Measurement of spiral artery jets: general principles and differences observed in small-for-gestational-age pregnancies.

OBJECTIVE: To investigate whether the jets of blood from the mouths of the spiral arteries could be measured reliably, as well as their relationship with the uterine artery (UtA) and any differences in small-for-gestational-age (SGA) pregnancies. METHODS: Participants underwent serial ultrasound scans, from 11 weeks' gestation. Pulsatility index (PI) and resistance index (RI) of jets into the intervillous space (IVS) and UtA were recorded at every visit. Intra- and interobserver variability studies were performed. Customized birth weight centiles were calculated and SGA was defined as < 10(th) centile. Linear mixed model analysis was used to allow for the longitudinal nature of the data. RESULTS: Sixty-six women were recruited; 58 remained normotensive and delivered at term. Of these, six women delivered SGA newborns and 52 delivered appropriate-for-gestational-age newborns. All had pulsatile jets until 20 weeks' gestation. The PI and RI of the jets decreased with advancing gestation, following a trend similar to that of the UtAs. There was no correlation between the jets and UtA waveforms when gestational age was controlled for. For intraobserver variability the intraclass correlation coefficient was 0.9. The interobserver study showed no significant difference between the observers. Mixed model analysis demonstrated that PI and RI of jets were different in SGA pregnancies (P < 0.06). This difference was not seen for the UtAs (P = 0.8). CONCLUSION: This technique enables examination of characteristics of the jets of blood flowing from spiral arteries into the IVS. It is both precise and reproducible, with biologically plausible results. Further work is required to assess differences in pregnancies with adverse outcomes.

Music therapy for people with dementia.

BACKGROUND: Dementia is a clinical syndrome with a number of different causes which is characterised by deterioration in cognitive functions. Research is pursuing a variety of promising findings for the treatment of dementia. Pharmacological interventions are available but have limited ability to treat many of the syndrome's features. Little research has been directed towards non-pharmacological treatments. In this review the evidence for music therapy as a treatment is examined. OBJECTIVES: To assess the effects of music therapy in the treatment of behavioural, social, cognitive and emotional problems of older people with dementia. SEARCH STRATEGY: The Cochrane Dementia and Cognitive Improvement Group (CDCIG) Specialised Register was searched on 30 June 2003 using the term "music*". This Register contains records from all major health care databases and many ongoing trial databases and is updated regularly. The principal reviewer conducted additional searches to retrieve randomised controlled trials (RCTs) concerning the effect of music therapy on older people with dementia. SELECTION CRITERIA: Randomised controlled trials that reported clinically relevant outcomes associated with music therapy in treatment of behavioural, social, cognitive and emotional problems of older people with dementia. DATA COLLECTION AND ANALYSIS: Two reviewers screened retrieved studies independently for methodological quality using a checklist. Data from accepted studies were independently extracted by the reviewers. MAIN RESULTS: Five studies were included. The methodological quality of the studies was generally poor and the study results could not be validated or pooled for further analyses. REVIEWERS' CONCLUSIONS: The methodological quality and the reporting of the included studies were too poor to draw any useful conclusions.

Donepezil for dementia due to Alzheimer's disease.

BACKGROUND: Alzheimer's disease is the most common cause of dementia in older people. One of the aims of therapy is to inhibit the breakdown of a chemical neurotransmitter, acetylcholine, by blocking the relevant enzyme. This can be done by a group of chemicals known as cholinesterase inhibitors. However, some (like tacrine) are associated with adverse effects such as hepatotoxicity, but donepezil (E2020, Aricept) is safer. OBJECTIVES: The objective of this review is to assess whether donepezil improves the well-being of patients with dementia due to Alzheimer's disease. SEARCH STRATEGY: The Cochrane Dementia and Cognitive Improvement Group's Specialized Register was searched using the terms 'donepezil', 'E2020' and 'Aricept' on 9 October 2002. This Register contains up-to-date records of all major health care databases and many ongoing trial databases. Members of the Donepezil Study Group and Eisai Inc were contacted. SELECTION CRITERIA: All unconfounded, double-blind, randomized controlled trials in which treatment with donepezil was compared with placebo for patients with mild, moderate or severe dementia due to Alzheimer's disease. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer (JSB ), pooled where appropriate and possible, and the weighted mean differences or Peto odds ratios (95%CI) estimated. MAIN RESULTS: Sixteen trials are included, involving 4365 participants. The trials were of 12, 24 or 52 weeks duration in selected patients. Available outcome data cover domains including cognitive function and global clinical state, but data on several important dimensions of outcome are unavailable. For cognition there is a statistically significant improvement for both 5 and 10 mg/day of donepezil at 24 weeks compared with placebo (-2.02 points on the ADAS-Cog scale WMD, 95%CI -2.77 to -1.26, p<0.00001; -2.92 points on the ADAS-Cog scale WMD 95% CI -3.74 to -2.10, p<0.00001)and for 10 mg/day donepezil compared with placebo at 52 weeks (1.84MMSE points, 95% CI, 0.53 to3.15, p=0.006). The results show some improvement in global clinical state (assessed by an independent clinician) in people treated with 5 and 10 mg/day of donepezil compared with placebo at 12 and 24 weeks. Benefits of treatment were also seen on measures of activities of daily living and behaviour. There were significantly more withdrawals before the end of treatment from the 10 mg/day (but not the 5 mg/day) donepezil group compared with placebo which may have resulted in some overestimation of beneficial changes at 10 mg/day.A variety of adverse effects were recorded, with more incidents of nausea, vomiting, diarrhoea and anorexia in the 10 mg/day group compared with placebo and the 5 mg/day group, but very few patients left a trial as a direct result of the intervention. REVIEWER'S CONCLUSIONS: People with mild, moderate or severe dementia due to Alzheimer's disease treated for periods of 12, 24 or 52 weeks with donepezil experienced benefits in cognitive function, activities of daily living and behaviour. Study clinicians rated global clinical state more positively in treated patients, and measured less decline in measures of global disease severity. Although no significant changes were measured on a patient-rated quality of life scales, the instrument used was crude and possibly unsuited to the task. The additional data now available confirm the findings of the previous issue of this review and extend the evidence for the effectiveness of treatment to at least 52 weeks and to those with severe dementia. More evidence is still needed for the economic efficacy of donepezil, but clinical efficacy is confirmed.

Donepezil for mild and moderate Alzheimer's disease.

BACKGROUND: Alzheimer's disease is the most common cause of dementia in older people. One of the aims of therapy is to inhibit the breakdown of a chemical neurotransmitter, acetylcholine, by blocking the relevant enzyme. This can be done by a group of chemicals known as cholinesterase inhibitors. However, some (like tacrine) are associated with adverse effects such as hepatotoxicity, but E2020 (donepezil, Aricept) is thought to be more specific in its action, and safer. OBJECTIVES: The objective of this review is to assess whether or not donepezil improves the well-being of patients with mild or moderate Alzheimer's disease. SEARCH STRATEGY: The Cochrane Dementia and Cognitive Improvement Group specialized register was searched using the terms 'donepezil', 'E2020' and 'Aricept'. Members of the Donepezil Study Group and Eisai Inc were contacted. SELECTION CRITERIA: All unconfounded, double-blind, randomized controlled trials in which treatment with donepezil was compared with placebo for patients with Alzheimer's disease. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer (JSB ), pooled where appropriate and possible, and the weighted mean differences or Peto odds ratios (95%CI) estimated. Where possible, intention-to-treat (ITT) data were used. MAIN RESULTS: Eight trials are included, involving 2664 participants. The trials were of 12, 24 or 52 weeks duration in selected patients. Available outcome data cover domains including cognitive function and global clinical state, but data on several important dimensions of outcome are not available. For cognition there is a statistically significant improvement for both 5 and 10 mg/day of donepezil at 24 weeks compared to placebo (1.9 points on the ADAS-Cog scale, WMD 1.86, 95%CI -2.60 to -1.11; 2.9 points on the ADAS-Cog scale, WMD -2.91, 95% CI -3.65 to -2.16)and for 10mg/day donepezil compared to placebo at 52 weeks (1.7 MMSE points, 95% CI, -2.59 to -0.82). The results of three studies show some improvement in global clinical state (assessed by an independent clinician) in those treated with 5 and 10mg/day of donepezil compared with placebo at 12 and 24 weeks. The patients' own ratings of their Quality of Life showed no benefit of donepezil compared with placebo. There were significantly more withdrawals before the end of treatment from the 10mg/day (but not the 5mg/day) donepezil group compared with placebo which may have resulted in some overestimation of beneficial changes at 10mg/day A variety of adverse effects were recorded, with more incidents of nausea, vomiting, diarrhoea and anorexia in the 10mg/day group compared with placebo and the 5mg/day group, but very few patients left a trial as a direct result of the intervention. REVIEWER'S CONCLUSIONS: In selected patients with mild or moderate Alzheimer's disease treated for periods of 12, 24 or 52 weeks, donepezil produced modest improvements in cognitive function and study clinicians rated global clinical state more positively in treated patients. No improvements were present on patient self-assessed quality of life and data on many important outcomes are not available. The practical importance of these changes to patients and carers is unclear.

Donepezil for mild and moderate Alzheimer's disease.

BACKGROUND: Alzheimer's disease is the most common cause of dementia and is a primary degenerative disease of the brain of unknown cause. Onset is usually late in life with increasing impairment of memory, developing gradually into a global impairment of cognition, orientation, linguistic ability and judgement. The clinical course is accompanied by growing disability and dependency on care. One of the characteristic features of the disease is the widely variable rate of progression seen in different patients. Acetylcholine is an important neurotransmitter associated with memory, and abnormalities in cholinergic neurones (including cell loss) are among the many neurological and neurochemical abnormalities that develop in AD. One approach to lessening the impact of these abnormalities is to inhibit the breakdown of acetylcholine by blocking the relevant enzyme. Tacrine was the first compound approved as a treatment for AD in the US and worked in this way, but caused severe side effects. E2020 (donepezil, Aricept) is a second generation cholinesterase inhibitor and appears to be highly specific, with relatively few side effects. OBJECTIVES: The objective of this review is to assess whether or not donepezil improves the well-being of patients with mild or moderate Alzheimer's disease. SEARCH STRATEGY: The Cochrane Dementia and Cognitive Impairment Group Register of Clinical Trials, was searched using the terms 'donepezil', 'E2020' and 'ARICEPT'. Medline, PsychLIT and EMBASE electronic databases were searched with the above terms. Members of the Donepezil Study Group and Eisai Inc were contacted. SELECTION CRITERIA: All unconfounded, double-blind, randomised controlled trials in which treatment with donepezil was administered for more than a day and compared with placebo in patients with Alzheimer's disease. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the reviewers (JSB & DB), pooled where appropriate and possible, and the weighted or standardised mean differences or Peto odds ratios (95%CI) estimated. Where possible, intention-to-treat data were used. MAIN RESULTS: There are 4 included trials, covering treatment of 12 or 24 weeks duration in highly selected patients. The only information available on one trial (Gauthier 1998) is a conference abstract which reports no usable results. Available outcome data cover domains including cognitive function and global clinical state, but data on several important dimensions of outcome are not available. The results of three trials suggest a small beneficial effect of donepezil in improving cognitive function: at a 5mg/day dose, improvements measured -2.6 points (95%CI -3.5 -- -1.8) on weighted mean difference, in the midrange of the 70 point ADAS-Cog scale. The results of two trials show some improvement in global clinical state (assessed by an independent clinician) in those treated with donepezil compared to placebo. The patient's own rating of their Quality of Life showed no benefit of donepezil compared with placebo. There were significantly more withdrawals before the end of treatment from the 10mg/d (but not the 5mg/d) donepezil group compared with placebo, which may have resulted in some overestimation of beneficial changes at 10mg/d in progressively declining characteristics, as last available measures were used in analyses. A variety of adverse effects were recorded, but very few patients left a trial as a direct result of the intervention. REVIEWER'S CONCLUSIONS: In selected patients with mild or moderate Alzheimer's disease treated for periods of 12 or 24 weeks, donepezil produced modest improvements in cognitive function and study clinicians rated global clinical state more positively in treated patients. No improvements were present on patient self-assessed quality of life and data on many important outcomes are not available. The practical importance of these changes to patients and carers is unclear.

Labour migration in the Arab Gulf states: patterns, trends and prospects.

PIP: This paper presents an analysis of recent changes in the scale and characteristics of non-national migration to, and employment in, the 6 Gulf Cooperation Council (GCC) member states. In 1985, the size of the workforce in the Gulf States was 7.1 million. Non-nationals comprised 68% (in Saudi Arabia) to almost 91% (in United Arab Emirates) of the workforce. 63% of the non-nationals were from Asia. Non-national Arab workers represented 30% of the total. In 1985, 36% of all migrant workers came from India and Pakistan. Almost 30% of the non-nationals were employed in services (financial, personal, and community), and almost 29% were in construction. Non-nationals dominate 3 sectors: construction, manufacturing, and utilities. Non-nationals account for a relatively low 55% of the oil sector. The phenomenal rate of growth in non-national workforces during the mid 1970s began to slow in the 1980s. Labor permit issues peaked in the late 1970s and again in 1983-84. The timing and scale of the decline varies by sending country and by destination, reflecting variations in the rate and extent of the economic slowdown in different GCC states, as well as relative wage rates, occupational composition, and organization of the various labor flows. For example, Indian case worker placements fell by 49% between 1983 and 1986, while the number of Filipinos placed fell by 15%. During the 1980s, most Gulf states have increased efforts to enforce labor and residence regulations, but the number of illegal workers has continued to grow. During the 1st half of the 1980s, demand for non-national labor increasingly turned towards new supplies in South and Southeast Asia, notably Bangladesh, Sri Lanka, Indonesia, Thailand, and the Philippines. Meanwhile, an increasing share of Arab and South Asian workers were renewing their work permits, often on less favorable terms. The construction sector has had the greatest decline in new labor inflows; however, the service sector is still growing. Wage rates have fallen an average of 20-30%, and up to 45% since 1983. Since 1985, about 615,000 non-national workers have left. Southeast Asian labor has been most acutely affected by the sharp downturn in economic activity. By 1990, the non-national workforce should decline to 4.36 million, but then it will increase slowly. The number and share of Southeast Asians will rise.^ieng

The demographic challenge in the Arab Gulf.

PIP: Demographic trends in the states of the Arab Gulf are analyzed. The author first describes some fundamental aspects of current demographic trends, particularly as they concern the relative share of nationals and non-nationals in the total population, and then draws some policy-related conclusions from the projections presented. Data are from national sources and from the data base developed by the U.N. Economic and Social Commission for Western Asia (ESCWA).^ieng

Migrant workers in the Arab Gulf: the impact of declining oil revenues.

"This article explores the relationship between government expenditure and labor immigration in the Arab Gulf states. This relationship was close and positive during the rapid growth of the 1970s. Using Kuwait as a case study, trends in immigrant labor movements over the period 1981-85 are considered in detail. This analysis shows that the current economic downturn, reflecting the collapse of the world oil prices, has not resulted in the large scale re-export of foreign labor which was envisaged. The reasons for this foreign labor retention are considered and the authors speculate on future migration trends in the region."

International migration in the Arab region: rapid growth, changing patterns, and broad implications.

PIP: The authors analyze trends and patterns of international migration in the Arab region, with a focus on labor shortages resulting from the migration of skilled manpower to the capital-rich Arab states. The effects of migration on both the sending and receiving countries are examined, and the utilization of new sources of manpower is considered^ieng