Older patients with nonspecific complaints at the Emergency Department are at risk of adverse health outcomes.

OBJECTIVE: Older adults at the Emergency Department (ED) often present with nonspecific complaints (NSC) such as 'weakness' or 'feeling unwell'. Health care workers may underestimate illness in patients with NSC, leading to adverse health outcomes. This study compares characteristics and outcomes of NSC-patients versus specific complaints (SC) patients. METHODS: Cohort study in patients ≥ 70 years in two Dutch EDs. NSC was classified according to the BANC-study-framework based on the medical history in the ED letter, before additional diagnostics took place. A second classification was performed at the end of the ED visit/hospital admission. Primary outcomes were functional decline, institutionalization, and mortality at 30 days. RESULTS: 26% (n = 228) of a total of 888 included patients presented with NSC. Compared with SC-patients, NSC-patients were older, more frail, and more frequently female. NSC-patients had a higher risk of functional decline and institutionalization at 30 days (adjusted ORs 1.84, 95% CI 1.27 - 2.72, and 2.46, 95% CI 1.51-4.00, respectively), but not mortality (adjusted OR 1.26, 95% CI 0.58 - 2.73). Reclassification to a specific complaint after the ED visit or hospital admission occurred in 54% of NSC-patients. CONCLUSION: NSC occur especially in older, frail female patients and are associated with an increased risk of functional decline and institutionalization, even after adjustment for worse baseline status. In half of the patients, a specific complaint revealed during ED or hospital stay. Physicians at the ED should consider NSC as a red flag needing appropriate observation and evaluation of underlying serious conditions and needs of this vulnerable patient group.

Herpes zoster after COVID vaccination.

COVID-19 presents in various ways, but mainly as a pulmonary disease (Marzano, 2020). Skin manifestations have been reported, including reactivation of the varicella-zoster virus (Marzano, 2020). Our case report describes two adults developing herpes zoster after vaccination with tozinameran (the Pfizer-BioNTech COVID-19 mRNA vaccine). A possible cause for this reaction is a transient lymphocytopenia that occurs after the vaccination - similar to that in COVID-19 disease (Mulligan, 2020; Wang, 2020; Qin, 2020; Brabilla, 2020; Wang, 2020; Wei, 2017). In the context of vaccinating older and/or immunocompromised adults, our observations can be the starting point for further evaluation of a possible relationship between COVID-19, COVID vaccines, and herpes zoster.

Benefit and Risk Evaluation of Biased µ-Receptor Agonist Oliceridine versus Morphine.

BACKGROUND: To improve understanding of the respiratory behavior of oliceridine, a µ-opioid receptor agonist that selectively engages the G-protein-coupled signaling pathway with reduced activation of the ß-arrestin pathway, the authors compared its utility function with that of morphine. It was hypothesized that at equianalgesia, oliceridine will produce less respiratory depression than morphine and that this is reflected in a superior utility. METHODS: Data from a previous trial that compared the respiratory and analgesic effects of oliceridine and morphine in healthy male volunteers (n = 30) were reanalyzed. A population pharmacokinetic-pharmacodynamic analysis was performed and served as basis for construction of utility functions, which are objective functions of probability of analgesia, P(analgesia), and probability of respiratory depression, P(respiratory depression). The utility function = P(analgesia ≥ 0.5) - P(respiratory depression ≥ 0.25), where analgesia ≥ 0.5 is the increase in hand withdrawal latency in the cold pressor test by at least 50%, and respiratory depression ≥ 0.25 is the decrease of the hypercapnic ventilatory response by at least 25%. Values are median ± standard error of the estimate. RESULTS: The two drugs were equianalgesic with similar potency values (oliceridine: 27.9 ± 4.9 ng/ml; morphine 34.3 ± 9.7 ng/ml; potency ratio, 0.81; 95% CI, 0.39 to 1.56). A 50% reduction of the hypercapnic ventilatory response by morphine occurred at an effect-site concentration of 33.7 ± 4.8 ng/ml, while a 25% reduction by oliceridine occurred at 27.4 ± 3.5 ng/ml (potency ratio, 2.48; 95% CI, 1.65 to 3.72; P < 0.01). Over the clinically relevant concentration range of 0 to 35 ng/ml, the oliceridine utility function was positive, indicating that the probability of analgesia exceeds the probability of respiratory depression. In contrast, the morphine function was negative, indicative of a greater probability of respiratory depression than analgesia. CONCLUSIONS: These data indicate a favorable oliceridine safety profile over morphine when considering analgesia and respiratory depression over the clinical concentration range.

Music and pain during endorectal ultrasonography examination: A prospective questionnaire study and literature review.

INTRODUCTION: Music interventions have been recognized as a method to reduce pain during medical procedures, but within medical imaging the subject has received little attention. Endorectal ultrasonography examination is in some patients associated with anxiety and pain, and since in Denmark pain relief is usually not administered by the Department of Radiology, it is important to find effective alternative methods to help patients manage their pain during imaging procedures. The primary aim of this study was to evaluate the effect of music on self-reported pain during endorectal examination of rectal cancer patients. METHODS: A prospective questionnaire study of patients undergoing endorectal ultrasonography was conducted. Patients were randomized into two groups: a music group (n = 66), and non-music group (n = 60). Standard endorectal ultrasonography was performed in all patients. Pain was self-assessed using a Visual Analogue Scale ranging from 0 to 10, with 0 representing "no pain" and 10 maximum pain. RESULTS: A total of 126 patients were included in the study, 81 (64.3%) men and 45 (35.7%) women. The demographics were similar in the two groups. The mean pain score during endorectal ultrasonography in the music and non-music group was 1.95 and 2.30, (p = 0.404). CONCLUSION: In this randomized study music did not significantly affect the pain level experienced by the patients. Endorectal ultrasound was not entirely painless but less painful than colonoscopy (Visual Analogue Scale 2.1 and 3.8, respectively). IMPLICATIONS FOR PRACTICE: Health care professionals may consider using music during painful procedures.

Screening instruments for identification of vulnerable older adults at the emergency department: a critical appraisal.

BACKGROUND: Early detection of vulnerable older adults at the emergency department (ED) and implementation of targeted interventions to prevent functional decline may lead to better patient outcomes. OBJECTIVE: To assess the level of agreement between four frequently used screening instruments: ISAR-HP, VMS, InterRAI ED Screener and APOP. METHODS: Observational prospective cohort study in patients ≥ 70 years attending Dutch ED. RESULTS: The prevalence of vulnerability ranged from 19% (APOP) to 45% (ISAR-HP). Overall there was a moderate agreement between the screening instruments (Fleiss Kappa of 0.42 (p<0.001)). CONCLUSION: Depending on the screening instrument used, either only a small percentage or almost as many as half of the presenting patients will be eligible for targeted interventions, leading to large dissimilarities in working processes, resources and costs.

Vaginal and anal human papillomavirus infection and seropositivity among female sex workers in Amsterdam, the Netherlands: Prevalence, concordance and risk factors.

BACKGROUND: We studied prevalence, risk factors and concordance of vaginal and anal HPV infection and L1 seropositivity among female sex workers (FSW) in Amsterdam. METHODS: In 2016, FSW aged ≥18 years having a sexually transmitted infections (STI) consultation were invited to participate. Participation entailed taking vaginal and anal self-swabs. Demographics and sexual behaviour data were collected. HPV DNA was analysed using the SPF10-PCR-DEIA-LiPA25-system-v1. Serum was tested for HPV L1 antibodies using multiplex serology assays. Determinants of vaginal and anal high risk HPV (hrHPV) infection and L1 seropositivity were assessed with logistic regression analyses. RESULTS: We included 304 FSW; median age was 29 years (IQR 25-37). Vaginal and anal hrHPV prevalence were 46% and 55%, respectively. HrHPV L1 seropositivity was 37%. Vaginal-anal hrHPV concordance was strong, but no significant association between vaginal or anal hrHPV infection and seropositivity was found. Having had anal sexual contact was not associated with anal hrHPV infection (P = 0.119). DISCUSSION: Vaginal and anal hrHPV prevalence is high among FSW in Amsterdam, the Netherlands. Promotion of HPV vaccination, preferably at the beginning of the sex (work) career, may be a useful prevention method against hrHPV infection and disease.

Syndromic approach to STD case management: where do we go from here?

In the absence of aetiological tests for the diagnosis of individual sexually transmitted diseases (STD), the syndromic approach has been developed as an effective and appropriate case management strategy. Algorithms provide guidance to healthcare workers and ensure standardised approaches to case management. The syndromic approach, utilising currently available algorithms, works well in the management of people with symptomatic urethritis, genital ulcer disease, and vaginitis. Owing to the frequently asymptomatic nature of gonococcal and/or chlamydial cervicitis, and the lack of specific defining risk factors and/or signs and symptoms, the syndromic approach performs less well in the identification and management of women with cervicitis. The syndromic approach can and should be adopted for the management of patients with urethral discharge, genital ulceration, vaginal discharge, and cervical signs. Further research is needed to improve the identification and management of cervical infections; to guide policy makers in selecting the most appropriate disease control strategy; to improve utilisation of available and future tests; to develop affordable, rapid, and simple diagnostic tests; and to develop STD vaccines.

Absorption and emission cross sections of Er(3+) in Al(2)O(3) waveguides.

Al(2)O(3) slab waveguide films were doped with erbium using ion implantation to a peak concentration of 1.5 at. %. Prism coupling measurements show absorption caused by (4)I (15/2) ?(4)I (13/2) intra-4f transitions in Er(3+) with a maximum at 1.530 mum of 8 dB/cm. The Er(3+) absorption cross section is determined as a function of wavelength. We used the McCumber theory to derive the emission cross section spectrum from the absorption results, which we then compared with the Er(3+) photoluminescence spectrum. The peak absorption and emission cross sections are found to be 6 x 10(-21) cm(-2). The results are used to predict the optical gain performance of an Er-doped Al(2)O(3) optical amplifier that operates around 1.5 mum.

Direct imaging of optical interference in erbium-doped Al(2)O(3) waveguides.

Interference of 1.48-microm light in multimode interference waveguides is made visible by imaging green and infrared upconversion luminescence from Er(3+) ions dispersed in the waveguide. A two-dimensional mode density image can be derived from the data and agrees well with mode calculations for this structure. This new technique provides an interesting tool for the study of optical mode distributions in complicated waveguide structures and photonic band-gap materials.

Sexually transmitted disease services in Madras: could their role in AIDS prevention be strengthened?

A baseline evaluation of the quality of STD case management was conducted in five areas of Madras city in 1992, using HIV prevention indicators recommended by the World Health Organization. Eighty-four interviews and 108 observations of private and public clinic practitioners were conducted. Sixty-one percent of interviewed doctors reported making only specific "clinical" diagnoses and 17% reported making only the WHO recommended syndrome-based diagnoses while 22% reported making both types of diagnosis. The adequacy of treatment was compared against various standards, including the Indian National Guidelines for STD management. Almost half of the health care providers (HCP) reported using a treatment effective against the two main pathogens that may cause male urethritis, while 20% reported using a treatment that was not effective against either. For male ulcers only 12% of HCPs reported using treatment effective against both syphilis and chancroid. Seventy-nine percent of the HCP reported that they advised their patients to use condoms, but in 30% only of observed consultations, condoms were promoted for STD or HIV/AIDS prevention. As information concerning the relative prevalence of pathogens in different areas is unlikely to be available, there is an urgent need for the syndromic approach to STD treatment be adopted by health care providers.

PIP: During November-December 1992, in Madras, India, interviews were conducted with 84 public and private physicians who treated at least five sexually transmitted disease (STD) patients each week in Royapuram, Washerman, Evr High Road, T. Nagar, and Adyar regions of the city. Field workers also observed 108 medical consultations of 48 of the physicians interviewed. Researchers aimed to use the findings of this baseline survey to optimize STD services in order to reduce the population at risk of HIV/AIDS. 61% of the physicians interviewed made specific clinical diagnoses. 17% made only syndrome-based diagnoses. 22% used both types of diagnoses. 48% used a treatment effective against the two main pathogens for male urethritis, Neisseria gonorrhoeae and Chlamydia trachomatis. 20% used a treatment that was not effective against either of these pathogens. Only 12% used a treatment effective against chancroid and syphilis for men with genital ulcers. 29% did not use a treatment effective against chancroid or syphilis. For female genital ulcers, only 10.7% of physicians used an effective treatment against chancroid or syphilis. 21.4% provided treatment effective against neither chancroid nor syphilis in female STD patients with genital ulcers. 79% claimed to counsel their STD patients to use condoms, but only 30% were observed actually promoting condoms for STD or HIV/AIDS prevention. Physicians instructed only 6% of STD patients how to use condoms. Condoms were given to only one STD patient. These findings highlight the need for physicians and other health care providers to adopt the syndromic approach to STD treatment and for developing and evaluating innovative and effective programs of patient education in order to reduce the risk of HIV infection.

HIV, STD and their current impact on reproductive health: the need for control of sexually transmitted diseases.

STD and HIV are the second most important cause of Disability Adjusted Life Years lost in women in the developing world. Reasons for this are multiple, and include their higher vulnerability for STD and HIV, poor health care seeking behavior and lack of accessible and acceptable services. There is considerable synergism between family welfare services and STD programs: complications and sequelae of STD affect the reproductive tract and child health and survival; reproductive and child health and survival are the focus of family welfare programs. Family welfare services are thus well positioned to incorporate STD and HIV prevention and control measures. This is feasible, although practical and logistical problems need to be addressed. Where indicated, pilot integration projects can assess the cost-effectiveness and outcome of such programs.

Sexually transmitted diseases and HIV infection: implications for control and prevention.

PIP: The most important mode of HIV spread globally is heterosexual intercourse. This article focuses upon the relationship between traditional sexually transmitted diseases (STD) and HIV infection, and considers the implications for STD control as a strategy to prevent HIV infection. Evidence is accumulating that the relationship between STD and HIV infection is threefold as follows: the presence of an STD is a marker of risk behavior for HIV infection, STDs are biological cofactors for HIV transmission, and concurrent HIV infection increases the virulence of some STD pathogens. Unprotected sexual intercourse with multiple partners predisposes one to infection with traditional STDs. The same behavior has also been shown to be a risk factor for HIV transmission. The incidence of both HIV infection and other STDs therefore indicates the practice of high risk sex behavior in a community. An increased incidence of HIV infection has been found in people with genital ulcer disease. It is therefore likely that genital ulcerations caused by traditional STDs provide easy entry or exit points for HIV. Since traditional STDs are important cofactors of HIV transmission, controlling STDs would be an important strategy in the fight against HIV/AIDS. STD control is based upon prevention through information, education, and communication aimed at reducing the level of unsafe sexual behavior, and diagnosing and treating STDs. Syndrome-based STD case management should be integrated into first-level health care services in the public and private sectors to develop effective, accessible, and acceptable services to people at increased risk of infection with STD. The support of specialized STD clinics and STD specialists will be needed.^ieng

The provision of safe blood--policy issues in the prevention of human immunodeficiency virus transmission.

The AIDS epidemic has focused attention on the constraints and deficiencies present in many blood transfusion services in the developing world. We discuss a variety of options for reducing transfusion-related HIV transmission, and suggest how new transfusion strategies may be implemented. We show that a transfusion service cannot rely solely on the screening of donor blood for anti-HIV antibodies and that a more comprehensive approach is needed. Important components of this approach include donor selection and improved clinical practice, in which blood and blood products are prescribed only when really necessary.

AIDS: is health education the answer?

In the absence of a vaccine or effective treatment, prevention of infection with the human immunodeficiency virus (HIV) is presently the only feasible option for the control of AIDS. Most transmission is related to high risk behaviours, and attempts to change these behaviours are key objectives of many AIDS Control Programmes. Health Education, or Information, Education and Communication (IEC) strategies have been developed to achieve these objectives. Yet few evaluations of health education programmes have been carried out, and the intimate relationship between AIDS and other sexually transmitted diseases is often ignored. Behaviour has a multitude of determinants, and consequently no simple approach focusing on one aspect of behaviour can be expected to be successful. Not only does knowledge need to be imparted, but attitudes, beliefs, social- and peer-group norms need to be addressed. The development of IEC programmes is hampered by the specific routes of transmission of the HIV, involving sensitive areas of human behaviour, and by a lack of knowledge about these behaviours. Nevertheless, a number of seemingly successful programmes have been carried out. Active participation of the target groups appears to be a key factor in success. Although health education makes intuitive sense, rigorous documentation and strict evaluation is necessary to provide its justification and to maximize the potential of this strategy.

Plasma essential fatty acids in pure and mixed race American Indians on and off a diet exceptionally rich in salmon.

Eskimos on a traditional diet have unusually low prevalences of cardiovascular disease and cancer. One possible reason is the high intake of eicosapentaenoic acid (EPA) which is thought to account for the high EPA and low arachidonic acid (AA) levels in Eskimo plasma. People who also consume a traditional diet exceptionally rich in EPA are the Indians of the west coast of Vancouver Island. There are about 12,000 of these people and their traditional diet has been affected much less than that of the Eskimos. When on their traditional diet the Vancouver Island Indians, like the Eskimos, have high EPA and low AA levels in plasma. When eating European food, EPA levels are in the European range, but AA levels are still exceptionally low, a finding also reported from Eskimos living in Denmark. In a small mixed race group, AA levels were intermediate between those in pure Indians and in Europeans. The high EPA levels in Eskimos and West Coast Indians are related to diet. The low AA levels, in contrast, are probably genetically determined. Unusual disease patterns in these populations cannot be entirely attributed to diet.

Low incidence of schizophrenia in British Columbia coastal Indians.

Schizophrenia rates were obtained from a British Columbia coastal Indian group numbering 14 000. One subgroup numbering 12 200 showed an incidence of 10 cases per 100 000 population a year. An atypical subgroup of 1800 showed an incidence of 49 cases per 100 000 a year. These rates appear to be relevant to a hypothesis that suggests that schizophrenia may be caused by abnormal fatty acid metabolism. A study is reviewed which implies the existence of a delta-5 or delta-6 desaturase enzyme mutation or both, in the Indian population under study.

Affinity chromatography of the phosphatidylcholine exchange protein from bovine liver.

Affinity chromatography has been used to purify the phosphatidylcholine exchange protein from bovine liver. The affinity resin consisted of 1-acyl-2-(9-carboxy)nonyl-glycero-3-phosphocholine linked to AH-Sepharose 4 B via the carboxyl group. Application of a crude exchange protein fraction to the affinity column resulted in a complete adsorption of the phosphatidylcholine exchange protein. The exchange protein eluted with a buffer containing 0.15% sodium deoxycholate. The most active fraction was 130-fold purified and accounted for 62% of the activity.