The primary care diagnosis of dementia in Europe: an analysis using multidisciplinary, multinational expert groups.

OBJECTIVES: To explore the extent of variation in the detection of dementia in primary care across Europe, and the potential for the development of European guidelines. METHOD: A mixture of focus group and adapted nominal group methods involving 23 experts of different disciplines and from eight European countries. RESULTS: The diagnosis of dementia should be 'timely' rather than 'early'. Timeliness has an impact on the patient, on the caregiver, on healthcare professionals, and on society. Ethical and moral issues may interfere with the aim of timely diagnosis. Guidelines may be important for facilitating a timely diagnosis of dementia, but were infrequently used and not even available in three of the eight countries. Referral pathways often depended on health care system characteristics, differing throughout the eight European countries, whilst diagnostic strategies differed due to varied cultural influences. There was consensus that national variations can be reduced and timely diagnosis enhanced by combining simple tests using a systematic stepwise case-finding strategy, in conjunction with a strong infrastructure of multidisciplinary collaboration. CONCLUSIONS: This study identified three key themes that should be considered in harmonizing European approaches to the diagnosis of dementia in primary care: (1) a focus on timely diagnosis, (2) the need for the development and implementation of guidelines, and (3) the identification of appropriate referral pathways and diagnostic strategies including multi-professional collaboration. The content of guidelines may be determined by the perspectives of the guideline developers.

Decision support software for dementia diagnosis and management in primary care: relevance and potential.

Dementia, which affects a large and growing number of older people, presents particular challenges to primary care. There is an acknowledged need to develop interventions that address practitioners' needs for information and guidance regarding the diagnosis and management of dementia. This paper examines the potential usefulness and constraints of a Computer Decision Support System (CDSS) to assist practitioners in diagnosing and managing dementia. Questionnaire information was obtained from 97 primary care practitioners regarding their current practice and views on dementia care, priority given to training and familiarity with computer use. Implications of these findings for the relevance and value of CDSS are discussed. The paper is part of a larger ongoing study, the aim of which is the evaluation of three educational interventions for primary care practitioners.

Reliability of indices of neuromuscular leg performance in end-stage renal failure.

The purpose of this study was to examine the day-to-day reproducibility and single measurement reliability of peak force, time to half peak force and rate of force development indices of knee extension neuromuscular performance in patients with end-stage renal failure. Eleven self-selected patients (6 men, 5 women) receiving maintenance dialysis (dialysis history 67 +/- 42.8 month) completed 3 inter-day assessment sessions. Each comprised a standardized warm-up and 3 intermittent static maximal voluntary actions of the knee extensors of the preferred limb (45 degrees knee flexion angle [0 degrees = full knee extension]) using a specially-constructed dynamometer. Repeated measures ANOVA of coefficient of variation scores revealed significant differences between indices in their reproducibility across day-to-day trials. Post-hoc comparisons of group mean scores suggested that peak force (6.6 +/- 3.0%) offers significantly greater measurement reproducibility than time to half peak force (16.8 +/- 9.5%) or rate of force development (20.3 +/- 12.1%). Intraclass correlation coefficients and standard error of measurement scores showed that single-trial assessments of peak force, time to half peak force and rate of force development would demonstrate limited precision and capability to discriminate subtle intra-subject or inter-subject changes in neuromuscular performance.

Design and implementation of a computer decision support system for the diagnosis and management of dementia syndromes in primary care.

BACKGROUND: Diagnosis and management of dementia is a complex process and primary care physicians are under-equipped to deal with uncertainties in the provision of optimal care for the patient. OBJECTIVE: To develop a computer decision support system (CDSS) which could assist physicians with diagnosis and management and improve patient care. METHODS: A design group including general practitioners derived logic pathways for diagnosis and management of dementia and validated them with a multiprofessional expert group. Logic pathways were used to construct a comprehensive CDSS rendered as a series of expert consultations. The CDSS was inserted into commercially available GP systems and bench and field-tested. RESULTS: The complexity of dementia diagnosis and management can be captured in logic pathways which can be expressed as decision trees within existing electronic patient records. The resulting CDSS appears useable in routine practice. CONCLUSION: The impact of this CDSS will be evaluated in a randomised controlled trial of educational interventions in primary care.

Development of a walking test for the assessment of functional capacity in non-anaemic maintenance dialysis patients.

BACKGROUND: Walk tests may be useful adjuncts or even alternatives to the assessment of peak oxygen uptake (VO2 peak) in patients with low functional capacity. Walk tests are easy to administer, appear to be well tolerated by patients and may represent a more meaningful measure for a patient group as they assess capability as well as fitness. However, the use of walk tests for the assessment of functional capacity in maintenance dialysis patients has received scant attention. The aim of this study was to assess the validity of a walking-stair-climbing test to predict VO2 peak in non-anaemic maintenance dialysis patients. METHODS: In the validation phase of the study, 14 subjects completed a cycle ergometer-graded exercise test (GXT) for the determination of VO2 peak and a walking-stair-climbing task (WALK), each separated by a period of 7 days. Three weeks later, 18 subjects completed two WALK tests, each separated by a period of at least 48 h, to facilitate reliability estimation. Estimates of differentiated and undifferentiated ratings of perceived exertion (RPE) were obtained during and immediately consequent to all exercise tests. RESULTS: VO2 peak (ml kg min) was significantly correlated with total WALK time (s) (r = -0.83; P < 0.001). VO2 peak (ml/kg/min) could be predicted from total WALK time with a standard error of prediction of 11%. Reliability assessment revealed no significant differences for any aspect of the WALK test performance, with intraclass correlation coefficients ranging from r = 0.71 (RPElegs) to 0.96 (total WALK time). CONCLUSION: These results indicate that the WALK test is a valid, reliable and potentially useful method by which to assess the functional capacity of non-anaemic maintenance dialysis patients.

Viral hemorrhagic septicemia virus, Ichthyophonus hoferi, and other causes of morbidity in Pacific herring Clupea pallasi spawning in Prince William Sound, Alaska, USA.

Pacific herring Clupea pallasi populations in Prince William Sound, Alaska, USA, declined from an estimated 9.8 x 10(7) kg in 1992 to 1.5 x 10(7) kg in 1994. To determine the role of disease in population decline, 233 Pacific herring from Prince William Sound were subjected to complete necropsy during April 1994. The North American strain of viral hemorrhagic septicemia virus (VHSV) was isolated from 11 of 233 fish (4.7%). VHSV was significantly related to myocardial mineralization, hepatocellular necrosis, submucosal gastritis, and meningoencephalitis. Ichthyophonus hoferi infected 62 of 212 (29%) fish. I. hoferi infections were associated with severe, disseminated, granulomatous inflammation and with increased levels of plasma creatine phosphokinase (CPK) and aspartate aminotransferase (AST). I. hoferi prevalence in 1994 was more than double that of most previous years (1989 to 1993). Plasma chemistry values significantly greater (p < 0.01) in males than females included albumin, total protein, cholesterol, chloride, glucose, and potassium; only alkaline phosphatase was significantly greater in females. Hypoalbuminemia was relatively common in postspawning females; other risk factors included VHSV and moderate or severe focal skin reddening. Pacific herring had more than 10 species of parasites, but they were not associated with significant lesions. Two of the parasites have not previously been described: a renal intraductal myxosporean (11% prevalence) and an intestinal coccidian (91% prevalence). Transmission electron microscopy of a solitary mesenteric lesion revealed viral particles consistent with lymphocystis virus. No fish had viral erythrocytic necrosis (VEN). Prevalence of external gross lesions and major parasites was not related to fish age, and fish that were year-lings at the time of the 1989 'Exxon Valdez' oil spill (1988 year class) had no evidence of increased disease prevalence.

Hospital and hospice resource use of HIV-positive patients in Edinburgh.

A prospective study of health service and hospice resource utilization (average length of stay or ALOS, discharge rate, bed day use, outpatient consultation) analysed with reference to gender, risk activity, immunological and clinical staging (1987 definition of AIDS) for the financial year 1992-93 was undertaken at the Regional Infectious Disease Unit (RIDU), City Hospital, Edinburgh, Scotland where 72% of 513 patients were infected via injection drug use. Not surprising therefore overall, drug users were the heaviest users of the inpatient facilities (74% of the discharges and 65% of the bed days) although homosexuals had the highest discharge rate (114 per 100 person years) and rate of bed day use (1654 days per 100 person years). Immunodeficiency (CD4 count < 200 cells/ul) and a clinical diagnosis of AIDS were both associated with greater inpatient and outpatient resource use compared to those without immunodeficiency (CD4 count > or = 200 CD4 cells/ul) or AIDS. Gender effects were complex; the ALOS for women was increased for all risk groups whatever the CD4 count whilst there was no consistent trend of more resource use for women by risk group. Drug users were the heaviest overall users of the local hospice (84% of all admissions, 83% of the bed days and a discharge rate of 76.4 per 100 person years), more than double the rates experienced by the other risk groups. Thus both clinical and immunological staging (AIDS or a CD4 count < 200 cells/ul) were associated with increased resource use in HIV infection and estimates of resource use for AIDS need to be increased by around one-third to take into account hospice use. Despite the preponderance of drug users in Edinburgh, comparisons with other centres did not reveal increased resource use.

The cost of health care for HIV-positive patients.

Utilizing a prospective study of health service activity for HIV/AIDS, 2 estimates of hospital costs of care analysed with reference to gender, risk activity, immunological and clinical staging (1987 definition of AIDS) were undertaken. Utilizing combined costs per life year (based on hospital and hospice activity but not primary and community care) the ratio of costs for CD4 < 200 and CD4 > 200 was for most risk groups between 2-5:1 whilst for AIDS: pre-AIDS it was between 3.6-8.3:1 except for homosexuals where it was 12.6:1. A comparison of the standard hospital costs for infectious diseases with the published accounts for clinical AIDS care in Lothian suggests a 3-4-fold underestimate in the costs of providing a comprehensive health care service.

A physico-chemical approach to morphogenesis: the roles of inorganic ions and crystals.

We consider morphogenesis with special references to the development of mineral frameworks, organic filamentous structures and the location of enzymes, including ion-pumps, in membranes. Starting from a description of the morphology of inorganic crystals we analyse so-called equilibrium growth, i.e. growth at constant shape, both outside and inside biological systems. It is shown that an initial small spherical cell in which linear, ordered, inorganic or organic features are built will become distorted. The distortion is due to stresses which affect membrane curvature and consequently rearrange enzymes in membranes. The cell system can rapidly attain a steady-state of development, ('equilibrium') growth, of fixed morphology. After a considerable growth period the cell may cease to grow or the steady state may be broken and a transition can then occur to a quite new morphology. Examples are taken mostly from unicellular organisms but the ideas apply to multi-cellular systems.

Analysis of two-way escape-avoidance conditioning measures from a diallel cross of eight strains of rats.

In a study designed to investigate genotype-environment interaction, eight strains of laboratory rats were crossbred in a replicated diallel cross employing infantile stimulation and its absence as environmental treatments. This paper reports on measures of the acquisition of two-way escape-avoidance conditioning, comprising number of avoidances, avoidance and escape latencies, and intertrial and presessional crossings, which were subjected to biometrical genetical analysis, all but the last successfully. Additive variation was prominent throughout and some measures showed directional dominance. Effects of stimulation were seen in avoidance number and crossings. The analysis of avoidances by successive blocks of trials using covariance:variance graphs revealed differences in the way the strains varied with respect to the changing relationships of proportions of dominant and recessive alleles governing this behavior. The results are discussed in the light of previous data and of their evolutionary implications.