Aged

Caregivers of persons with dementia do not use community resources until late in the disease process, despite the fact that judicious use of community resources can delay nursing home admission. Data from the National Caregiver Training Project, based on progressively lowered stress threshold (PLST) model, were used to examine variables related to use of community resources. Spouse and adult child caregivers were divided into two groups based on amount of community resources used per week. Within this geographically diverse sample of caregivers, 64% did not use professional services, 79% did not use respite services, and 65% did not use other services. Being a spouse decreased the odds that the caregiver would use community resources. Resource use was also related to the care recipient's problems with activities of daily living and the increase in frequency of memory and behavioral problems.

This study reviewed all single experience of splenic injuries after colonoscopy in the last 40 years to define the possible risk factors and the management of this complication. A MEDLINE and a PubMed search was undertaken to identify articles in English, French, Spanish, and Italian from 1974 to 2012 using the key words: "splenic injury," "splenic rupture," and "colonoscopy." Data were analyzed using descriptive statistic. A total of 103 cases have been described in 75 reports. The majority of the patients were women (71.56%) and 6.85% underwent previous pelvic surgery. The mean age was 63 years (range, 29 to 90 y). About 61 of the 103 studies (59.2%) reported the presence or the absence of previous abdominal surgery and within these, only 31 of 61 patients (50.82%) underwent previous abdominal surgery. In this review, over half of the patients with splenic injury underwent colonoscopy for routine surveillance (62.75%), and only one third of the splenic injures were associated with biopsy or polypectomy. The majority of patients (78.57%) developed symptoms within the first 24 hours after colonoscopy and in a minority of cases (21.43%), there was a delayed presentation 24 hours after colonoscopy. Computed tomography was used as the primary modality to make the diagnosis in 69 of 98 cases (70.41%) and as a confirmatory test in many additional cases. Twenty-six of 102 patients (25.49%) were treated by conservative methods, whereas the majority of patients (69.61%) underwent splenectomy as a definitive treatment. Because of possible medicolegal implications, the endoscopists should consider mentioning splenic injury on the consent form of colonoscopy after bowel perforation and bleeding, particularly in higher risk patients.

Purpose: To evaluate our experience of thoracic endoluminal graft (ELG) repair of various thoracic aortic pathologies using a commercially available device approved by the Food and Drug Administration. Our patient population includes patients eligible for open surgical repair and those with prohibitive surgical risk. Methods: From March 1998 to March 2006, endovascular stent repair of the thoracic aorta was performed on 406 patients with 324 patients (median age 72; 200 male) receiving the Gore Excluder endograft. Patient demographics, procedural characteristics, complications, including endoleak, spinal cord ischemia, and mortality, were retrospectively reviewed during follow-up. All patients were followed with chest computer tomography at 6 months and yearly. Statistical analysis was performed utilizing the SPSS Windows 11.0 program. Logistic regression (univariate) analysis used to identify risk factors for paraplegia; analysis of variance (ANOVA) for endoleak distribution; and 2 used to analyze variables. Survival analysis was done using SAS version 9.1 (SAS Institute, Cary, NC). Results: Three hundred twenty-four patients were treated with Gore Excluder graft between March 1998 and March 2006. One hundred fifty-seven patients (48.5%) had atherosclerotic aneurysms, 82 (25.3%) had dissections type B (DTB), 34 (10.5%) had penetrating ulcers (PU), 26 (8.0%) with pseudoaneurysms (PSA), 11 (3.4%) had transections (MVAT), 9 (2.8%) aorto-bronchial fistulas (AoBF), 4 (1.2%) embolization, and 1 (0.3%) aorto-esophageal fistula (AoEF). Preoperative aneurysm sac size in TAA ranged from 5 to 12 centimeters, average size 6.3 cm. Sac shrinkage occurred in 65% (102 of 157) of patients. Average postoperative sac size of 5.4 cm in a mean follow-up of 20.4 months. One hundred cases (31.5%) were nonelective; 49 (15.1%) were ruptures. Overall complication was 22.7%, 14.2% (46) in elective cases and 8.5% (28) in nonelective cases.

Background: This study was designed to compare the efficacy of two different sites of active forced air warming, upper body or lower body, to maintain normothermia; and their respective effect on thenar skin temperature in relation to the accelerographic monitoring of neuromuscular blockade during longlasting abdominal surgery. Methods: Twenty-six patients were randomised into two groups: upper body, (nΩ13) and lower body, (nΩ13), for intraoperative forced air warming. General anaesthesia was induced with thiopentone, sufentanil, and maintained with a mixture of N 2 O/O 2 /isoflurane. Pancuronium, 0.1 mg ¡ kg ª1 was used to facilitate tracheal intubation. Reinjection doses of 0.01 mg ¡ kg ª1 were administered once 25% recovery of first twitch height of train-of-four stimulation had occurred, or if surgical relaxation was estimated as inadequate by the surgeon. Thenar skin temperature and core temperature were monitored continuously. Results: A similar trend for core temperature profile was observed in both groups. After an initial mild hypothermia, normothermia was reached progressively. Normothermia was obtained faster with lower body forced air warming than with upper body (2 h versus 3 h), PϽ0.05. Thenar skin temperature

Age-related decline in allocentric (viewer-independent) spatial memory is seen across species. We employed a virtual reality analogue of the Morris Water Maze to study the effect of healthy ageing on neural activity during allocentric spatial memory using functional magnetic resonance imaging. Voxelbased morphometry was used to ascertain hippocampal volumetric integrity. A widespread neural network comprising frontal, parietal, occipital, thalamic, and cerebellar regions was activated in young and older adults, but only young adults significantly activated bilateral hippocampus and left parahippocampus, as well as right frontal pole and dorso-lateral prefrontal cortex (DLPFC) during encoding and right DLPC during retrieval. Hippocampal grey matter volume was unchanged in older adults; however, prefrontal and parahippocampal functional attenuation was accompanied by volumetric reduction. We conclude that the decline in allocentric spatial memory with age is associated with attenuated hippocampal function, as well as compromised function and structure of prefrontal and parahippocampal regions.

Introduction. Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater risk of mortality; however, factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy.

The authors aimed to evaluate age-related differences in inflammation biomarkers during the first 72 h of hospitalization for sepsis. This was a secondary analysis of a prospective observational cohort of adult patients (n = 855) from 10 urban academic emergency departments with confirmed infection and two or more systemic inflammatory response syndrome criteria. Six inflammation-related biomarkers were analyzedVchemokine (CC-motif) ligand-23, C-reactive protein, interleukin-1 receptor antagonist, neutrophil gelatinaseYassociated lipocalin (NGAL), peptidoglycan recognition protein, and tumor necrosis factor receptor-1a (TNFR-1a)Vmeasured at presentation and 3, 6, 12, 24, 48, or 72 h later. The median age was 56 (interquartile range, 43 Y 72) years, and sepsis severity was 38% sepsis, 16% severe sepsis without shock, and 46% septic shock; the overall 30-day mortality was 12%. Older age was associated with higher sepsis severity: 41% of subjects aged 18 to 34 years had severe sepsis or septic shock compared with 71% for those aged 65 years or older (P G 0.001). In longitudinal models adjusting for demographics, comorbidities, and infection source, older age was associated with higher baseline values for chemokine (CC-motif) ligand-23, interleukin-1 receptor antagonist, NGAL, and TNFR-1a (all P G 0.05). However, older adults had higher mean values during the entire 72-h period only for NGAL and TNFR-1a and higher final 72-h values only for TNFR-1a. Adjustment or stratification by sepsis severity did not change the ageinflammation associations. Although older adults had higher levels of inflammation at presentation and an increased incidence of severe sepsis and septic shock, these age-related differences in inflammation largely resolved during the first 72 h of hospitalization.

The purpose of this study was to explore the use of metaphor by independent seniors taking medication for chronic health conditions. Narratives from a larger study using grounded theory were analyzed using constant comparative analysis and induction. A secondary analysis of the narratives of 21 participants was undertaken. Transcripts were read line-by-line and all relevant language was highlighted and reviewed with the aim of identifying relationships and themes. The narratives revealed a diverse range of metaphoric language. Four categories were identified: being shackled, hope, external authority, and communication fears. Three additional themes were interwoven into the narratives: aging and death, medication personified, and the body as object. The authors conclude that metaphor reveals the tension and unresolved dilemmas faced by seniors with regard to medication use.

Objective. To examine racial differences in the risk of hospitalization for nursing home (NH) residents. Data Sources. National NH Minimum Data Set, Medicare claims, and Online Survey Certification and Reporting data from 2000 were merged with independently collected Medicaid policy data. Study Design. One hundred and fifty day follow-up of 516,082 long-stay residents. Principle Findings. 18.5 percent of white and 24.1 percent of black residents were hospitalized. Residents in NHs with high concentrations of blacks had 20 percent higher odds (95 percent confidence interval [CI] 5 1.15-1.25) of hospitalization than residents in NHs with no blacks. Ten-dollar increments in Medicaid rates reduced the odds of hospitalization by 4 percent (95 percent CI 5 0.93-1.00) for white residents and 22 percent (95 percent CI 5 0.69-0.87) for black residents. Conclusions. Our findings illustrate the effect of contextual forces on racial disparities in NH care.

Malignant eccrine poroma is a rare disease with approximately 200 cases reported in the literature. Regional cutaneous and systemic metastases are rarely observed and their management has been generally unsuccessful. We report on a case in which topical 5-fluorouracil application and intra-arterial chemotherapy with docetaxel resulted in a histologically confirmed complete response of multiple regional skin metastases for more than 2 years. Despite intravenous administration of docetaxel, slow progression of systemic disease was observed. Ó 2005 British Association of Dermatologists • British Journal of Dermatology 2005 152, pp1051-1055 Locoregional chemotherapy for porocarcinoma, E. de Bree et al. 1053 Ó 2005 British Association of Dermatologists • British Journal of Dermatology 2005 152, pp1051-1055 Locoregional chemotherapy for porocarcinoma, E. de Bree et al. 1055

The authors sought to develop a short form of the Severe Impairment Battery (SIB). Methods: Authors describe the development of an empirically-derived short form of the SIB (SIB-S) by use of data from 191 subjects with severe dementia in the United States and France. Results: Mean (standard deviation) Mini-Mental State Exam scores for the American and French samples were 7.7 (4.8) and 5.7 (3.4), respectively, and original SIB scores were 71.87 (18.34) and 58.38 (26.86), respectively. Exploratory factor analyses were conducted separately and in combination for the two samples, to determine the number of clinically meaningful factors. An eightfactor model, explaining 60.2% of the common variance, was selected. The eight constructs were described as: expressive language, memory (verbal and nonverbal), social interaction, color-naming, praxis, reading and writing, fluency, and attention. Derived SIB-S scores were 38.41 (9.12) and 29.79 (13.17) for the American and French samples, respectively. Conclusions: The original SIB is a valid and reliable research tool developed to enable reliable assessment of patients with severe dementia; it takes approximately 30 minutes to administer. The SIB-S takes only 10-15 minutes to administer, making it more appropriate for use in patients with very severe dementia, while it maintains the attributes of the original SIB. (Am J Geriatr Psychiatry 2005; 13:-)