxisomal very long-chain fatty acyl-CoA transporter, ABCD1, with limited therapeutic options. ALD may manifest in a slowly progressive adrenomyeloneuropathy (AMN) phenotype, or switch to rapid inflammatory demyelinating cerebral disease (cALD), in which microglia have been shown to play a pathophysiological role. The aim of this study was to determine the role of patient phenotype in the immune response of ex vivo monophagocytic cells to stimulation, and to evaluate the efficacy of polyamidoamine dendrimer conjugated to the antioxidant precursor N-acetyl-cysteine (NAC) in modulating this immune response. METHODS: Human monophagocytic cells were derived from fresh whole blood, from healthy (n = 4), heterozygote carrier (n = 4), AMN (n = 7), and cALD (n = 4) patients. Cells were exposed to very long-chain fatty acids (VLCFAs; C24:0 and C26:0) and treated with dendrimer-NAC (D-NAC). RESULTS: Ex vivo exposure to VLCFAs significantly increased tumor necrosis factor α (TNFα) and glutamate secretion from cALD patient macrophages. Additionally, a significant reduction in total intracellular glutathione was observed in cALD patient cells. D-NAC treatment dose-dependently reduced TNFα and glutamate secretion and replenished total intracellular glutathione levels in cALD patient macrophages, more efficiently than NAC. Similarly, D-NAC treatment decreased glutamate secretion in AMN patient cells. INTERPRETATION: ALD phenotypes display unique inflammatory profiles in response to VLCFA stimulation, and therefore ex vivo monophagocytic cells may provide a novel test bed for therapeutic agents. Based on our findings, D-NAC may be a viable therapeutic strategy for the treatment of cALD.

Urogenital problems are dramatically increasing; especially chronic pelvic pain syndrome (CPPS) poses a major challenge for physicians and therapists. Few forms of therapy have been able to promise relief because the cause of CPPS remains unclear. Functional complaints are increasingly discussed as triggers. Osteopathic treatment has been reported to help many patients in recent years. In this article, the approach and osteopathic point of view of functional complaints are presented. In addition, possible causes for the development of CPPS and important anatomical structures that are directly involved in it are explained. Further interdisciplinary research of functional relationships would be desirable in the future.

OBJECTIVE Research is needed to determine specific factors that contribute to the success of nonpharmacologic interventions. In this study, we examined the influence of personal characteristics (demographic, medical, and functional variables) and possible barriers (eg, staff or family barriers) on the efficacy of nonpharmacological interventions in reducing agitation. METHOD Agitation was systematically observed at baseline and intervention stages using the Agitation Behavior Mapping Instrument (ABMI) in a sample of 89 residents from 6 Maryland nursing homes (mean age = 85.9 years). Each participant received interventions based on an individualized algorithm (TREA-Treatment Routes for Exploring Agitation), which identifies unmet needs and matches interventions to needs and to the participant's sensory, cognitive, and functional abilities, as well as to self-identity and preferences. The study was conducted between June 2006 and December 2011. RESULTS Analyses revealed that decreased levels of agitation during intervention correlated significantly with higher levels of cognitive function (r = 0.36, P < .001), with fewer difficulties in the performance of activities of daily living (r = 0.29, P < .01), speech (r = 0.47, P < .001), communication (r = 0.23, P < .05), and responsiveness (r = 0.28, P < .01). In addition, less reduction of agitation during intervention was significantly related to the presence of staff barriers (eg, refusals, interruptions) (r = -0.38, P < .001) and the occurrence of pain (r = -0.21, P ≤ .05). CONCLUSIONS The findings elucidate the characteristics of those who are most likely to respond to TREA intervention, and point to the need of systemic changes to reduce staff-related barriers and to improve methodologies for increasing the impact of intervention on those at the lowest levels of functioning.

Purpose This retrospective study investigated 3-dimensional (3D) imaging with intraoperative Cone-Beam Computed Tomography (CBCT) in Mandibular Angle Fractures (MAF) treated by open reduction. The aim of this study was to demonstrate the image quality of intraoperative CBCT in this region and the benefit for the patients. Methods 83 patients with 86 MAF were included in this study. 8 patients were female and 75 male. Patient age ranged from 11 to 68 years (average age 26.8 years). All patients were examined with the mobile CBCT scanner ARCADIS Orbic 3D (Siemens Medical Solutions, Erlangen, Germany) directly after surgical treatment of the MAF. Results As a direct result of intraoperative CBCT four patients (5%) underwent intraoperative revision. The intraoperative acquisition of the data sets was uncomplicated and in all cases it was possible to effectively visualise and assess the MAF in 3D quality. Conclusion The results showed that intraoperative CBCT is a reliable imaging technique for real-time intraoperative assessment of treated MAF. Use of the mobile 3D CBCT scanner is easy to integrate into routine practice and offers the advantage that immediate revision surgery can be performed.

Gut dysfunction is suspected to play a major role in the pathophysiology of post-resuscitation disease through an increase in intestinal permeability and endotoxin release. However this dysfunction often remains occult and is poorly investigated. The aim of this pilot study was to explore intestinal failure biomarkers in post-cardiac arrest patients and to correlate them with endotoxemia.Following resuscitation after cardiac arrest, 21 patients were prospectively studied. Urinary intestinal fatty acid-binding protein (IFABP), which marks intestinal permeability, plasma citrulline, which reflects the functional enterocyte mass, and whole blood endotoxin were measured at admission, days 1-3 and 6. We explored the kinetics of release and the relationship between IFABP, citrulline and endotoxin values.IFABP was extremely high at admission and normalized at D3 (6668 pg/mL vs 39 pg/mL, p=0.01). Lowest median of citrulline (N=20-40 μmol/L) was attained at D2 (11 μmol/L at D2 vs 24 μmol/L at admission, p=0.01) and tended to normalize at D6 (21 μmol/L). During ICU stay, 86% of patients presented a detectable endotoxemia. Highest endotoxin level was positively correlated with highest IFABP level (R(2)=0.31, p=0.01) and was inversely correlated with lowest plasma citrulline levels (R(2)=0.55, p0.001). Endotoxin levels increased between admission and D2 in patients with post-resuscitation shock, whereas it decreases in patients with no shock (median +0.33 EU vs -0.19 EU, p=0.03). Highest endotoxin level was positively correlated with D3 SOFA score (R(2)=0.45, p=0.004).Biomarkers of intestinal injury are altered after cardiac arrest and are associated with endotoxemia. This could worsen post-resuscitation shock and organ failure.

Objective Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms. Design A descriptive study of barriers to intervention delivery in a controlled trial. Settings The study was conducted in six nursing homes in Maryland. Participants Participants were 89 agitated nursing home residents with dementia. Intervention Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined. Measurements Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect. Results Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment. Conclusion Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery.

Background: Affect, behavior, and cognition can be considered as basic constructs that dictate human functioning, with intricate and bi-directional relationships among them. Prior to the present study, relationships among these constructs have not been systematically examined within the context of dementia.Methods: Sample 1 contained 185 nursing home residents with a diagnosis of dementia. Sample 2 contained 117 residents with dementia, all of whom manifested agitated behaviors. Outcome measures included stimulus engagement (assessed via the Observational Measure of Engagement), affect (measured using Lawton's Modified Behavior Stream), and agitation/problem behavior (recorded via the Agitated Behaviors Mapping Instrument). Real time direct observations were collected during both stimulus presentation and control conditions.Results: The relationship of engagement with positive affect, represented by the variables of interest and pleasure, were high and positive. No relationship emerged for engagement with negative affect or agitated behavior. A consistent positive relationship was found between agitated behavior and negative affect, and in Sample 2, a negative relationship between agitated behavior and both pleasure and interest.Conclusion: This is the first study to examine relationships among variables that are typically examined individually and, in doing so, has clarified the nomenclature used to describe the constructs of affect, engagement, and agitated behaviors in persons with dementia. The finding that the constructs of engagement, agitated behavior, and affect are multidimensional and that relationships among these constructs occur for some of the dimensions is important for the development of interventions and for clear communication in practice and research.

OBJECTIVE To explore the impact of personal attributes, environmental attributes, and the presentation of 9 categories of stimuli on agitation in nursing home residents with dementia. METHOD Participants in this randomized, controlled, observational cross-sectional study were 193 residents of 7 nursing homes, all with a diagnosis of dementia, for whom we obtained data pertaining to cognitive functioning (via the Mini-Mental State Examination), performance of activities of daily living (Minimum Data Set), and role-identity/activities of past interest (Self-Identity Questionnaire). Environmental attributes (eg, noise, lighting) and direct observations of agitation (primary outcome) were recorded via the Agitation Behavior Mapping Inventory. Engagement was measured using the Observational Measurement of Engagement. Both agitation and engagement were assessed for each stimulus (including a control condition). RESULTS Univariate findings (ie, for 1 explanatory variable at a time) showed agitation to be related to several personal attributes--ie, female gender was related to verbal agitation (P < .0001); low cognitive function was related to total, verbal, and physical agitation (P < .001 for each); low performance of activities of daily living was significantly related to all types of agitation (P < .01 for total agitation and P < .05 for each type of agitation); and unclear speech was significantly related to total agitation (P < .01). Eight of the 9 stimulus categories were significantly related to decreased levels of agitation, with ORs ranging from 0.37 (live human stimuli, P < .001) to 0.79 (inanimate social stimuli, P < .05). Higher levels of engagement were related to lower levels of agitation (P < .001 for total agitation). In the multivariate analyses, higher cognitive function (P < .001), male gender (P < .05), level of engagement with stimuli (eg, duration of engagement for 3 minutes or longer, P < .05), and all 9 stimulus categories, with the exception of music, were independently predictive of lower levels of agitation (P < .001). CONCLUSIONS The finding that both type of stimuli and engagement level with the stimuli were significant predictors of agitation underscores the importance of engagement as a determinant of agitation levels.

Background Engagement refers to the act of being occupied or involved with an external stimulus. In dementia, engagement is the antithesis of apathy. Objective The Comprehensive Process Model of Engagement was examined, in which environmental, personal, and stimulus characteristics impact the level of engagement. Methods Participants were 193 residents of 7 Maryland nursing with a diagnosis of dementia. Stimulus engagement was assessed via the Observational Measure of Engagement, measuring duration, attention, and attitude to the stimulus. Twenty-five stimuli were presented, which were categorized as live human social stimuli, simulated social stimuli, inanimate social stimuli, a reading stimulus, manipulative stimuli, a music stimulus, task and work-related stimuli, and two different self-identity stimuli. Results All stimuli elicited significantly greater engagement in comparison to the control stimulus. In the multivariate model, music significantly increased engagement duration, whereas all other stimuli significantly increased duration, attention, and attitude. Significant environmental variables in the multivariate model that increased engagement were: use of the long introduction with modeling (relative to minimal introduction), any level of sound (especially moderate sound), and the presence of between 2 and 24 people in the room. Significant personal attributes included Mini-Mental State Examination scores, activities of daily living performance and clarity of speech, which were positively associated with higher engagement scores. Conclusions Results are consistent with the Comprehensive Process Model of Engagement. Personal attributes, environmental factors, and stimulus characteristics all contribute to the level and nature of engagement, with a secondary finding being that exposure to any stimulus elicits engagement in persons with dementia.

Author(s): Cleary, Robert K; Kassir, Andrew; Johnson, Craig S; Bastawrous, Amir L; Soliman, Mark K; Marx, Daryl S; Giordano, Luca; Reidy, Tobi J; Parra-Davila, Eduardo; Obias, Vincent J; Carmichael, Joseph C; Pollock, Darren; Pigazzi, Alessio | Abstract: BackgroundThe primary objective of this study was to retrospectively compare short-term outcomes of intracorporeal versus extracorporeal anastomosis for minimally invasive laparoscopic and robotic-assisted right colectomies for benign and malignant disease. Recent studies suggest potential short-term outcomes advantages for the intracorporeal anastomosis technique.MethodsThis is a multicenter retrospective propensity score-matched comparison of intracorporeal and extracorporeal anastomosis techniques for laparoscopic and robotic-assisted right colectomy between January 11, 2010, and July 21, 2016.ResultsAfter propensity score-matching, there were a total of 1029 minimal invasive surgery cases for analysis-379 right colectomies (335 robotic-assisted and 44 laparoscopic) done with an intracorporeal anastomosis and 650 right colectomies (253 robotic-assisted and 397 laparoscopic) done with an extracorporeal anastomosis. There were no significant differences in any preoperative patient characteristics between groups. The minimally invasive intracorporeal anastomosis group had significantly longer operative times (pl0.0001), lower conversion to open rate (p = 0.01), shorter hospital length of stay (p = 0.02) and lower complication rate from after discharge to 30-days (p = 0.04) than the extracorporeal anastomosis group.ConclusionsThis comparison shows several clinical outcomes advantages for the intracorporeal anastomosis technique in minimally invasive right colectomy. These data may guide future refinements in minimally invasive training techniques and help surgeons choose among different minimally invasive options.

We examined engagement with stimuli in 193 nursing home residents with dementia. We hypothesized that activities and stimuli based on a person's past and current preferences would result in more engagement than other activities/stimuli.The expanded version of the self-identity questionnaire [Cohen-Mansfield, J., Golander, H.Arheim, G. (2000)] was used to determine participants' past/present interests (as reported by relatives) in the following areas: art, music, babies, pets, reading, television, and office work. We utilized the observational measurement of engagement (Cohen-Mansfield, J., Dakheel-Ali, M.,Marx, M.S. (2009).Analysis revealed that residents with current interests in music, art, and pets were more engaged by stimuli that reflect these interests than residents without these interests.Our findings demonstrate the utility of determining a person's preferences for stimuli in order to predict responsiveness. Lack of prediction for some stimuli may reflect differences between past preferences and activities that are feasible in the present.

Objective To examine the impact of personal attributes on engagement in persons with dementia. Methods Participants were 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Cognitive functioning was assessed via the Mini-Mental State Examination, and engagement was assessed via the Observational Measure of Engagement. Data pertaining to activities of daily living were obtained from the Minimum Data Set. Results Women had longer mean engagement duration than men, and significant results were not seen with the other demographic variables. Significant, positive correlations were found between higher cognitive functioning and longer engagement duration, more attention, a more positive attitude, and a higher refusal rate. There was a positive and significant correlation between the comorbidity index and engagement duration, and between the number of medications and attention. All functional status variables yielded significance in a positive direction. Participants with poor hearing had a higher refusal rate. Cognitive status was the most consistent and potent predictor of engagement in this population. Conclusion Despite a higher refusal rate among those with higher cognitive levels, their overall engagement with stimuli is higher. Caregivers should anticipate higher refusal rates in those with poor hearing, and therefore compensatory methods should be used in presenting stimuli in this population. The potent role of cognitive and functional status on engagement of persons with dementia underscores the importance of tailoring activities to nursing home residents' needs, interests, and limitations. Copyright © 2009 John Wiley & Sons, Ltd.

Nursing home residents with dementia often lack the skills needed for successful communication, with the result being that social interactions become limited. In fact, Cohen-Mansfield et al1 found that nursing home residents with dementia were alone during 22% of their waking hours. One way to promote social interactions in the nursing home is through animal-assisted therapy (AAT),2,3 which involves interaction with a trained animal facilitated by a human handler. Outcomes of AAT include providing relaxation and pleasure or providing rehabilitation.3 Animal-assisted therapy is well suited for nursing home residents with dementia as it provides social interaction that is not dependent on the resident’s level of cognitive functioning; that is, a dog will provide companionship regardless of a resident’s state of awareness. A dog is a nonjudgmental listener and would not react negatively to hearing repetitions of the same phrase or story. The literature contains many anecdotal reports of positive results from AAT in persons with dementia as well as some published findings from controlled studies. When comparing a group of 7 persons in a closed psychiatric ward (6 with dementia, 1 with schizophrenia) with matched controls, Walsh et al4 found that the presence of a visiting dog resulted in fewer loud or aggressive outbursts (such that the noise level on the unit was lower) as well as a reduction in heart rate (suggestive of a calming effect) in the experimental group. The study participants reverted to their former behaviors after the dog was removed. In an experimental, within-participant repeated-measures design, Churchill et al5 studied persons with dementia who manifested increased agitated behavior in the evening hours (“sundown syndrome”). Study participants were observed during 2 conditions—dog with researcher and researcher alone (control condition). Analysis revealed that the frequency and duration of socialization behaviors (eg, leans, smiles, looks toward, tactile contact, and verbalization) increased and agitation decreased in the presence of the dog relative to the control condition. The authors reported that interaction with the dog was linked with less confusion and served to stimulate reminiscence and memories, distracting the participant from agitation during the sundowning hours. Other investigators have corroborated the findings of Churchill et al5 in other samples of nursing home residents with dementia, reporting increases in socialization and decreases in agitation as a result of AAT.6–10 Additionally, AAT has been reported to improve apathetic state11 and improve emotional well-being12 in nursing home residents with dementia. A link between study participants’ past interest in or ownership of animals and positive outcomes has been reported.8, 13 As it is not always practical to bring live animals to nursing homes, some researchers have focused on robotic animals or plush animals (also called stuffed animals) for their residents. In 2004, Libin and Cohen-Mansfield14 compared an enhanced robotic cat (NeCoRo) to a plush cat in a study of 9 agitated nursing home residents with dementia. Statistically significant decreases in agitation (relative to baseline) were seen with the plush cat, and a similar trend was seen with the robotic cat. In addition, statistically significant increases in interest and pleasure were found with the robotic cat, and while test statistics for the plush cat were not significant, the authors reported a trend in the same direction. Tamura et al15 compared a metal robotic dog (AIBO) with a plush motor-driven toy dog in a group of 13 persons with severe dementia in a geriatric health care facility. Statistical analyses were not provided for this study; however, results suggest that the study participants responded to both dogs with social behaviors (eg, talking, watching, clapping, touching, and caring for the dog), with more of these behaviors being directed at the plush motor-driven toy dog. In addition, fewer interventions on the part of the occupational therapist were observed with the plush motor-driven toy dog than with the metal robotic dog. Recently, in a group of nursing residents with neither cognitive impairment nor a diagnosis of Alzheimer’s disease, AIBO was compared with a live dog and results showed that AAT with either led to similar improvements in loneliness relative to a control group.16 Banks et al16 noted that some residents and staff were initially reluctant to interact with AIBO but that this resistance dissipated with exposure. The present study focused on dogs and was conducted to provide further empirical evaluation of AAT in a group of 56 nursing home residents with dementia. Filan and Llewellyn-Jones,3 in a literature review of AAT for persons with dementia, noted that the AAT studies in nursing homes to date have been limited by small sample sizes (ranging from 7 to 28 persons; 1 study included 62 persons). We included a standard poodle as well as 2 miniature schnauzers (one was 11 pounds and the other was 25 pounds) in our study because it is conceivable that residents may have a preference for a dog on the basis of size. As some residents may be afraid or allergic to dogs, we also included a variety of dog-related stimuli—a plush dog, pictures of dogs to color with markers, a robotic dog, and a puppy video—and evaluated the engaging value of these stimuli. In addition, we looked at the influence of a past preference for dogs on our response measures. Indeed, it has been shown that interventions based on past identity roles result in greater interest, pleasure, and involvement than the typical structured activities for residents with dementia.17

Objectives:The management of advanced laryngeal cancer has evolved in the last century, from total laryngectomy to chemoradiation. The aim of this study was to examine our experience with supracricoid partial laryngectomy as a possible solution for patients with advanced laryngeal tumours, with a focus on the oncological safety of the procedure and the functionality of the preserved larynges.Study design:We reviewed the medical records of patients with laryngeal cancer who had undergone primary or salvage supracricoid partial laryngectomy at our department between 1998 and 2004.Results:Twenty-three patients treated with supracricoid partial laryngectomy for endolaryngeal squamous cell carcinoma were identified. Median follow-up time was 35 months. Twelve patients had advanced laryngeal tumours. Eight patients were radiation failures. These factors were not associated with increased local recurrence or with decreased survival.Conclusion:Supracricoid partial laryngectomy appears to be a feasible option for the treatment of laryngeal tumours, even in the advanced stage or after failure of radiation therapy.

Objective To assess nursing home physicians’ and social workers’ perceptions of the new Maryland Patient Plan of Care Form (PPOC). Design Mailed survey. Setting Nursing homes in Maryland. Participants Thirty-seven physicians and 60 social workers. Measurements Views of physicians and social workers were assessed through quantitative questions about the use of the PPOC form and qualitative questions about barriers in completing the form and recommendations to improve the form. Results The majority (79.2%) of physicians and social workers reported that completing the PPOC is somewhat of a major burden. An overwhelming majority (85.6%) reported that social workers are completing the form, while close to half of the physicians and a quarter of the social work respondents say that physicians are involved in completing the form. Moreover, significantly more social workers (63.3%) than physicians (36.7%) believe the form would be more useful as a physician’s order ( X 2 = 5.287; d f = 1; P = .021). Both physicians and social workers identify barriers to completing the form and offer recommendations to improve the form. Conclusions Despite legislation requiring physicians to sign the PPOC, it is not a physician’s order, thus shifting the burden of completing the PPOC to social workers. We conclude that most physicians and social workers view the PPOC as burdensome and do not feel that it is useful, but whether it is having an effect on patient care preferences merits further investigation.

The Unmet Needs Model states that problem behaviors of people with dementia result from unmet needs stemming from a decreased ability to communicate those needs and to provide for oneself. The purpose of this study is to describe the unmet needs of persons with dementia exhibiting behavior problems. Eighty-nine residents with dementia from six Maryland nursing homes were assessed by research assistants and nursing assistants for their unmet needs using multiple assessment tools. Three unmet needs per resident were identified on average, with informants rating boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activity as the most prevalent needs. Discomfort was associated with higher levels of verbally agitated behaviors (e.g., complaining). Based on results and independent ratings of pain, the authors estimate notable under-detection of discomfort and pain by both types of informants. The study demonstrates methodologies for uncovering unmet needs among persons with dementia and highlights the importance of developing programs that address those unmet needs, especially social and activity needs of nursing home residents. The detection of pain, and possibly that of discomfort, may require a different methodology.

Background and aims: Two different models of exercise behavior in an older population have been previously published (Schuster et al., 1995 and Resnick et al., 2000). We aimed to validate the models with data from a different sample, and to examine whether any of these models explained a greater proportion of the variance in exercise behavior in this population. Methods: Participants were 324 community-dwelling persons aged 74–85 years who completed a mailed questionnaire. The questionnaire included questions about demographics, current exercise habits, health, activities of daily living, depressed affect, living arrangement, attitudes about exercise, self-efficacy, barriers to exercise, and enjoyment of exercise. Results: While our data explained some of the variance of the two previously published models of exercise behavior, the percentage of variance explained was less impressive than that reported by those authors. A path analysis of demographic and psychological constructs, which have been used in both models, demonstrated that physical health, mental health, gender, and past enjoyment of exercise affect self-efficacy, attitudes/outcome expectancy, and reported barriers to exercise. These psychological constructs in turn affect exercise habits. Conclusions: The relatively low percentage of variance explained by the models may imply that other factors contribute to exercise behavior in older adults, that the constructs are very sensitive to measurement differences, or that these factors are not as important as previously thought. Our results are consistent with the models of both Schuster et al. and Resnick et al., but suggest that a combined model may better represent the data. Future investigations of exercise behavior in older persons should examine this possibility.

Objective: To determine correlates of hoarding behavior in frail elderly persons. Methods: Information about nursing home residents (n = 408) and community-dwelling senior day-care participants (n = 177) was gathered through interviews with family and professional caregivers, medical chart review, and physician examinations, and included the following areas of assessment: hoarding behavior, demographic and health information, level of cognitive functioning, activities of daily living (ADL) performance, depressed affect, social functioning, manifestations of agitated behaviors, and previous stressful life experiences. Results: We found that 15% of the nursing home residents and 25% of the community-dwelling senior day-care participants manifested hoarding behavior at a rate of several times a week or higher. For nursing home residents, hoarding behavior was significantly related to a larger appetite, taking fewer medications, higher social functioning, comparatively less ADL impairment, and manifestations of physically nonaggressive agitated behaviors. For senior day-care participants, hoarding behavior was significantly associated with being female, a larger appetite, comparatively less gait impairment, fewer medical diagnoses, more involvement in activities, a positive diagnosis of dementia, hallucinations, the delusion of infidelity, and manifestations of three syndromes of agitated behaviors. Conclusion: While hoarding behavior in our samples presents differently from compulsive hoarding described in the literature, we obtained robust findings that show that despite differences in living conditions, the elderly persons who manifested hoarding behavior were those with relatively fewer health and functional disabilities. In addition, those who exhibited hoarding behavior also manifested agitated behaviors. We suggest that future researchers develop alternative measures of hoarding behavior so as to further clarify the phenomenon of hoarding behavior in the elderly.

Background Recent guidelines recommend assessing medical inpatients for bleeding risk prior to providing chemical prophylaxis for VTE. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS) was derived from a well-defined population of medical inpatients but it has not been validated externally. We sought to externally validate the IMPROVE BRS. Methods We prospectively collected characteristics on admission and VTE prophylaxis data each hospital day for all patients admitted for a medical illness to the Walter Reed Army Medical Center over an 18-month period. We calculated the IMPROVE BRS for each patient using admission data and reviewed medical records to identify bleeding events. Results From September 2009 through March 2011, 1,668 inpatients met the IMPROVE inclusion criteria. Bleeding events occurred during 45 separate admissions (2.7%); 31 events (1.9%) were major and 14 (0.8%) were nonmajor but clinically relevant. Two hundred fifty-six patients (20.7%) had an IMPROVE BRS ≥ 7.0. Kaplan-Meier curves showed a higher cumulative incidence of major ( P = .02) and clinically important (major plus clinically relevant nonmajor) ( P = .06) bleeding within 14 days in patients with an IMPROVE BRS ≥ 7.0. An IMPROVE BRS ≥ 7.0 was associated with major bleeding in Cox-regression analysis adjusted for administration of chemical prophylaxis (OR, 2.6; 95% CI, 1.1-5.9; P = .03); there was a trend toward a significant association with clinically important bleeding (OR, 1.9; 95% CI, 0.9-3.7; P = .07). Conclusions The IMPROVE BRS calculated at admission predicts major bleeding in medical inpatients. This model may help assess the relative risks of bleeding and VTE before chemoprophylaxis is administered.

Two representational abilities, expressive and receptive language and symbolic play, were assessed in multiple formats in hearing and deaf 2-year-old children of hearing and deaf mothers. Based on maternal report, hearing children of hearing and deaf mothers produced more words than deaf children of hearing mothers, hearing children of hearing mothers more words than deaf children of deaf mothers, and deaf children of deaf mothers more words than deaf children of hearing mothers. Based on experimenter assessments, hearing children in both groups produced and comprehended more words than deaf children in both groups. By contrast, no differences emerged among these groups in child solitary symbolic play or in child-initiated or mother-initiated child collaborative symbolic play; all groups also increased equivalently in symbolic play between solitary and collaborative play. Representational language and symbolic play were unrelated in hearing children of hearing mothers and in deaf children of deaf mothers, but the 2 abilities were associated in children in the 2 child/mother mismatched hearing status groups. These findings are placed in the context of a proposed developing modularity of verbal and nonverbal symbol systems, and the implications of hearing status in communicative exchanges between children and their mothers in diverse hearing and deaf dyads are explored.

A prospective cohort study was conducted to examine predictors of mortality in the nursing home. Participants were 399 long-term nursing home residents, who were followed up for 11 years at the end of which 380 had died, 16 were still alive, 2 were discharged with unknown status, and 1 was alive when discharged. The median duration from baseline to death was 2.75 years. For cognitively intact residents, male gender, larger number of medical diagnoses, and manifestations of physically nonaggressive agitated behaviors (e.g., restlessness, pacing) were significant predictors. For cognitively impaired residents, the significant predictors were older age, impaired activities of daily living, and screaming behavior at a high frequency. Cognitive impairment is important both in predicting death in this population and in understanding the impact of other predictors. The impact of agitated behaviors, quality of social relations, and appetite on mortality highlights issues of quality of life at the end of life.

To explore how well medical schools prepare students to address end-of-life issues with their patients.In 1997, the authors surveyed 226 fourth-year students at Georgetown University School of Medicine and Mayo Medical School, assessing relevant knowledge, experiences, and attitudes, and the students' sense of preparedness to address end-of-life issues.Seventy-two percent (162) of the eligible students responded. Almost all (99%) recognized the importance of advance directives and anticipated discussing end-of-life issues with patients in their practices (84%). However, only 41% thought their education regarding end-of-life issues had been adequate, only 27% had ever discussed end-of-life issues with a patient themselves, and only 35% thought they had had adequate exposure and education regarding advance directives. Eighty percent favored more education about end-of-life issues. Educational exposure to end-of-life issues and to role models, ability to correctly define an advance directive, number of end-of-life discussions witnessed, and age all were associated the students' sense of preparedness to discuss advance directives with patients.Most of the students felt unprepared to discuss end-of-life issues with their patients, but wanted to learn more. The factors associated with a sense of preparedness suggest several possible, easily made, educational interventions, but further research is required to understand the scope of the problem and to implement curricular modifications.

Objective This study compares different nonpharmacological interventions for persons with behavioral symptoms and dementia on frequency of use and perceived efficacy in terms of change in behavior and interest. Methods Participants were 89 nursing home residents from six Maryland nursing homes with a mean age of 85.9 years (SD: 8.6 years). Research assistants presented interventions tailored to the participants' needs and preferences in a pre-intervention trial phase and in an intervention phase. The impact of each intervention on behavioral symptoms and on the person's interest was rated immediately after the intervention by a research assistant. Results The most utilized interventions in both trial and treatment phases were the social intervention of one-on-one interaction, simulated social interventions such as a lifelike doll and respite video, the theme intervention of magazine, and the sensory stimulation intervention of music. In contrast, the least utilized interventions in both phases were sewing, fabric book, and flower arrangement. Interventions with the highest impact on behavioral symptoms included one-on-one social interaction, hand massage, music, video, care, and folding towels. Other high impact interventions included walking, going outside, flower arranging, food or drink, sewing, group activity, book presentation, ball toss, coloring or painting, walking, and family video. Conclusions The results provide initial directions for choosing specific interventions for persons with dementia and also demonstrate a methodology for increasing knowledge through ongoing monitoring of practice.

OBJECTIVE: To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation. DESIGN: Controlled clinical trial. SETTING: The internal medicine residents’ practice of an urban, university medical center. PATIENTS/PARTICIPANTS: Medical residents and 250 patients seen at least twice in the 3 months prior to the study. INTERVENTIONS: We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives. MEASUREMENTS AND MAIN RESULTS: We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p

A prospective study of vision-related outcomes of cataract surgery as well as cognitive functioning, activities of daily living (ADL) functioning, and depressed affect was conducted with 19 nursing home residents scheduled for cataract surgery. Also studied were 22 candidates for cataract surgery who decided against it. Comparison of both groups at baseline revealed that residents who chose cataract surgery were less cognitively and ADL impaired. Analysis after cataract surgery showed that visual acuity improved significantly at 4 months and was maintained at 1 year after surgery.

BACKGROUND A randomized, placebo-controlled clinical trial was undertaken to determine the efficacy of nonpharmacologic individualized interventions (individualized to address unmet needs such as boredom or pain) in decreasing agitation in persons with dementia. METHOD Agitated nursing home residents with advanced dementia (from 9 nursing homes in 5 locations in Maryland, United States) were randomized into an intervention group (n = 89) and a placebo control group (n = 36). On the basis of data from baseline assessment, a systematic methodology for individualizing nonpharmacologic interventions, Treatment Routes for Exploring Agitation (TREA), was used with the intervention group: an unmet need was hypothesized, a corresponding treatment category was identified, and specifics of the treatment were chosen to fit the person's need, past identity, preferences, and abilities. (Unmet needs were hypothesized based on physician evaluations, structured staff interviews, relative questionnaires, direct observations of agitation with the Agitation Behavior Mapping Instrument [the primary outcome measure] and affect with Lawton's Modified Behavior Stream [the secondary outcome measure], and resident assessments.) TREA interventions were implemented for 2 weeks, and observations of agitation and affect were recorded. The study was conducted from June 2006 until December 2011. RESULTS Relative to a control group, TREA interventions for unmet needs produced statistically significant declines in total (P < .001), physical nonaggressive (P < .001), and verbal agitation (P = .004) and significant increases in pleasure (P < .001) and interest (P < .05). CONCLUSIONS This is the first large randomized controlled trial to demonstrate the efficacy of TREA and one of only a few such trials of nonpharmacologic interventions for agitation in persons with dementia. The translation of these findings into practice is sorely needed and would require structural changes dedicating staff time to observing each agitated resident, determining unmet needs, obtaining appropriate intervention materials, conducting the individualized nonpharmacologic interventions, and evaluating results. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00820859.

We examined the impact of environmental, person, and stimulus characteristics on pleasure in persons with dementia. Study participants were 193 residents of 7 Maryland nursing homes who were presented with 25 stimuli from these categories: live human social stimuli, live pet social stimuli, simulated social stimuli, inanimate social stimuli, a reading stimulus, manipulative stimuli, a music stimulus, task and work-related stimuli, and two different self-identity stimuli. Systematic observations of pleasure in the natural environment were conducted using Lawton's Modified Behavior Stream. Analysis showed that pleasure is related to stimulus category, personal attributes and environmental conditions. In the multivariate analyses, all types of social stimuli (live and simulated, human and nonhuman), self-identity stimuli, and music were related to significantly higher levels of pleasure than the control condition. Females and persons with higher ADL and communication functional status exhibited more pleasure. Pleasure was most likely to occur in environments with moderate noise levels. These results demonstrate that these nursing home residents are indeed capable of showing pleasure. Caregivers of nursing home residents with dementia should incorporate social, self-identity, and music stimuli into their residents' care plans so that eliciting pleasure from each resident becomes the norm rather than a random occurrence.

International audience; We examined whether antidepressants alter expression of psychopathic personality traits in patients with major depressive disorder (MDD). Data were collected from a double-blind, placebo-controlled 8-week trial evaluating the efficacy of sertraline (50-200 mg/day) combined with either tri-iodothyronine (T3) or matching placebo in adult outpatients with major depressive disorder. Administration of sertraline was open-label; T3/placebo was double-blind. At the baseline and week 8 visits, patients completed the short form of the Psychopathic Personality Inventory (PPI), a well-validated self-report measure assessing two major factors of psychopathy: Fearless Dominance (PPI-1) and Self-Centered Impulsivity (PPI-2). Change in PPI scores were assessed using paired t-tests for all participants who completed a baseline and postrandomization PPI. Ninety patients (84 completers and six who terminated the trial early) were eligible for the analysis. Both PPI factors changed significantly from baseline to endpoint, but in opposing directions. The mean score on PPI-1 increased significantly during treatment; this change was weakly correlated with change in depression scores. In contrast, the mean score on PPI-2 decreased significantly, but these changes were not correlated with changes in depression scores. Independent of their effects on depression, antidepressants increase adaptive traits traditionally observed in psychopathic individuals, such as social charm and interpersonal and physical boldness. Antidepressants reduce other, more maladaptive, traits associated with psychopathy, including dysregulated impulsivity and externalization.

The present study examined the impact of different attributes of social stimuli using the stimulus attributes aspect of the Comprehensive Process Model of Engagement (Cohen-Mansfield et al., (2009a) Am J Geriatr Psychiatry. 17:299–307). Participants were 193 residents of 7 Maryland nursing homes with a diagnosis of dementia. Stimuli were chosen to represent different levels of the following social attributes: social versus not social, realistic versus not realistic, animated versus nonanimated, human versus nonhuman, and alive versus not alive. Participants had significantly longer engagement, were significantly more attentive, and displayed a significantly more positive attitude with social stimuli than with nonsocial stimuli. Longer durations and higher ratings of attention and attitude were seen with realistic and animated stimuli as compared to their counterparts. Human and live stimuli resulted in significantly more engagement than their counterparts. Giving any social stimulus to the residents is preferable to providing none, and the social attributes of stimuli should be maximized.

Objectives To determine which stimuli are 1) most engaging 2) most often refused by nursing home residents with dementia, and 3) most appropriate for persons who are more difficult to engage with stimuli. Methods Participants were 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Stimulus engagement was assessed by the Observational Measure of Engagement. Results The most engaging stimuli were one-on-one socializing with a research assistant, a real baby, personalized stimuli based on the person's self-identity, a lifelike doll, a respite video, and envelopes to stamp. Refusal of stimuli was higher among those with higher levels of cognitive function and related to the stimulus' social appropriateness. Women showed more attention and had more positive attitudes for live social stimuli, simulated social stimuli, and artistic tasks than did men. Persons with comparatively higher levels of cognitive functioning were more likely to be engaged in manipulative and work tasks, whereas those with low levels of cognitive functioning spent relatively more time responding to social stimuli. The most effective stimuli did not differ for those most likely to be engaged and those least likely to be engaged. Conclusion Nursing homes should consider both having engagement stimuli readily available to residents with dementia, and implementing a socialization schedule so that residents receive one-on-one interaction. Understanding the relationship among type of stimulus, cognitive function, and acceptance, attention, and attitude toward the stimuli can enable caregivers to maximize the desired benefit for persons with dementia.

A 3-month observational study of 24 agitated and severely cognitively impaired nursing home residents was conducted to document the typical ways in which residents spend their time and how time use relates to the manifestation of agitated behaviors. We found that these residents were involved in no activity during 63% of the observations. In addition, residents spent little time in structured activities (e.g., music therapy) or social activities (e.g., receiving visitors). Yet data analysis revealed that residents manifested a greater number of agitated behaviors when they were unoccupied and fewer agitated behaviors when involved in structured or social activities. We discuss implications for caregivers.

To examine how presentation of different stimuli impacts affect in nursing home residents with dementia.Participants were 193 residents aged 60 to 101 years from 7 Maryland nursing homes who had a diagnosis of dementia (derived from the medical chart or obtained from the attending physician). Cognitive functioning was assessed via the Mini-Mental State Examination (MMSE), and data pertaining to activities of daily living were obtained through the Minimum Data Set. Affect was assessed using observations of the 5 moods from Lawton's Modified Behavior Stream. Baseline observations of affect were performed for comparisons. During the study, each participant was presented with 25 predetermined engagement stimuli in random order over a period of 3 weeks. Stimuli were categorized as live social, simulated social, manipulative, work/task-related, music, reading, or individualized to the participant's self-identity. The dates of data collection were 2005-2007.Differences between stimulus categories were significant for pleasure (F(6,144) = 25.137, P.001) and interest (F(6,144) = 18.792, P.001) but not for negative affect. Pleasure and interest were highest for the live social category, followed by self-identity and simulated social stimuli for pleasure, and for manipulative stimuli in terms of the effect on interest. The lowest levels of pleasure and interest were observed for music. Participants with higher cognitive function had significantly higher pleasure (F(1,97) = 6.27, P.05). Although the general trend of the impact of the different categories was similar for different levels of cognitive function, there were significant differences in pleasure in response to specific stimuli (interaction effect: F(6,92) = 2.31, P.05). Overall, social stimuli have the highest impact on affect in persons with dementia.The findings of the present study are important, as affect is a major indicator of quality of life and this study is the first to systematically examine the impact of specific types of stimuli on affect. As live social stimuli are not always readily available, particularly in busy nursing home environments, simulated social stimuli can serve as an effective substitute, and other stimuli should have a role in the activity tool kit in the nursing home. The relative ranking of stimuli was different for interest and pleasure. The findings demonstrate the differential effect of presentation of different types of stimuli on the affect of persons with dementia, and that, while the impact is greater on persons with higher levels of cognitive function, there is a different effect of varying stimuli even in persons with MMSE scores of 3 or lower. Future research should attempt to ascertain a person's degree of interest in stimuli prior to developing an intervention.

Purpose The aim of this article is to delineate the underlying premises of the concept of engagement in persons with dementia and present a new theoretical framework of engagement. Setting/Subjects The sample included 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Methodology The authors describe a model of factors that affect engagement of persons with dementia. Moreover, the authors present the psychometric qualities of an assessment designed to capture the dimensions of engagement (Observational Measurement of Engagement). Finally, the authors detail plans for future research and data analyses that are currently underway. Discussion This article lays the foundation for a new theoretical framework concerning the mechanisms of interactions between persons with cognitive impairment and environmental stimuli. Additionally, the study examines what factors are associated with interest and negative and positive feelings in engagement.

Two studies concerning pacing by nursing home residents are presented. The first was a cross-sectional survey of 402 residents, which found that 39% of the subjects were pacers. In comparison to residents who did not pace, the pacers had fewer medical diagnoses, better appetites, and had resided in the facility for fewer years. Additionally, pacing was positively related to cognitive impairment and to past life-threatening experiences. Results of the second study, an observational study of six cognitively impaired residents who paced frequently, showed that these residents paced more when the environmental conditions were conducive to pacing (e.g., adequate lighting, enough room within which to pace). We believe that pacing is a reflection of good health within the nursing home population and suggest that caregivers may want to encourage rather than inhibit this behavior in some nursing home residents.

In a previous article, we discussed a theoretical framework asserting that a combination of stimulus attributes, personal attributes and environmental attributes as well as interactions among these affects engagement with stimuli by persons with dementia [Cohen-Mansfield, J., Dakheel-Ali, M., Marx, M.S., 2009. Engagement in persons with dementia: The concept and its measurement. American Journal of Geriatric Psychiatry 7, 299-307]. Based on this framework, we tested the impact on engagement of the personal meaning of stimuli, specifically examining work-like stimuli, stimuli based on the person's identity, and gender role-based activities. We hypothesized that having such meanings will render stimuli more engaging than stimuli without these meanings. Participants were 193 residents of 7 Maryland nursing homes. All participants had a diagnosis of dementia. Results confirmed the hypotheses, demonstrating that the meaning of the stimulus impacts engagement shown by persons with dementia. Interventions that involve objects or tasks with meaning specific to the person with dementia will be more likely to engage that person. Future research could explore more identity roles as well as other mechanisms affecting engagement.

We examined the influence of stimulus attributes on the engagement of 69 nursing home residents with dementia. Specifically, we looked at work-related stimuli versus manipulative block stimuli, and whether the color, size, and material of a stimulus affect the duration and quality of engagement. Engagement was assessed using the Observational Measurement of Engagement (OME). Results revealed a clear preference for the work-related rather than manipulative block stimuli. In addition, the study participants showed a significant preference for small rather than large blocks, regardless of color or material. The effect of material and color was not statistically significant. These findings may assist nursing home caregivers who wish to provide appropriate stimuli for engaging nursing home residents with dementia.

The occurrence of falls and the manifestations of three dimensions of agitation (aggressive behaviors, physically nonaggressive behaviors, verbal behaviors) were recorded in 408 nursing home residents during each of the three nursing shifts. Falls occurred most frequently during the busiest shift (the day shift) and least frequently during the night shift when most residents were sleeping and nursing staff were not as busy, a result that confirms previous reports. In comparison to residents who did not fall, residents who fell manifested significantly more physically nonaggressive behaviors, more aggressive behaviors, more verbally agitated behaviors, and overall, a greater total number of agitated behaviors.

Background. To examine preferences concerning social and environmental aspects of exercise in the elderly population. Methods. Participants were 324 community-dwelling persons aged 74–85 years who completed a health questionnaire that included items on exercise preferences as well as questions on demographic variables, health, and exercise habits. Selected participants then completed a physical performance battery to measure lower body functioning. Results. A physician's advice to exercise, monitoring by a health professional, an evaluation of the exercise program by a professional, and the quality of the instructor were all rated as important or very important by at least 70% of the participants. Several other factors such as easy access to exercise facilities, type of exercise performed, free or low cost of a program, and other participants being of the same age were rated as slightly important or important. Preferences were related to participants' health and demographic characteristics. For example, participants who were not married were more interested in the social aspects of exercise programs, and those with higher levels of education and more resources were less concerned with program costs. Conclusions. The findings suggest that exercise programs should be tailored to meet the needs and wishes of subgroups of this population. In order to motivate at-risk elderly persons to exercise, programs must take these varying preferences into account and explore their meaning for program design.

Objective To determine if changes in depressive symptoms or anxiety lead to changes in the activity of systemic lupus erythematosus (SLE). Methods Twenty-three patients with SLE were examined prospectively every 2 weeks for up to 40 weeks. At each assessment, patients completed the Centers for Epidemiologic Studies--Depression scale (CES-D), the State subscale of the State-Trait Anxiety Inventory and a global assessment of the activity of their SLE by visual analogue scale. SLE activity was also assessed at each visit by physician global assessment, the Systemic Lupus Activity Measure (SLAM), the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the European Consensus Lupus Activity Measure (ECLAM). Results Changes in depression and anxiety were positively correlated with simultaneous changes in the patient global assessment of SLE activity and in the SLAM, but not with changes in the physician global assessment, SLEDAI or ECLAM. Depression and anxiety scores were also correlated with patient global assessments and SLAM scores 2 weeks later, but lagged scores were not significantly associated with the patient global assessment or SLAM after controlling for current depression and anxiety scores. The associations between depression and anxiety scores and the SLAM were not present when SLAM scores were modified to exclude ratings of depression and fatigue. No measure of SLE activity increased in the 2 weeks immediately after a large increase in CES-D or State Anxiety scores. Conclusions Depression and anxiety scores parallel changes in patients' assessments of the activity of their SLE. We found no evidence to support the hypothesis that psychological distress causes increased SLE activity.

Preference measures may be useful tools to assess patients' overall health-related quality of life. We studied the validity and sensitivity to change of the rating scale preference measure in patients with systemic lupus erythematosus (SLE), and compared its properties with those of the patient global assessment of SLE activity, in a prospective longitudinal observational study of changes in the symptoms and clinical disease activity of 23 patients. Patients were assessed every two weeks for up to 40 weeks. Construct validity was assessed by the strength of correlations between changes over time in the rating scale preference measure and patient global assessment and changes in the physician global assessment, Systemic Lupus Activity Measure (SLAM), European Consensus Lupus Activity Measure (ECLAM), the British Isles Lupus Assessment Group index (BILAG), and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Changes in the rating scale were more highly correlated with changes in each of these standards than were changes in the patient global assessment, demonstrating the construct validity of this measure. Sensitivity to change was measured using the two-week interval of greatest change in either the physician global assessment or the SLE activity measures as standards. The rating scale preference measure was less sensitive to change than the patient global assessment when tested against four different standards. The sensitivity to change of the rating scale was less than one-half that of the patient global assessment when either the SLAM or ECLAM was used as the standard. Although these results support the validity of the rating scale as a measure of health-related quality of life in patients with SLE, its limited sensitivity to change may make it less attractive as an endpoint measure in clinical trials.

Objective: To explore the link between low vision and Activities of Daily Living (ADL) performance in cognitively intact nursing home residents. Design: Survey. Setting: A non-profit geriatric long-term care facility. Subjects: 21 males, 82 females, aged 66–98. Measures: Survey of 103 nursing home residents. ADL functioning assessed via Maryland Appraisal of Patient Progress (MAPP); medical data collected through chart review; ophthalmological data obtained through dilated eye examination by an ophthalmologist. Results: In comparison with residents having good vision (n = 52), a significantly greater proportion of residents with low vision (n = 51) were dependent on caregivers for performing ADLs (eg, toileting, transferring, washing). Residents with low vision had significantly more eye pathology (eg, cataracts, age-related macular degeneration) than did residents with good vision. There were no significant differences between groups with regard to presence of musculoskeletal problems (eg, arthritis) or number of medical conditions (eg, cardiovascular disorder, cerebrovascular accident). Conclusions: There is a strong link between low vision and ADL disability in nursing home residents. Moreover, ADL dependency is significantly related to the presence of eye disorders. J Am Geriatr Soc 40:1018–1020, 1992

Identification of criterion standards for clinically important changes for groups of patients requires that judgments of the degree of change that represents a clinically important change are consistent among patients. We demonstrate the use of receiver operating characteristic (ROC) curves to test if patients' judgments of clinically important changes are consistent. Twenty-three patients with systemic lupus erythematosus (SLE) were examined prospectively every 2 weeks for up to 40 weeks. At each assessment, each patient rated the activity of their SLE on a visual analog scale, rated whether their SLE was more active, less active, or unchanged over each 2-week interval, and rated the importance of any change in SLE activity. One of three physician examiners completed similar assessments. Each measured change in the patient global assessment was categorized according to the patient's judgment of whether no change in SLE activity was noted or whether the patient thought their SLE was more or less active during the interval. ROC curves were constructed from these data. Areas under the ROC curve that were significantly greater than 0.5 were considered evidence for consistent ratings among patients of important changes in SLE activity. Patient assessments of change were available for 383 of 392 2-week intervals (97.7%). Of these, patients reported no change in SLE activity in 200 intervals, improvement in 72 intervals, and worsening in 111 intervals. Intervals of improvement could be distinguished from intervals of no change by changes in the patient global assessments [ROC area = 0.68; 95% confidence interval (CI) 0. 60, 0.76]. The cutpoint with the greatest sensitivity and specificity for any improvement was a decrease of 5 points or more (on a 0-100 scale) in patient global assessment. Intervals of worsening could also be distinguished from intervals of no change (ROC area = 0.80; 95% CI 0.74, 0.85), and the best cutpoint was an increase of 5 points or more in the patient global assessment. Group criteria for major improvement or worsening and for relative changes in the patient global assessment could also be determined, as could criteria for important changes in physician global assessments. By testing the consistency of patients' judgments of important changes, ROC curves provide a means to determine if group criteria for clinically important change can be established.

To compare the construct validity and sensitivity to change of the Systemic Lupus Activity Measure (SLAM), Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), Lupus Activity Index (LAI), British Isles Lupus Assessment Group index (BILAG), and the European Consensus Lupus Activity Measure (ECLAM).Twenty-three patients with systemic lupus erythematosus (SLE) were examined prospectively every 2 weeks for up to 40 weeks. Nineteen patients completed all 20 assessments. At each assessment, each of the 5 activity indices was scored, along with physicians' and patients' global assessments of SLE activity. Construct validity was determined by the strength of correlations between changes over time in each activity index and changes in physician and patient global assessments. Sensitivity to change was determined by the magnitude of change in each index over the 2 week interval of greatest change in the physician or patient global assessments, and calculated as standardized response means (SRM; mean change/standard deviation of change). Thirteen patients were also examined monthly by a second physician who was blinded to previous scores on the activity indices and to the patient global assessments.Patients had substantial changes in SLE activity during the study. Changes in each activity index were correlated with changes in the physician global assessment (SLAM r = 0.54; SLEDAI r = 0.52; LAI r = 0.75; BILAG r = 0.61; ECLAM r = 0.65; all p0.0001). Correlations were somewhat lower with the blinded physician assessment (SLAM r = 0.42; SLEDAI r = 0.12; LAI r = 0.30; BILAG r = 0.28; ECLAM r = 0.32). The SLAM was the only index that was positively correlated with changes in the patient global assessment (r = 0.22; p0.0001). Sensitivity to change was greatest for the LAI (SRM = 0.74) and the ECLAM (SRM = 0.75) and smallest for the SLEDAI (SRM = 0.48) when the physician global assessment was used as the standard. Sensitivity to change was greatest for the SLAM (SRM = 0.61) and the BILAG (SRM = 0.57) and smallest for the SLEDAI (SRM = -0.01) when the patient global assessment was used as the standard.Each index is a valid measure of SLE activity. The SLAM captures patients' assessments better than the other indices, perhaps because it assesses the patients' subjective complaints to a greater extent. Estimates of sensitivity to change varied with the standard used, but the SLEDAI was least sensitive to change. Larger studies are indicated to further compare the sensitivity to change of these indices.

92% of peripheral blood mononuclear cells from a patient with chronic lymphocytosis (WBC 22 x 10(9)/l) were recognized by pan-gamma delta monoclonal antibody (mAb) TCR delta 1. Further analysis with anti-V gamma/V delta mAb indicated that the expanded gamma delta T-cell population was stained by mAb specific for V gamma 2/3/4, V gamma 5 and V delta 1 but not mAb specific for V gamma 8, V gamma 9, V delta 2 or V delta 3. Cloning and sequencing of reverse transcription PCR products revealed the presence of V gamma 4, V gamma 5 and V delta 1 in-frame transcripts. All the cDNA clones obtained from each of these variable elements had identical junction regions, thus clearly demonstrating clonality. As far as we know, this is the first description of a pathological clonal expansion of gamma delta T cells with two distinct surface-expressed T-cell receptor molecules.

Background It has been suggested that faculty members' inadequate knowledge of and unfavorable attitudes toward ethics may present barriers to effective education in ethics for house officers. Method To test this hypothesis, the authors administered a questionnaire assessing the knowledge, confidence, and attitudes regarding ethics of the 73 house officers and 73 full-time faculty members in the Department of Medicine at the Georgetown University Medical Center in 1992-93. Statistical analysis of the responses was performed using chi-square, two-tailed t-tests, and linear regression. Results Fifty-five house officers (75%) and 57 faculty (78%) responded. The knowledge scores were similarly low for both groups (53% correct for the faculty and 50% for the house officers). However, the faculty were significantly more confident than the house officers regarding ability to address ethical issues (mean ratings of 3.9 vs 3.4 on a scale from 1, very low, to 5, very high; p = .0001). Seventy-five percent of the faculty and 65% of the house officers believed that ethics training should be mandatory during residency. Conclusion The attitudes of the faculty per se do not appear to represent a barrier to teaching ethics. However, the gap between the faculty members' confidence and knowledge could interfere with their abilities to model and teach ethics to house officers.

Twenty-four highly agitated, cognitively impaired nursing home residents were studied in depth to determine whether they manifested temporal patterns of agitation. Results demonstrated that agitated behaviors were significantly associated with temporal factors. For instance, residents made more requests for attention during lunch than other time periods, and residents screamed most often during the night. Some agitated behaviors (e.g., aggression) were manifested more frequently in the evening than in the day, consistent with the notion of sundowning in the nursing home. Implications of temporal patterns of agitation for caregivers of severely cognitively impaired and agitated nursing home residents are discussed.