Volunteer-led online group exercise for community-dwelling older people: a feasibility and acceptability study.

BACKGROUND: Despite the clear benefits of physical activity in healthy ageing, engagement in regular physical activity among community-dwelling older adults remains low, with common barriers including exertional discomfort, concerns with falling, and access difficulties. The recent rise of the use of technology and the internet among older adults presents an opportunity to engage with older people online to promote increased physical activity. This study aims to determine the feasibility and acceptability of training volunteers to deliver online group exercises for older adults attending community social clubs. METHODS: This was a pre-post mixed-methods study. Older adults aged ≥ 65 years attending community social clubs who provided written consent and were not actively participating in exercise classes took part in the feasibility study. Older adults, volunteers, and staff were interviewed to determine the acceptability of the intervention. The intervention was a once weekly volunteer-led online group seated strength exercises using resistance bands. The duration of the intervention was 6 months. The primary outcome measures were the feasibility of the intervention (determined by the number of volunteers recruited, trained, and retained, participant recruitment and intervention adherence) and its acceptability to key stakeholders. Secondary outcome measures included physical activity levels (Community Health Model Activities Programme for Seniors (CHAMPS) questionnaire), modified Barthel Index, Health-related quality of life (EQ-5D-5L), frailty (PRISMA-7) and sarcopenia (SARC-F), at baseline and 6 months. RESULTS: Nineteen volunteers were recruited, 15 (78.9%) completed training and 9 (47.3%) were retained after 1 year (mean age 68 years). Thirty older adults (mean age 77 years, 27 female) participated, attending 54% (IQR 37-67) of exercise sessions. Participants had no significant changes in secondary outcome measures, with a trend towards improvement in physical activity levels (physical activity in minutes per week at baseline was 1770 min, and 1909 min at six months, p = 0.13). Twenty volunteers, older adults, and staff were interviewed and found the intervention acceptable. The seated exercises were perceived as safe, manageable, and enjoyable. CONCLUSIONS: Trained volunteers can safely deliver online group exercise for community-dwelling older adults which was acceptable to older adults, volunteers, and club staff. TRIALS REGISTRATION: NCT04672200.

Volunteer-led physical activity interventions to improve health outcomes for community-dwelling older people: a systematic review.

BACKGROUND: Physical activity (PA) is important for older people to maintain functional independence and healthy ageing. There is strong evidence to support the benefits of physical activity interventions on the health outcomes of older adults. Nonetheless, innovative approaches are needed to ensure that these interventions are practical and sustainable. AIM: This systematic review explores the effectiveness of volunteer-led PA interventions in improving health outcomes for community-dwelling older people. METHODS: Five databases (MEDLINE, Embase, CINAHL, PEDro, Cochrane library) were systematically searched for studies using trained volunteers to deliver PA interventions for community-dwelling older people aged ≥ 65 years. Meta-analysis was not conducted due to included study heterogeneity. RESULTS: Twelve papers describing eight studies (five papers reported different outcomes from the same study) were included in the review. All eight studies included strength and balance exercises and frequency of PA ranged from weekly to three times a week. Volunteer-led exercises led to improvements in functional status measured using the short physical performance battery, timed up and go test, Barthel Index, single leg stand, step touch test, chair stand test, and functional reach. Frailty status identified by grip strength measurement or the use of long-term care insurance improved with volunteer-led exercises. Interventions led to improvement in fear of falls and maintained or improved the quality of life. The impact on PA levels were mixed. CONCLUSION: Limited evidence suggests that volunteer-led PA interventions that include resistance exercise training, can improve outcomes of community-dwelling older adults including functional status, frailty status, and reduction in fear of falls. More high-quality RCTs are needed to investigate the effects of volunteer-led PA interventions among older people.

Poor Appetite Is Associated with Six Month Mortality in Hospitalised Older Men and Women.

OBJECTIVES: Appetite loss is common in hospitalised older individuals but not routinely assessed. Poor appetite in hospital has previously been identified as predictive of greater mortality in the six months following discharge in a single study of female patients. The present study aimed to assess this association in a larger sample including both hospitalised men and women. DESIGN: Longitudinal observational study with six month follow up. SETTING: Acute hospital wards in a single large hospital in England. PARTICIPANTS: Older inpatients aged over 70 years. MEASUREMENTS: Appetite was assessed using the Simplified Nutritional Appetite Questionnaire (SNAQ) during hospital stay. Deaths during six month follow-up period were recorded. Association between SNAQ score during hospital admission and death 6 months post-discharge was assessed using binary logistic regression in unadjusted and adjusted analysis. RESULTS: 296 participants (43% female, mean age 83 years (SD 6.9)) were included in this study. Prevalence of poor appetite (SNAQ score <14) was 41%. In unadjusted analysis a SNAQ score of <14 was associated with a 2.47 increase in odds of mortality at six months (OR 2.47 (95% CI 1.27,4.82)). This association remained after adjusting for number of comorbidities (Charlson index), length of stay and gender (OR 2.62 (95% CI 1.30, 5.27)). In unadjusted continuous analysis, every one point decrease in SNAQ score led to a 1.20 fold increase in odds of mortality at six months (OR 1.20 (95% CI 1.06-1.36)). This association remained in adjusted analysis (OR 1.22 (95% CI 1.07-1.39)). CONCLUSION: Poor appetite is common in hospitalised older people. We have confirmed the association, previously reported in older women, between poor appetite during hospital stay and greater mortality at six months post-discharge but in a larger study including older men and women. Further research is needed to understand the mechanisms of poor appetite, which lead to increased mortality.

Can probiotics, prebiotics and synbiotics improve functional outcomes for older people: a systematic review.

PURPOSE: Research evaluating the effect of probiotics, prebiotics and synbiotics (PPS) on laboratory markers of health (such as immunomodulatory and microbiota changes) is growing but it is unclear whether these markers translate to improved functional outcomes in the older population. This systematic review evaluates the effect of PPS on functional outcomes in older people. METHODS: We conducted a systematic review of the effect of PPS in older adults on functional outcomes (physical strength, frailty, mood and cognition, mortality and receipt of care). Four electronic databases were searched for studies published since year 2000. RESULTS: Eighteen studies (including 15 RCTs) were identified. One of five studies evaluating physical function reported benefit (improved grip strength). Two analyses of one prebiotic RCT assessed frailty by different methods with mixed results. Four studies evaluated mood with no benefit reported. Six studies evaluated cognition: four reported cognitive improvement in participants with pre-existing cognitive impairment receiving probiotics. Seven studies reported mortality as a secondary outcome with a trend to reduction in only one. Five studies reported length of hospital stay but only two peri-operative studies reported shorter stays. CONCLUSION: There is limited evidence that probiotics may improve cognition in older people with pre-existing cognitive impairment but no clear evidence of benefit of PPS on physical function, frailty, mood, length of hospitalisation and mortality. Larger studies with more homogenous interventions, accounting for confounding factors, such as diet, co-morbidities and medications, are required. There is currently inadequate evidence to recommend PPS use to older people in general. PROSPERO REGISTRATION NUMBER: PROSPERO registration number is CRD42020173417. Date of PROSPERO registration: 01/05/20.

Priorities for research in multiple conditions in later life (multi-morbidity): findings from a James Lind Alliance Priority Setting Partnership.

INTRODUCTION: multiple conditions in later life (multi-morbidity) is a major challenge for health and care systems worldwide, is of particular relevance for older people, but has not (until recently) received high priority as a topic for research. We have identified the top 10 research priorities from the perspective of older people, their carers, and health and social care professionals using the methods of a James Lind Alliance Priority Setting Partnership. METHODS: in total, 354 participants (162 older people and carers, 192 health professionals) completed a survey and 15 older people and carers were interviewed to produce 96 'unanswered questions'. These were further refined by survey and interviews to a shortlist of 21 topics, and a mix of people aged 80+ living with three or more conditions, carers and health and social care providers to prioritised the top 10. RESULTS: the key priorities were about the prevention of social isolation, the promotion of independence and physical and emotional well-being. In addition to these broad topics, the process also identified detailed priorities including the role of exercise therapy, the importance of falls (particularly fear of falling), the recognition and management of frailty and Comprehensive Geriatric Assessment. CONCLUSION: these topics provide a unique perspective on research priorities on multiple conditions in later life and complement existing UK and International recommendations about the optimisation of health and social care systems to deliver essential holistic models of care and the prevention and treatment of multiple co-existing conditions.

Physical activity among hospitalised older people: insights from upper and lower limb accelerometry.

BACKGROUND: Few studies have explored the activity levels of hospitalised older people and the intra-daily activity patterns in this group have not been described. AIMS: To describe the quantity and daily pattern of physical activity among hospitalised older people using two accelerometers: the ankle-worn StepWatch Activity Monitor (SAM), and the wrist-worn GENEActiv. METHODS: This cross-sectional observational study was conducted on the acute medical wards for older people in one UK hospital. INCLUSION CRITERIA: participants aged ≥ 70 years, and able to mobilise prior to admission. Participants wore both devices for up to seven consecutive days, or until hospital discharge, whichever was sooner. Intra-daily activity levels were analysed hourly over each 24 h period. RESULTS: 38 participants (mean age 87.8 years, SD 4.8) had their activity levels measured using both devices. The SAM median daily step count was 600 (IQR 240-1427). Intra-daily activity analysis showed two peak periods of ambulatory activity between 9 am-11 am and 6 pm-7 pm. With physical activity defined as ≥ 12 milli-g (GENEActiv), the median time spent above this cut-off point was 4.2 h. 62% of this activity time was only sustained for 1-5 min. Acceptability of both devices was high overall, but the wrist-worn device (96%) was more acceptable to patients than the ankle-worn device (83%). CONCLUSION: Activity levels of these hospitalised older people were very low. Most physical activity was sustained over short periods. The intra-daily pattern of activity is an interesting finding which can help clinicians implement time-specific interventions to address the important issue of sedentary behaviour.

Assessment of Physical Activity of Hospitalised Older Adults: A Systematic Review.

BACKGROUND: The assessment of physical activity levels of hospitalised older people requires accurate and reliable measures. Physical activities that older people in hospital commonly engage in include exercises and walking. Measurement of physical activity levels of older inpatients is essential to evaluate the impact of interventions to improve physical activity levels and to determine associations between physical activity in hospital and other health-related outcome measures. OBJECTIVE: To determine which measures are used to measure physical activity of older people in hospital, and to describe their properties and applications. METHOD: A systematic review of four databases: Medline, Embase, CINAHL and AMED was conducted for papers published from 1996 to 2016. Inclusion criteria were participants aged ≥ 65 years and studies which included measures of physical activity in the acute medical inpatient setting. Studies which specifically assessed the activity levels of surgical patients or patients with neurological conditions such as stroke or brain injury were excluded. All study designs were included in the review. RESULTS: 18 studies were included from 127 articles selected for full review. 15 studies used objective measures to measure the physical activity of older inpatients: 11 studies used accelerometers and four used direct systematic observations. Seven accelerometers were identified including the StepWatch Activity Monitor, activPAL, GENEActiv, Kenz Lifecorder EX, Actiwatch-L, Tractivity and AugmenTech Inc. Pittsburgh accelerometer. Three studies used a subjective measure (interviews with nurses and patients) to classify patients into low, intermediate and high mobility groups. The StepWatch Activity Monitor was reported to be most accurate at step-counting in patients with slow gait speed or altered gait. The activPAL was reported to be highly accurate at classifying postures. CONCLUSION: Physical activity levels of older inpatients can be measured using accelerometers. The accuracy of the accelerometers varies between devices and population-specific validation studies are needed to determine their suitability in measuring physical activity levels of hospitalised older people. Subjective measures are less accurate but can be a practical way of measuring physical activity in a larger group of patients.

Can fortified foods and snacks increase the energy and protein intake of hospitalised older patients? A systematic review.

BACKGROUND: Undernutrition affects over 44% of hospitalised older people, who often dislike oral nutritional supplements (ONS). This review summarises the evidence for an alternative strategy, using energy and protein dense meals (via fortification) or snacks (supplementation) to increase the dietary energy and protein intake of older inpatients. METHODS: A search was conducted through PubMed, EMBASE, CINAHL and the Cochrane database of systematic reviews (May 1996 to May 2016) that used fortification or supplementation to increase the energy or protein intake of patients (mean age ≥60 years) in hospitals or rehabilitation centres. RESULTS: Ten articles (546 patients, mean age 60-83 years) were identified. Compared with usual nutritional care, six studies using either energy or protein based fortification and supplementation significantly increased intake of energy (250-450 kcal day-1 ) or protein (12-16 g day-1 ). Two studies enriched menus with both energy and protein, and significantly increased both energy (698 kcal day-1 and 21 kJ kg-1 ) and protein (16 g and 0.2 g kg-1 ) intake compared to usual care. ONS was similar to supplementation in one study but superior to fortification in another. Four studies reported good acceptability of enriched products and two studies that found they were cost-effective. CONCLUSIONS: Compared with usual nutritional care, energy- and protein-based fortification and supplementation could be employed as an effective, well-tolerated and cost-effective intervention to improve dietary intake amongst older inpatients. This strategy may be particularly useful for patients with cognitive impairment who struggle with ONS, and clinical trials are required to compare these approaches and establish their impact on functional outcomes.

The Impact of Trained Volunteer Mealtime Assistants on Dietary Intake and Satisfaction with Mealtime Care in Adult Hospital Inpatients: A Systematic Review.

BACKGROUND: Malnutrition is common in hospital inpatients and is associated with increased morbidity and mortality. Insufficient assistance at mealtimes can contribute to this and therefore trained volunteer mealtime assistants may be of benefit. OBJECTIVES: To identify and review the current evidence for the impact of trained volunteer mealtime assistants on dietary intake and satisfaction with mealtime care in adult hospital inpatients. METHODS: A systematic search of Medline, Embase and CINAHL was conducted to identify relevant articles. Articles of any methodology were considered. Quality assessment and data extraction were carried out by two reviewers independently. PARTICIPANTS: Participants were inpatients in a hospital setting, including rehabilitation units. Participants in long term care facilities were excluded. INTERVENTION: Articles that examined the effect of trained volunteer mealtime assistants on nutritional outcomes or satisfaction with mealtime care were included. RESULTS: 5576 articles were identified, of which 14 were included in the review. Nine were small research studies and five were quality improvement initiatives. The quality of eight studies was moderate, with one study being of lower quality. Eight articles reported dietary intake and seven demonstrated an improvement, with protein intakes at volunteer mealtimes increasing by 4.3g-10.1g and energy intakes by 44-105kcal. Ten articles reported positive staff, patient and volunteer feedback. No adverse events were reported. CONCLUSION: There is evidence from small studies and improvement projects that trained volunteer mealtime assistants are safe and improve satisfaction with mealtime care in hospital inpatients, although evidence for an effect on dietary intake was less consistent. Larger studies with robust methodology are required to confirm this.

New horizons in comprehensive geriatric assessment.

In this article, we discuss the emergence of new models for delivery of comprehensive geriatric assessment (CGA) in the acute hospital setting. CGA is the core technology of Geriatric Medicine and for hospital inpatients it improves key outcomes such as survival, time spent at home and institutionalisation. Traditionally It is delivered by specialised multidisciplinary teams, often in dedicated wards, but in recent years has begun to be taken up and developed quite early in the admission process (at the 'front door'), across traditional ward boundaries and in specialty settings such as surgical and pre-operative care, and oncology. We have scanned recent literature, including observational studies of service evaluations, and service descriptions presented as abstracts of conference presentations to provide an overview of an emerging landscape of innovation and development in CGA services for hospital inpatients.

A randomized controlled feasibility trial exploring partnered ballroom dancing for people with Parkinson's disease.

OBJECTIVE: To determine the feasibility of a Dance Centre delivering a programme of mixed dances to people with Parkinson's and identify suitable outcomes for a future definitive trial. DESIGN: A two-group randomized controlled feasibility trial. METHODS: People with Parkinson's were randomized to a control or experimental group (ratio 15:35), alongside usual care. In addition, participants in the experimental group danced with a partner for one hour, twice-a-week for 10 weeks; professional dance teachers led the classes and field-notes were kept. Control-group participants were given dance class vouchers at the end of the study. Blinded assessments of balance, mobility and function were completed in the home. Qualitative interviews were conducted with a subsample to explore the acceptability of dance. RESULTS: A total of 51 people with Parkinson's (25 male) with Hoehn and Yahr scores of 1-3 and mean age of 71 years (range 49-85 years), were recruited to the study. Dance partners were of similar age (mean 68, range 56-91 years). Feasibility findings focused on recruitment (target achieved); retention (five people dropped out of dancing); outcome measures (three measures were considered feasible, changes were recommended). Proposed sample size for a Phase III trial, based on the 6-minute walk test at six months was 220. Participants described dance as extremely enjoyable and the instructors were skilled in instilling confidence and motivation. The main organizational challenges for a future trial were transport and identifying suitable dance partners. CONCLUSION: We have demonstrated the feasibility of conducting the study through a Dance Centre and recommend a Phase III trial.

The Impact of Trained Volunteer Mealtime Assistants on the Dietary Intake of Older Female In-Patients: The Southampton Mealtime Assistance Study.

OBJECTIVE: Malnutrition among older hospital inpatients is common and is associated with poor clinical outcomes. Time-pressured staff may struggle to provide mealtime assistance. This study aimed to evaluate the impact of trained volunteer mealtime assistants on the dietary intake of older inpatients. DESIGN: Quasi-experimental two year pre and post- test study of the introduction of volunteer mealtime assistants to one acute medical female ward, with contemporaneous comparison with a control ward. SETTING: Two acute medical female wards in a university hospital in England. PARTICIPANTS: Female acute medical inpatients aged 70 years and over who were not tube fed, nil by mouth, terminally ill or being nursed in a side room. INTERVENTION: The introduction of volunteer mealtime assistants to one ward to help patients during weekday lunchtimes in the intervention year. MEASUREMENTS: Patients' background and clinical characteristics were assessed; 24-hour records were completed for individual patients to document dietary intake in both years on the two wards. RESULTS: A total of 407 patients, mean (SD) age 87.5 (5.4) years, were studied over the two-year period; the majority (57%) needed mealtime assistance and up to 50% were confused. Patients' clinical characteristics did not differ between wards in the observational or intervention years. Throughout the intervention year volunteers provided mealtime assistance on weekday lunchtimes on the intervention ward only. Daily energy (median 1039 kcal; IQR 709, 1414) and protein (median 38.9 g: IQR 26.6, 54.0) intakes were very low (n=407). No differences in dietary intake were found between the wards in the observational or intervention years, or in a pre-post-test comparison of patients on the intervention ward. Data were therefore combined for further analysis to explore influences on dietary intake. In a multivariate model, the only independent predictor of energy intake was the feeding assistance required by patients; greater need for help was associated with lower energy intake (P<0.001). Independent predictors of protein intake were the feeding assistance given (P<0.001) and use of sip feeds; sip feed users had slightly higher protein intakes (P=0.014). CONCLUSIONS: Trained volunteers were able to deliver mealtime assistance on a large scale in an effective and sustainable manner, with the potential to release time for nursing staff to complete other clinical tasks. The study participants had a low median intake of energy and protein highlighting the importance of patient factors associated with acute illness; a stratified approach including oral and parenteral nutritional supplementation may be required for some acutely unwell patients. The level of mealtime assistance required was the factor most strongly associated with patients' poor intake of energy and protein and may be a useful simple indicator of patients at risk of poor nutrition.

Measuring Appetite with the Simplified Nutritional Appetite Questionnaire Identifies Hospitalised Older People at Risk of Worse Health Outcomes.

OBJECTIVES: Poor appetite is commonly reported by older people but is rarely measured. The Simplified Nutritional Appetite Questionnaire (SNAQ) was validated to predict weight loss in community dwelling older adults but has been little used in hospitals. We evaluated it in older women on admission to hospital and examined associations with healthcare outcomes. DESIGN: Longitudinal observational with follow-up at six months. SETTING: Female acute Medicine for Older People wards at a University hospital in England. PARTICIPANTS: 179 female inpatients. MEASUREMENTS: Age, weight, Body Mass Index (BMI), grip strength, SNAQ, Barthel Index Score, Mini Mental State Examination (MMSE), Geriatric Depression Scale: Short Form (GDS-SF), Malnutrition Universal Screening Tool (MUST), category of domicile and receipt of care were measured soon after admission and repeated at six month follow-up. The length of hospital stay (LOS), hospital acquired infection, readmissions and deaths by follow-up were recorded. RESULTS: 179 female participants mean age 87 (SD 4.7) years were recruited. 42% of participants had a low SNAQ score (<14, indicating poor appetite). A low SNAQ score was associated with an increased risk of hospital acquired infection (OR 3.53; 95% CI: 1.48, 8.41; p=0.004) and with risk of death (HR 2.29; 95% CI: 1.12, 4.68; p = 0.023) by follow-up. CONCLUSION: Poor appetite was common among the older hospitalised women studied, and was associated with higher risk of poor healthcare outcomes.

Fall frequency, predicting falls and participating in falls research: similarities among people with Parkinson's disease with and without cognitive impairment.

OBJECTIVE: We compared fall frequency and prediction among People with Parkinson's Disease (PwP) with and without cognitive impairment (CI); researchers sometimes overlook the former, concerned about consent, recall and adherence and differences in fall frequency and predictability. METHODS: We recruited 101 PwP from one clinic, used the Montreal Cognitive Assessment to measure CI, noted repeated falls recalled retrospectively over 12 months and evaluated 'repeated falls' and 'difficulty turning' as predictors of falls over three months. RESULTS: Participant median age was 76 years, and time since diagnosis 6 years. Of 40 participants without CI, 40% recalled falls and 55% fell during follow-up (1.9 (±3.8) falls/person), the sensitivity of fall history being 57% and of turning 36%. Of 36 participants with mild CI, 42% recalled falls and 42% fell during follow-up (1.2 (±1.8) falls/person), the sensitivity of fall history being 67% and of turning 69%. Of 25 participants with moderate CI, 60% recalled falls and 58% fell during follow-up (1.2 (±1.8) falls/person), the sensitivity of fall history being 71% and of turning 69%. CONCLUSIONS: Researchers need not exclude people with CI assuming falls are more frequent and less predictable than among those without. Fall rates (falls/person during follow-up) were similar among people with and without CI. Falls and difficulty turning were more sensitive predictors of falling in those with CI than those without: a simple mobility test may suggest an individual's risk of falling if a history is unavailable. Most PwP with moderate CI fall repeatedly: carer involvement facilitates their inclusion in research.

Response to an emerging vector-borne disease: surveillance and preparedness for Schmallenberg virus.

Surveillance for new emerging animal diseases from a European perspective is complicated by the non-harmonised approach across Member States for data capture, recording livestock populations and case definitions. In the summer of 2011, a new vector-borne Orthobunyavirus emerged in Northern Europe and for the first time, a coordinated approach to horizon scanning, risk communication, data and diagnostic test sharing allowed EU Member States to develop early predictions of the disease, its impact and risk management options. There are many different systems in place across the EU for syndromic and scanning surveillance and the differences in these systems have presented epidemiologists and risk assessors with concerns about their combined use in early identification of an emerging disease. The emergence of a new disease always will raise challenging issues around lack of capability and lack of knowledge; however, Schmallenberg virus (SBV) gave veterinary authorities an additional complex problem: the infection caused few clinical signs in adult animals, with no indication of the possible source and little evidence about its spread or means of transmission. This paper documents the different systems in place in some of the countries (Germany and the Netherlands) which detected disease initially and predicted its spread (to the UK) and how information sharing helped to inform early warning and risk assessment for Member States. Microarray technology was used to identify SBV as a new pathogen and data from the automated cattle milking systems coupled with farmer-derived data on reporting non-specific clinical signs gave the first indications of a widespread issue while the UK used meteorological modelling to map disease incursion. The coordinating role of both EFSA and the European Commission were vital as are the opportunities presented by web-based publishing for disseminating information to industry and the public. The future of detecting emerging disease looks more positive in the light of this combined approach in the EU.

Pictorial review of the many faces of bronchioloalveolar cell carcinoma.

Bronchioloalveolar cell carcinoma (BAC) has a varied appearance on CT that often leads to an incorrect or delayed diagnosis. The purpose of this pictorial review is to define common CT characteristics that are specific to BAC. A retrospective review was undertaken of 20 CT scans of pathologically proven cases of BAC; tumours were categorized as focal or diffuse, single or multiple, and infiltrative or well defined. Additional radiological features noted include the density (solid, part solid, non-solid), the presence of unaffected vessels within the tumour(s), and the presence of internal air bronchograms. We illustrate cases of localized and diffuse BAC presenting as (i) solitary or multiple pulmonary nodules, with and without air bronchograms, (ii) bubble-like lucencies of pseudocavitation associated with nodules of varying density, (iii) unifocal or multifocal ground-glass opacities, (iv) crazy paving, (v) nodules and airspace opacities with unaffected vessels coursing through them and (vi) lobar or multilobar consolidation and cavitating nodules. In conclusion, BAC may present with a variety of CT appearances. However, there are typical features such as the CT-angiogram sign or air-brochochograms in solitary nodules and in the periphery of larger consolidations, persisting pure ground-glass opacities, unresolving consolidation and the combination of diffuse nodules and consolidation. These features should alert the radiologist to the diagnosis of BAC.

Differential roles for small leucine-rich proteoglycans in bone formation.

This paper reviews our current state of knowledge of the roles the small leucine-rich proteoglycans (SLRPs) play in the formation of connective tissue and mineralised tissue matrices. Both, the SLRPs biglycan and decorin are highly expressed in extracellular bone matrix and there is now substantial evidence to support an increasing role for biglycan and decorin in influencing bone cell differentiation and proliferative activity. In addition decorin and biglycan have been implicated in regulating mineral deposition and crystal morphology, whilst decorin has also roles in organic matrix assembly. In order to further assess the role of these SLRPs during bone formation we have initiated studies investigating primary bone cell culture models from rats (bone marrow stromal cells, and bone cells from alveolar bone explants), and identified periods relating to cell proliferation, organic matrix deposition, remodeling of the osteoid, and mineral deposition. Analysis of mRNA levels and the nature of the proteoglycan demonstrated that dermatan sulphate substituted biglycan was expressed during phases relating to cell proliferation, ceased at early matrix deposition, and then biglycan was re-expressed at the onset of mineralisation, but was conjugated to chondroitin sulphate. Decorin was expressed later than biglycan, was associated with early matrix deposition, but then continued to the mineralisation stages. Again, dermatan sulphate-decorin prevailed earlier within osteoid matrix, whilst chondroitin sulphate-decorin predominated later within the mineralizing matrix. The nature of the GAG chain conjugated to SLRP and the timing of its expression would seem to dictate the functions biglycan and decorin play in bone formation.

Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial.

OBJECTIVE: To analyze the frequency, clinical characteristics, and predictors of symptomatic intracerebral hemorrhage (ICH) after intraarterial (IA) thrombolysis with recombinant pro-urokinase (r-proUK) in acute ischemic stroke. METHOD: The authors conducted an exploratory analysis of symptomatic ICH from a randomized, controlled clinical trial of IA thrombolysis with r-proUK for patients with angiographically documented occlusion of the middle cerebral artery within 6 hours from stroke onset. Patients (n = 180) were randomized in a ratio of 2:1 to either 9 mg IA r-proUK over 120 minutes plus IV fixed-dose heparin or IV fixed-dose heparin alone. As opposed to intention to treat, this analysis was based on "treatment received" and includes 110 patients given r-proUK and 64 who did not receive any thrombolytic agent. The remaining six patients received out-of-protocol urokinase and were excluded from analysis. The authors analyzed centrally adjudicated ICH with associated neurologic deterioration (increase in NIH Stroke Scale [NIHSS] score of > or =4 points) within 36 hours of treatment initiation. RESULTS: Symptomatic ICH occurred in 12 of 110 patients (10.9%) treated with r-proUK and in two of 64 (3.1%) receiving heparin alone. ICH symptoms in r-proUK-treated patients occurred at a mean of 10.2 +/- 7.4 hours after the start of treatment. Mortality after symptomatic ICH was 83% (10/12 patients). Only blood glucose was significantly associated with symptomatic ICH in r-proUK-treated patients based on univariate analyses of 24 variables: patients with baseline glucose >200 mg/dL experienced a 36% risk of symptomatic ICH compared with 9% for those with < or =200 mg/dL (p = 0.022; relative risk, 4.2; 95% CI, 1.04 to 11.7). CONCLUSIONS: Symptomatic ICH after IA thrombolysis with r-proUK for acute ischemic stroke occurs early after treatment and has high mortality. The risk of symptomatic ICH may be increased in patients with a blood glucose >200 mg/dL at stroke onset.

Multisection dynamic CT perfusion for acute cerebral ischemia: the "toggling-table" technique.

A new CT perfusion technique providing extended anatomic coverage was evaluated in 12 patients with suspected acute middle cerebral artery ischemia. With a multidetector CT scanner, scans were obtained in an alternating fashion at two distinct "toggling" table positions (two 1-cm sections each) during a 40-mL contrast agent bolus (approximately 5 seconds per image), and perfusion parameter maps were created. The CT perfusion results were compared with follow-up images. Nine patients showed focal perfusion abnormalities in at least one section, most commonly on mean transit time maps. Using a single table location would have underestimated or missed the involved tissue in most cases. In three of 12 patients, perfusion maps failed to delineate any abnormality. In two patients, perfusion and diffusion MR imaging confirmed the absence of perfusion abnormality and tissue injury, respectively. In one case, a small ischemic injury was revealed by diffusion MR imaging. By using the toggling-table approach, perfusion images can be obtained over an extended anatomic area and, thus, reveal the presence and the extent of presumed tissue injury.