[Spondylodiscitis in the elderly]. / Spondylodiscitis bij de oudere patiënt.

The incidence of spondylodiscitis is highest among the elderly. Because of the ageing population the incidence of spondylodiscitis is rising. In this article, we illustrate dilemmas which may occur when treating older patients with spondylodiscitis by presenting two cases. The first patient is a 74-year-old man in whom there was uncertainty about the diagnosis on the basis of imaging results. The second patient is an 82-year-old man with dementia in whom longstanding intravenous treatment was too burdensome and treatment with oral antibiotics was started. The diagnosis of spondylodiscitis in elderly can be challenging because of frequent atypical presentation and comorbidity. So far, there is not much known about the prognosis of spondylodiscitis in the elderly, which make decisions about treatment difficult. The prognosis seems worse in elderly with multimorbidity. A comprehensive geriatric assessment can help to guide treatment decisions by estimating the chance of good functional recovery.

Cyclin-dependent kinase 9 activity regulates neutrophil spontaneous apoptosis.

Neutrophils are the most abundant leukocyte and play a central role in the immune defense against rapidly dividing bacteria. However, they are also the shortest lived cell in the blood with a lifespan in the circulation of 5.4 days. The mechanisms underlying their short lifespan and spontaneous entry into apoptosis are poorly understood. Recently, the broad range cyclin-dependent kinase (CDK) inhibitor R-roscovitine was shown to increase neutrophil apoptosis, implicating CDKs in the regulation of neutrophil lifespan. To determine which CDKs were involved in regulating neutrophil lifespan we first examined CDK expression in human neutrophils and found that only three CDKs: CDK5, CDK7 and CDK9 were expressed in these cells. The use of CDK inhibitors with differing selectivity towards the various CDKs suggested that CDK9 activity regulates neutrophil lifespan. Furthermore CDK9 activity and the expression of its activating partner cyclin T1 both declined as neutrophils aged and entered apoptosis spontaneously. CDK9 is a component of the P-TEFb complex involved in transcriptional regulation and its inhibition will preferentially affect proteins with short half-lives. Treatment of neutrophils with flavopiridol, a potent CDK9 inhibitor, increased apoptosis and caused a rapid decline in the level of the anti-apoptotic protein Mcl-1, whilst Bcl2A was unaffected. We propose that CDK9 activity is a key regulator of neutrophil lifespan, preventing apoptosis by maintaining levels of short lived anti-apoptotic proteins such as Mcl-1. Furthermore, as inappropriate inhibition of neutrophil apoptosis contributes to chronic inflammatory diseases such as Rheumatoid Arthritis, CDK9 represents a novel therapeutic target in such diseases.

Building capacity for dementia care: training program to develop primary care memory clinics.

PROBLEM BEING ADDRESSED: Currently, dementia care provided by family physicians is suboptimal and access to specialist resources is limited. With the aging population, there is a need for system-wide, programmatic interventions to improve the diagnosis and management of patients with memory difficulties. The development of primary care memory clinics addresses this need. OBJECTIVE: The Memory Clinic Training Program aims to develop highly functioning interprofessional memory clinics that assist family physicians in providing improved care for patients with dementia and other forms of cognitive impairment. PROGRAM DESCRIPTION: The interprofessional training program consists of a 2-day case-based workshop, 1 day of observership and clinical training at the Centre for Family Medicine Memory Clinic, and 2 days of on-site mentorship at each newly formed memory clinic. CONCLUSION: The Memory Clinic Training Program is an accredited, comprehensive program designed to assist family practice groups with developing primary care memory clinics. These clinics aim to transform the current limited practice capability of individual family physicians into a systematic, comprehensive, interprofessional health care service that improves capacity and quality of primary care for patients with cognitive impairment and dementia.

Conflict on interprofessional primary health care teams--can it be resolved?

Increasingly, primary health care teams (PHCTs) depend on the contributions of multiple professionals. However, conflict is inevitable on teams. This article examines PHCTs members' experiences with conflict and responses to conflict. This phenomenological study was conducted using in-depth interviews with 121 participants from 16 PHCTs (10 urban and 6 rural) including a wide range of health care professionals. An iterative analysis process was used to examine the verbatim transcripts. The analysis revealed three main themes: sources of team conflict; barriers to conflict resolution; and strategies for conflict resolution. Sources of team conflict included: role boundary issues; scope of practice; and accountability. Barriers to conflict resolution were: lack of time and workload; people in less powerful positions; lack of recognition or motivation to address conflict; and avoiding confrontation for fear of causing emotional discomfort. Team strategies for conflict resolution included interventions by team leaders and the development of conflict management protocols. Individual strategies included: open and direct communication; a willingness to find solutions; showing respect; and humility. Conflict is inherent in teamwork. However, understanding the potential barriers to conflict resolution can assist PHCTs in developing strategies to resolve conflict in a timely fashion.

Mechanisms for communicating within primary health care teams.

OBJECTIVE: To explore the types of communication used within primary health care teams (PHCTs), with a particular focus on the mechanisms teams use to promote optimal clinical and administrative information sharing. DESIGN: A descriptive qualitative study. SETTING: Primary health care teams in Ontario between August 2004 and October 2005. PARTICIPANTS: Purposive sampling was used to recruit 121 members from 16 PHCTs reflecting a range of health care professionals, including family physicians, nurse practitioners, nurses, pharmacists, dietitians, social workers, office managers, health promoters, and receptionists. METHODS: Individual in-depth interviews were conducted. An iterative analysis process was used to examine the verbatim transcripts created from the interviews. Techniques of immersion and crystallization were used in the analysis. MAIN FINDINGS: Analysis of the data revealed that communication occurs through formal and informal means. Formal communication included regular team meetings with agendas and meeting minutes, memorandums, computer-assisted communication, and communication logs. Informal communication methods were open and opportunistic, reflecting the traditional hallway consultation. For patient care issues, face-to-face communication was preferred. Team member attributes facilitating communication included approachability, availability, and proximity. Finally, funding issues could be an impediment to optimal communication. CONCLUSION: Primary health care is experiencing demands for enhanced and efficient communication that optimizes team functioning and patient care. This study describes formal and informal mechanisms of communication currently used by PHCTs. Attributes that facilitate team communication, such as approachability, availability, and proximity of team members, were highlighted. New funding arrangements might alleviate concerns about remuneration for attendance at meetings.

Women and their partners' perceptions of the key roles of the labor and delivery nurse.

This descriptive qualitative study examined the perspectives of women and their partners regarding the key roles of the labor and delivery nurse during labor and birth.Ten couples were interviewed separately.The data analysis, conducted through independent and team analysis, was both iterative and interpretive. Participants identified four key roles of the labor and delivery nurse: support person, educator, patient advocate, and provider of continuity. Nurses provided both physical and emotional support.As an educator, they normalized the birth experience and served as a coach for the couple. Nurses advocated on behalf of the woman in labor, particularly when there was an adverse event. The continuity of care provided by the nurses wove the above roles into a cohesive whole. Findings provide important information for nursing educators, supervisors, and hospital administrators to reinforce the meaningful roles nurses serve in the labor and birth experiences of women and their partners.

Level of acceptance of different models of maternity care.

To elicit nurses' opinions on five proposed models of maternity care in Ontario, to examine barriers to collaborative practice, and to identify factors that would encourage nurses to practise in the area of intrapartum care, a survey was mailed to a stratified random sample of nurses in Ontario (N = 750). Participants were asked whether they would consider practising in one or more of the five proposed models of maternity care. Almost half the participants endorsed the model of nurses' providing labour and delivery care to patients of family physicians and obstetricians. Almost one-third (28.7%) reported that they would consider working in an interprofessional maternity care clinic. There was minimal interest in working with midwives. Participants identified resistance to change (49.9%) and lack of communication (47.2%) as the two main barriers to collaborative practice. The majority of respondents (84.2%) ranked good medical and obstetrical backup as the key factor that would encourage them to provide intrapartum care. A respectful work environment and collaborative models of maternity care were also ranked highly.

Training needs of pediatric occupational therapists in assistive technology.

The training of providers working with children who need assistive technology devices or services has not kept pace with the explosion of new, more sophisticated assistive technology devices now available. This article reports on a national survey of 272 pediatric occupational therapists, who responded to questions about their training needs in the area of assistive technology and delivering assistive technology services. A sizable percentage of these therapists reported less-than-adequate training in policies governing assistive technology services and the organization and function of the service system. The therapists would like training that is accessible and affordable in the areas of funding of technology and services; collaborating with families and other service providers; and accessing reliable, knowledgeable vendors. These findings underscore the need to develop pre-service and in-service training in assistive technology for providers who work with children who have disabilities.

Calcium supplementation does not augment bone gain in young women consuming diets moderately low in calcium.

In earlier observational work, the dietary calcium:protein ratio was directly related to bone accrual in healthy postadolescent women. In this study, we sought to test the hypothesis that augmented calcium intake would increase postadolescent skeletal consolidation, using a double-blind, randomized, placebo-controlled design. We recruited 152 healthy young women (age 23.1 +/- 2.7 y, BMI 22.5 +/- 3.0 kg/m2); their usual diets, as assessed by 7-d food diaries, were low in calcium (605 +/- 181 mg/d; 15.1 +/- 4.5 mmol/d) and in the calcium:protein ratio (10.1 +/- 2.0 mg/g). The subjects were randomly assigned to supplemental calcium [500 mg calcium (12.5 mmol) as the carbonate, 3 times/d, with meals] or placebo capsules identical in appearance; all participants also took a daily multivitamin, and they were followed for up to 36 mo with bone densitometry (dual energy X-ray absorptiometry; DXA) at 6-mo intervals. A total of 121 subjects remained in the study for at least 12 mo (median time in the study, 35 mo), with a mean compliance level (observed/expected tablet consumption) of 87.7%. DXA data for these 121 subjects indicated modest but significant mean rates of increase (i.e., 0.24 to 1.10%/y) in bone mineral content (BMC; total body, total hip, and lumbar spine) and in lumbar spine bone mineral density (BMD) but no change in total hip BMD. None of these rates of change differed by group, i.e., calcium supplementation did not have any measurable effect on bone mass accrual. By midstudy, the calcium content of the subjects' usual diets for both groups had risen by approximately 15%. The combined effect of improved intakes of dietary calcium and the small amount of calcium added by the multivitamin tablets resulted in a mean calcium intake for the control group > 800 mg (20 mmol)/d, possibly at or near the threshold beyond which additional calcium has no further effect on bone accrual.

Calcium absorptive efficiency is positively related to body size.

BACKGROUND: Calcium absorption efficiency is a more important determinant of calcium balance than calcium intake itself. The sources of variability in absorptive performance are only partly elucidated. PURPOSE: The aim of the study was to explore the relationship between body size and calcium absorption efficiency. DESIGN AND SETTING: Metabolic studies were performed on an inpatient metabolic unit in an academic health sciences center. SUBJECTS: One hundred seventy-eight women, with an average age of 50.2 yr, were studied from one to five times and yielded an aggregate data set containing 633 individual studies. METHODS: Calcium absorption fraction was measured by the dual-tracer method. Observed values were expressed as residuals from predicted values for each woman's actual calcium intake, using the previously published relationship between intake and absorption. RESULTS: Absorption residuals were significantly positively correlated with height, weight, and surface area, and after adjusting for estrogen status, these body size variables accounted for approximately 4% of the total variability. CONCLUSION: The magnitude of the effect is such that a woman 1.8 m in height would absorb 30+% more calcium from a given intake than a woman 1.4 m tall.

The elusive concept of bone quality.

This paper outlines information from recent publications that aid our understanding of bone quality in relation to osteoporosis. In practical terms, bone quality designates the properties of bone that contribute to strength but are not assessed by bone densitometry. While osteoporosis is still defined in terms of bone density, the limitations of this approach, long questioned, have become indisputable. In parallel, the results of treatment trials of antiresorptive agents demonstrate that bone density is a flawed surrogate for bone fragility and a weak indicator of antifracture efficacy. The case for emphasizing bone turnover in assessing fracture risk, has become increasingly strong, and a redefinition of osteoporosis on this basis may well occur. New technologies for studying bone microstructure and matrix composition, merging with sophisticated biomechanical assessments, are advancing our ideas regarding bone "damageability" and its effects over time.

Human serum 25-hydroxycholecalciferol response to extended oral dosing with cholecalciferol.

BACKGROUND: The cholecalciferol inputs required to achieve or maintain any given serum 25-hydroxycholecalciferol concentration are not known, particularly within ranges comparable to the probable physiologic supply of the vitamin. OBJECTIVES: The objectives were to establish the quantitative relation between steady state cholecalciferol input and the resulting serum 25-hydroxycholecalciferol concentration and to estimate the proportion of the daily requirement during winter that is met by cholecalciferol reserves in body tissue stores. DESIGN: Cholecalciferol was administered daily in controlled oral doses labeled at 0, 25, 125, and 250 micro g cholecalciferol for approximately 20 wk during the winter to 67 men living in Omaha (41.2 degrees N latitude). The time course of serum 25-hydroxycholecalciferol concentration was measured at intervals over the course of treatment. RESULTS: From a mean baseline value of 70.3 nmol/L, equilibrium concentrations of serum 25-hydroxycholecalciferol changed during the winter months in direct proportion to the dose, with a slope of approximately 0.70 nmol/L for each additional 1 micro g cholecalciferol input. The calculated oral input required to sustain the serum 25-hydroxycholecalciferol concentration present before the study (ie, in the autumn) was 12.5 micro g (500 IU)/d, whereas the total amount from all sources (supplement, food, tissue stores) needed to sustain the starting 25-hydroxycholecalciferol concentration was estimated at approximately 96 micro g (approximately 3800 IU)/d. By difference, the tissue stores provided approximately 78-82 micro g/d. CONCLUSIONS: Healthy men seem to use 3000-5000 IU cholecalciferol/d, apparently meeting > 80% of their winter cholecalciferol need with cutaneously synthesized accumulations from solar sources during the preceding summer months. Current recommended vitamin D inputs are inadequate to maintain serum 25-hydroxycholecalciferol concentration in the absence of substantial cutaneous production of vitamin D.

Bone microstructure in osteoporosis: transilial biopsy and histomorphometry.

The bone fragility of osteoporosis is not fully explained by a deficit in bone mass. Histomorphometric examination of transilial bone biopsies has identified microstructural defects that-in light of what is known about the mechanical properties of structural materials-further compromise bone strength. Histomorphometric measures describe the biopsy specimen, the configuration of its trabeculae in space, and the extent to which its trabecular lattice is intact. In postmenopausal women with established osteoporosis, a deficit of both cortical and cancellous bone is typical, i.e., both cortical thickness and cancellous bone volume tend to be substantially reduced. Much of the cancellous bone deficit can be attributed to loss of entire trabecular elements rather than to generalized thinning of trabeculae. Direct measures of trabecular connectivity confirm this impression: women with established osteoporosis have fewer trabecular nodes and more termini than healthy women, even at the same cancellous bone volume. Evidence for accumulated microdamage in transilial biopsies is circumstantial, and the phenomenon itself may well be localized to fracture sites. Histomorphometric data from transilial biopsies comprise a large body of information about the structural and functional character of osteoporosis and provide valuable information about the effects of new treatments on bone microstructure.

Effects of above average summer sun exposure on serum 25-hydroxyvitamin D and calcium absorption.

The purpose of this study was to examine the effects of summer sun exposure on serum 25-hydroxyvitamin D [25(OH)D], calcium absorption fraction, and urinary calcium excretion. Subjects were 30 healthy men who had just completed a summer season of extended outdoor activity (e.g. landscaping, construction work, farming, or recreation). Twenty-six subjects completed both visits: after summer sun exposure and again approximately 175 d later, after winter sun deprivation. We characterized each subject's sun exposure by locale, schedule, and usual attire. At both visits we measured serum 25(OH)D, fasting urinary calcium to creatinine ratio, and calcium absorption fraction. Median serum 25(OH)D decreased from 122 nmol/liter in late summer to 74 nmol/liter in late winter. The median seasonal difference of 49 nmol/liter (interquartile range, 29-67) was highly significant (P < 0.0001). However, we found only a trivial, nonsignificant seasonal difference in calcium absorption fraction and no change in fasting urinary calcium to creatinine ratio. Findings from earlier work indicate that our subjects' sun exposure was equivalent in 25(OH)D production to extended oral dosing with 70 micro g/d vitamin D(3) (interquartile range, 41-96) or, equivalently, 2800 IU/d (interquartile range, 1640-3840). Despite this input, at the late winter visit, 25(OH)D was less than 50 nmol/liter in 3 subjects and less than 75 nmol/liter in 15 subjects.

Calcium and weight: clinical studies.

Data from six observational studies and three controlled trials in which calcium intake was the independent variable (and either bone mass or blood pressure the original outcome variable) have been reanalyzed to evaluate the effect of calcium intake on body weight and body fat. Analysis reveals a consistent effect of higher calcium intakes, expressed as lower body fat and/or body weight, and reduced weight gain at midlife. Similarly, studies relating nutrient intake to body composition report negative associations between calcium intake and body weight at midlife and between calcium and body fat accumulation during childhood. There is a fairly consistent effect size, with each 300 mg increment in regular calcium intake associated with approximately 1 kg less body fat in children and 2.5-3.0 kg lower body weight in adults. Taken together these data suggest that increasing calcium intake by the equivalent of two dairy servings per day could reduce the risk of overweight substantially, perhaps by as much as 70 percent.

Diálisis peritoneal intermitente en pediatría / Intermittent peritoneal dialysis in pediatrics

Se presenta la experiencia de la diálisis peritoneal intermitente en 8 niños insuficientes renales crónicos en su etapa previa al transplante renal, entre 1983 y 1985 en el Hospital Luis Calvo Mackenna. La muestra comprende seis mujeres. La edad de los pacientes fluctuó entre 2 años 1 mes y 12 años 10 meses con un promedio de 9 años 4 meses. En la diálisis se usaron catéteres de Silastic y soluciones gluco-electrolíticas isotónicas a 37-C, en volúmenes de 30 a 40 ml x kg que fueron mantenidas en la cavidad peritoneal por 45 minutos y removidos en 15 minutos, repitiendo el procedimiento 24 veces cada día 2 veces por semana. Se efectuaron en total 268 días de diálisis con un mínimo de 10 y un máximo de 60 por cada paciente. Cada 15 días se hizo una evaluación antropométrica, bioquímica y hematológica observando mejoría, aunque no normalización de estos parámetros. Sin embargo los pacientes pudieron realizar una vida normal y llegar al trasplante en excelentes condiciones generales. De los 8 pacientes, 6 recibieron trasplantes renales donados por parientes y 2 esperan riñones de otros donantes. En 2 pacientes se obstruyeron los catéteres de diálisis por lo que hubo que removerlos; registramos 3 episodios de peritonitis bacteriana, en los que no se logró aislar el germen causal. Nuestros resultados parciales parecen buenos y como el sistema es barato y simple en comparación con la hemodiálisis y la diálisis peritoneal continua ambulatoria, creemos que la diálisis peritoneal intermitente es un procedimiento recomendable en países en desarrollo que no cuentan con los medios de financiamiento necesario para aplicar términos que por ahora son más costosas