Diagnosis and treatment of pustular disorders in the neonate

The analytical result of a laboratory examination is a scientific fact and has no medical meaning as such. It must be interpreted to become a medical finding. To explain the very complex cognitive procedure of the interpretation a three-level model is used. In an environment of cost containment in health care systems the quality of medical laboratory findings is very important. Analytical results are monitored by quality control procedures. For measuring the performance of medical findings the concept of the 'validity' of a laboratory test is used. Validity means the 'degree of achieving the objective'. Accordingly, a valid laboratory finding is one which correctly answers the question which the physician at the sick-bed directs to the laboratory. Quantitative measures for the validity of interpretation can be developed by an analysis of the underlying classification processes. Characteristic indices describing the validity quantitatively in terms of conditional probabilities can be derived from decision tables. Examples of 'validity indices' are diagnostic (or prognostic) 'sensitivity' and 'specificity'. These indices are powerful tools for developing strategies for the clinical use of laboratory examinations in diagnosis, prognosis and therapy management. Moreover, validity indices are appropriate output quantities for the estimation of effectiveness and efficiency of a diagnostic or prognostic examination.     

Diagnosis and treatment of affective disorders

The rates of major depression (5-12%) are considerably higher than for bipolar disorder (ca. 1%). Depressive disorder is most frequent in general practice. Although general practitioners recognise and manage efficiently a large number of depressed patients, at any consultation about half the patients are not diagnosed. Recognising depression is made difficult by the frequency in general practice of presentations with somatic symptoms (masked depression) and of depression related to physical disorder. The best method for the general practitioner to overcome these problems is by using a relatively direct interview for the main specific symptoms of depression. The general practitioner has a key role in the management of depression and as a gatekeeper with a prime responsibility to make appropriate referrals to specialists. Counselling members of the family or friends and recommending self-help groups are important to improve the therapeutic compliance of the patients.     

Laparoscopic cholecystectomy in the geriatric population

OBJECTIVE: To assess effectiveness and conversion rates of inpatient laparoscopic cholecystectomy in older people living in the community. SETTING AND SUBJECTS: All acute care hospitals providing cholecystectomy in a single state. Medicare patients who underwent inpatient cholecystectomy in fiscal year 1994 in Arkansas. METHODS: A random sample comprising 449 of 2182 geriatric patients who underwent inpatient cholecystectomy in fiscal year 1994, stratified by hospital bed size, had charts reviewed for type of cholecystectomy performed, occurrence of conversion from a laparoscopic to an open cholecystectomy, surgical complications, and need for transfusion. RESULTS: Eighty-two percent of nonincidental cholecystectomies were initially laparoscopic. Total conversion rate for all inpatient laparoscopic cases was 20%. Forty-two percent of this group suffered acute cholecystitis with male patients exhibiting a higher rate of acute cholecystitis than female patients. Conversion rates for elective cholecystectomy for both sexes was between 13 and 14%. Conversion rate to an open procedures was 28% for patients with acute disease, with male patients again having a higher rate than female patients (40% vs 19%, P < .001). Surgical complications and intraoperative transfusions were rare. Conversion rates did not vary between large and small hospitals or among different age groups within the older population. CONCLUSIONS: Inpatient laparoscopic cholecystectomy is common in older people both for acute and chronic gallbladder conditions. Conversion rates ranged from 13% for elective cholecystectomy to 28% for acute disease. These rates are higher than published literature, which focuses on younger populations undergoing elective procedures. Audit committees need to be aware of this higher conversion rate in older people when assessing surgical proficiency.     

Anxiety disorders and insomnia in geriatric patients

Anxiety and insomnia are among the more frequently encountered problems in geriatric cases. The effective clinical approach identifies underlying diagnostic syndromes or general medical conditions. An integrated approach to management combines pharmacotherapy and behavioral interventions as appropriate. Overall the prognosis for most patients is excellent.     

Infectious disease emergencies in the geriatric population

Infectious diseases continue to be a common cause for emergency department visits among the elderly population. This phenomenon may be due to the existence of comorbid diseases as well as alterations in immune function with senescence. Diagnosis and acute management of specific infections are discussed in this article, including meningitis, endocarditis, urinary tract and skin infections, septic shock, and fever of unknown origin.     

Uro-gynecologic disorders in female geriatric patients

As geriatric patients those above 60 years of age are described. Incontinence is not necessarily an associated symptom of old age. In women above 60 years 15-30% suffer from urinary incontinence. With advancing age the prevalence rises to more than 40%. The cause of miction trouble must not be sought only in the urogenital tract, where with advancing age under the influence of atrophic processes typical functional and anatomical changes take place, but also in the sphere of the CNS where in geriatric patients may be the cause of impaired continence. A preliminary classification of urinary incontinence may be made already on the basis of a detailed case-history. Data provided by the patient are usually not sufficient and it is necessary to obtain the required information on the character of incontinence by aimed questions. Furthermore it is of interest what sort of medication the patient is taking at the time, incl. medication she take spontaneously. Sometimes after mere discontinuation of certain drug groups complaints can be markedly reduced or completely eliminated. In the case-history we must always focus attention on risk factors associated with incontinence and questions on the abuse of alcohol are also justified. Somatic examination comprises gynaecological examination for evaluation of the anatomical characteristics at rest and during elevated intraabdominal pressure. Functional geriatric examination is the starting point for optimal care of old people. There is a number of functional geriatric tests. For clinical practice due to its straightforward character Barthel's test of basic everyday activities is useful. Urodynamic examination is not essential in geriatric patients. Information obtained in diagnostic processes may serve as a basis for rational therapy of incontinence. Different urodynamic methods are used in case therapy fails or when the anamnestic data are obscure.     

Diagnosis and treatment of cerebrovascular disorders as a common problem of neurology and internal medicine from the internal medicine point of view]

Efforts to predict a future event assume varying levels of confidence depending on its base rate and the error rate of the prediction instrument. Most researchers working with suicide prediction instruments seem tacitly to assume they will be able to predict a future suicide most of the time. Applying basic decision theory on a neuropsychiatric hospital population indicates that researchers using a prediction schedule will be unlikely to predict a future suicide beyond a 20% level of efficiency. Contrary to the general clinical view, eliminating false negatives was shown to be more practical than eliminating false positives in increasing the efficiency of a predictive schedule.     

Rehabilitation for musculoskeltal disorders in geriatric patients

The difficulties with early detection of autistic disorder in children are discussed. DSM-IV diagnostic criteria are presented. Usefulness of clinical interview and clinical experiment in diagnosing autistic disorder are analyzed.     

Geographic isolation in the geriatric population of a rural town

OBJECTIVE: To estimate the prevalence and characteristics of geographic isolation in the elder people from Alora (Málaga). DESIGN: A transversal observational study. SETTING: Town of Alora. PATIENTS OR OTHER PARTICIPANTS: Elder people of both sexes, who lives habitually in Alora and born in 1927 or before. Home interview in a 153 individuals random sample proceeding from actual census during june to september 1992. MEASUREMENTS AND MAIN RESULTS: We found 25 individuals with the isolation conditions being the 16.34% (IC 95%: 10.48-22.20). In the 24% of them (IC 95%: 11.5-43.4) we found dependence of other person for two and more basic functions in the current life. Half of them this deficits are cover by the couple, the rest depends on their sons. We didn't found significative differences in none variables with the urban group. CONCLUSIONS: The geographic isolation affect to an important proportion of elder people in rural areas and must be used in the designs of care elderly programs.     

Skeletal proportions and metabolic disorders in adults

OBJECTIVE: The present study investigated the associations of stature, lower leg length (LLL) and demi-arm span (demi-AS) with major predisposing cardiovascular risk factors and coronary heart disease. STUDY DESIGN AND SUBJECTS: Cross-sectional study set at Glasgow Royal Infirmary of a subsample of 543 men and 646 women aged 25-66 y from the random MONICA sample. ASSOCIATED MEASURES: LLL, demi-AS, blood pressure, plasma total cholesterol, diabetes mellitus and coronary heart disease (angina, angioplasty, heart attack, and coronary artery bypass graft). RESULTS: The numbers (and proportions) of men and women, respectively, with hypertension were 126 (23.6%) and 80 (14.0%), hypercholesterolaemia 155 (29.0%) and 171 (30.1%), coronary heart disease 53 (10.1%) and 47 (8.4%), and diabetes 15 (2.9%) and 9 (1.6%). Results were adjusted for age, social class and smoking. Analysis of variance showed that in men, shortness of height, LLL or demi-AS were all associated significantly (P < 0.05) with hypercholesterolaemia. Long LLL, high ratios of LLL:height or LLL:demi-As were associated significantly (P < 0.05) with diabetes mellitus. In women, shortness of height or LLL were associated with significantly (P < 0.05) with coronary heart disease. High ratio of demi-AS:height or low ratio of LLL:demi-AS was associated significantly (P < 0.05) with coronary heart disease. CONCLUSIONS: Short stature and limb lengths, and also altered skeletal proportions, which may reflect interrupted early growth, are associated with several metabolic disorders. Skeletal disproportion associates with diabetes in men and coronary heart disease in women.     

Psychosocial enhancement of immunocompetence in a geriatric population.

Assessed the enhancement of immunocompetence by relaxation and social contact in 45 60–88 yr old geriatric residents of independent-living facilities. Ss were randomly assigned to 1 of 3 protocols: (1) relaxation training, (2) social contact, or (3) no contact. Ss in the relaxation and social-contact conditions were seen individually 3 times/wk for 1 mo. Blood samples and self-report data were obtained at baseline, at the end of the intervention, and at a 1-mo follow-up. At the end of the intervention, Ss in the relaxation group, who had been taught progressive relaxation and guided imagery as an active coping skill, showed a significant increase in natural killer cell activity and significant decreases in antibody titers to Herpes simplex virus and self-rated distress. The other 2 groups showed nonsignificant changes. There was a general increase in the T-lymphocyte response to phytohemagglutinin stimulation at the end of the intervention, with greater change at lower mitogen concentrations. Data suggest that cellular immunocompetence may be enhanced by psychosocial interventions. (34 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A clinical trial of the INTERPLAK powered toothbrush in a geriatric population

This study was conducted to test the effectiveness of the counter-rotational powered toothbrush in a nursing home environment. A group of 60 nursing home patients were selected; each was assigned to a specific trained toothbrusher. Participants were divided into two groups stratified by gingival inflammation in a crossover-design clinical trial. Each individual used the powered brush for one 4-week period, and a manual or conventional brush for another 4-week period. A suitable period of nonintervention separated the two 4-week periods of intervention to allow plaque and gingival scores to revert to baseline. The participants were evaluated for plaque and gingivitis before and after each brushing period. The experimental brush reduced both plaque and gingivitis more effectively than the conventional brush. The mean reduction in plaque scores was 1.44 for the conventional brush, 1.92 for the powered brush (Quigley-Hein Plaque Index). The mean reduction in gingival inflammation scores was 0.47 for the conventional brush, and 0.77 for the experimental brush (L?e and Silness Gingival Index). Participants perceived the counter-rotational powered brush to be more effective, and at the exit interview overwhelmingly preferred to keep it rather than the conventional brush.     

Aggressive behavior of psychiatric patients among geriatric population

The effects of protein supplements and culture dish type on in vitro fertilization (IVF) and embryo development in culture were examined in the domestic cat. In Experiment I, follicular oocytes were fertilized and cultured in either 1) modified Earle's balanced salt solution, designated MK-1, supplemented with one of the following: 10% human serum (HS), 10% FCS or 0.4% BSA, or 2) Medium 199 (M-199) supplemented with 10% FCS. Fertilization rates were lower (P < 0.01) in MK-1 + BSA (74.4%), MK-1 + FCS (56.1%), and M-199 + FCS (51.4%) than in MK-1 + HS (94.7%). A greater (P < 0.01) percentage of blastocysts was obtained in MK-1 + HS (50.0%) than in other treatment groups (range, 4.3-17.2%). In Experiment II, the effect of dish type (tissue culture dish, TCD, versus suspension culture dish, SCD) on embryo development was evaluated in MK-1 supplemented with either HS or BSA. Significantly higher proportions of IVF-derived embryos developed to blastocysts at 120 and 144 hr post-insemination, respectively, when cultured in HS/SCD (47.2 and 71.7%) than in BSA/SCD (11.4 and 27.3%) or BSA/TCD (10.4 and 25.0%). At 120 hr post-insemination, there was a lower (P < 0.01) percentage of blastocysts in HS/TCD (22.2%) than in HS/SCD. In Experiment III, six embryos per cat were transferred to the uterine horns of 17 recipients at 144 hr after hCG treatment. Five of 7 recipients which received late morulae cultured in MK-1 + BSA (SCD) for 120 hr became pregnant (71.4%). Eight of 10 recipients which received early blastocysts cultured in MK-1 + HS (SCD) for 120 hr became pregnant (80.0%). We conclude that MK-1 containing HS is highly beneficial for overcoming the in vitro developmental block of IVF-derived feline embryos and increasing the success rate of IVF/ET.     

Comorbidity of mental and insomnia disorders in the general population

The co-occurrence of insomnia and mental disorders constitutes the most prevalent diagnosis pattern found in sleep disorder clinics. Yet, there remains a paucity of epidemiological information regarding comorbidity of mental disorders and sleep disorder symptomatology in the general population. The present study showed results based on a large representative French cohort (n = 5,622; 80.7% of the contacted stratified sample). A total of 997 (17.7%) individuals with insomnia complaints were identified and divided into six diagnostic categories: (1) Insomnia related to a Depressive Disorder; (2) Insomnia related to an Anxiety Disorder; (3) Depressive Disorder accompanied by insomnia symptomatology; (4) Anxiety Disorder accompanied by insomnia symptomatology; (5) Primary Insomnia; and (6) isolated insomnia symptomatology. Telephone interviews were conducted using the Sleep-Eval System. Subjects with insomnia related to a Mental Disorder have a longer history of insomnia complaints and are usually younger than those with Depressive or Anxiety Disorders accompanied by insomnia symptoms. Subjects with Insomnia related to a Depressive Disorder experienced more repercussions than any other group. A surprisingly high percentage of individuals with depressive symptomatology had sought independent medical treatment specifically for their sleep problems, which raises the unsettling possibility that many cases of depression go undetected by the general medical community. The distinct predictability of commonly undiagnosed depression leading to chronic depression speaks directly to the imperative that physicians receive additional training in this area of community mental health.     

Compliance issues with the geriatric population: complexity with aging

Nonadherence with the prescribed treatment regimen is a major issue in health care. This article focuses specifically on adherence issues in the geriatric population. The strengths and weaknesses of measurement methods to assess nonadherence with medication regimens are discussed. Determinants of noncompliance with special emphasis on risk factors for geriatric patients are described. Finally, an overview of preventative and restorative compliance interventions is given.