Exenatide, Dapagliflozin, or Phentermine/Topiramate Differentially Affect Metabolic Profiles in Polycystic Ovary Syndrome.

CONTEXT: Glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors reduce weight and improve insulin sensitivity via different mechanisms. OBJECTIVE: The efficacy of once-weekly exenatide (EQW) and dapagliflozin (DAPA) alone and coadministered (EQW/DAPA), DAPA/extended-release (ER) metformin (DAPA/MET), and phentermine topiramate extended release (PHEN/TPM) on metabolic parameters, body composition, and sex hormones were examined in obese women with PCOS. METHODS: Nondiabetic women (n = 119; aged 18-45 years) with a body mass index (BMI) greater than 30 and less than 45 and polycystic ovary syndrome (National Institutes of Health criteria) were randomly assigned in a single-blinded fashion to EQW (2 mg weekly); DAPA (10 mg daily), EQW/DAPA (2 mg weekly/10 mg daily), DAPA (10 mg)/MET (2000 mg XR daily), or PHEN (7.5 mg)/TPM (46 mg ER daily) treatment for 24 weeks. Study visits at baseline and 24 weeks included weight, blood pressure (BP), waist (WC) measures, and body composition evaluated by dual-energy x-ray absorptiometry (DXA). Oral glucose tolerance tests were conducted to assess glycemia and mean blood glucose (MBG), and compute insulin sensitivity (SI) and secretion (IS) measures. Sex steroids, free androgen index (FAI), and lipid profiles were measured in the fasting sample. RESULTS: EQW/DAPA and PHEN/TPM resulted in the most loss of weight and total body fat by DXA, and WC. Despite equivalent reductions in BMI and WC with PHEN/TPM, only EQW/DAPA and EQW resulted in significant improvements in MBG, SI, and IS. Reductions in fasting glucose, testosterone, FAI, and BP were seen with all drugs. CONCLUSION: Dual therapy with EQW/DAPA was superior to either alone, DAPA/MET and PHEN/TPM in terms of clinical and metabolic benefits in this patient population.

Long-term responses of rainforest erosional systems at different spatial scales to selective logging and climatic change.

Long-term (21-30 years) erosional responses of rainforest terrain in the Upper Segama catchment, Sabah, to selective logging are assessed at slope, small and large catchment scales. In the 0.44 km(2) Baru catchment, slope erosion measurements over 1990-2010 and sediment fingerprinting indicate that sediment sources 21 years after logging in 1989 are mainly road-linked, including fresh landslips and gullying of scars and toe deposits of 1994-1996 landslides. Analysis and modelling of 5-15 min stream-suspended sediment and discharge data demonstrate a reduction in storm-sediment response between 1996 and 2009, but not yet to pre-logging levels. An unmixing model using bed-sediment geochemical data indicates that 49 per cent of the 216 t km(-2) a(-1) 2009 sediment yield comes from 10 per cent of its area affected by road-linked landslides. Fallout (210)Pb and (137)Cs values from a lateral bench core indicate that sedimentation rates in the 721 km(2) Upper Segama catchment less than doubled with initially highly selective, low-slope logging in the 1980s, but rose 7-13 times when steep terrain was logged in 1992-1993 and 1999-2000. The need to keep steeplands under forest is emphasized if landsliding associated with current and predicted rises in extreme rainstorm magnitude-frequency is to be reduced in scale.

The primary care physician and Alzheimer's disease: an international position paper.

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Maintaining the integrity of home care.

The arguments and model put forward by MacAdam are laudable, but fall short. The proposal would create a home-care system that is a support system for medical care, thus fulfilling only one of the three functions of home care. The emphasis in the model on expanding professional services addresses the demands for increases in intensive post-acute care. However, the support of chronic long-term care and of health promotion and disease prevention would not be strengthened and, indeed, would lead to the already visible demise of traditional chronic long-term care as evident throughout recent health reform. It would ensure that a preventive function is not developed.

Dimensions of care for dementia sufferers in long-term care institutions: are they related to outcomes?

OBJECTIVES: This study empirically examined whether dimensions of care cluster in special care units (SCUs) compared with non-SCUs. The relationship between SCU status plus separate measures of the dimensions of care and outcomes for dementia sufferers was then investigated. METHODS: Data were drawn from the Intermediate Care Facility Project. The sample (N = 510) included residents with dementia, aged 65 and older, in intermediate care facilities throughout the province of British Columbia. Canada. Longitudinal data included 6 outcomes: cognitive function, behavioral problems of agitation and social skills, physical functioning, and quality of life measured through affect and expressive language skills. Separate multiple linear regression equations were estimated, relating each of these outcomes to 5 dimensions of care: preadmission and admission procedures. staff training and education, nonuse of physical and chemical restraints, flexible care routines and resident-relevant activities, and the environment. RESULTS: The results showed there is virtually no clustering of dimensions along SCU/non-SCU lines. Neither SCU status nor the individual dimensions were highly predictive of outcomes. Residents' affect at t1 emerged as a characteristic that was significantly correlated with other outcomes. DISCUSSION: This Canadian research can be added to the few but growing number of rigorous studies that suggest SCUs are not homogeneous and do not necessarily provide better care than non-SCUs. Moreover, it raises questions about the benefits of "best practice" dimensions of care, regardless of SCU status.

Receptivity to new technology among older adults.

PURPOSE: Both absolute and relative increases in the older adult population are occurring concurrently with the growth of high technology. Technological devices offer sophisticated solutions to some of the problems associated with ageing. This study borrows from the health utilization literature in order to develop and test a model for understanding receptivity to specific technological products by older adults. RESULTS: Receptivity is directly influenced by predispositional, need and social support factors, as well as by one's level of concern for problems that could be alleviated through the use of technology. Hierarchical regression equations reveal that this latter variable, concern, has the strongest influence on receptivity, while need factors display strong indirect effects. Those with unsatisfactory contact with others are also more receptive, suggesting that the lack of social support acts as a need factor. Contrary to past research, women are more receptive to technology than men. CONCLUSIONS: The results indicate that new technology geared toward enhancing the quality of life of seniors in their homes would be welcomed by many.

The role of extreme events in the impacts of selective tropical forestry on erosion during harvesting and recovery phases at Danum Valley, Sabah.

Ten years' hydrological investigations at Danum have provided strong evidence of the effects of extremes of drought, as in the April 1992 El Niño southern oscillation event, and flood, as in January 1996. The 1.5 km2 undisturbed forest control catchment experienced a complete drying out of the stream for the whole 1.5 km of defined channel above the gauging station in 1992, but concentrated surface flow along every declivity from within a few metres of the catchment divide after the exceptional rains of 19 January 1996. Under these natural conditions, erosion is episodic. Sediment is discharged in pulses caused by storm events, collapse of debris dams and occasional landslips. Disturbance by logging accentuates this irregular regime. In the first few months following disturbance, a wave of sediment is moved by each storm, but over subsequent years, rare events scour sediment from bare areas, gullies and channel deposits. The spatial distribution of sediment sources changes with time after logging, as bare areas on slopes are revegetated and small gullies are filled with debris. Extreme storm events, as in January 1996, cause logging roads to collapse, with landslides leading to surges of sediment into channels, reactivating the pulsed sediment delivery by every storm that happened immediately after logging. These effects are not dampened out with increasing catchment scale. Even the 721 km2 Sungai Segama has a sediment yield regime dominated by extreme events, the sediment yield in that single day on 19 January 1996 exceeding the annual sediment load in several previous years. In a large disturbed catchment, such road failures and logging-activity-induced mass movements increase the mud and silt in floodwaters affecting settlements downstream. Management systems require long-term sediment reduction strategies. This implies careful road design and good water movement regulation and erosion control throughout the logging process.

Parsimonious modelling of water and suspended sediment flux from nested catchments affected by selective tropical forestry.

The ability to model the suspended sediment flux (SSflux) and associated water flow from terrain affected by selective logging is important to the establishment of credible measures to improve the ecological sustainability of forestry practices. Recent appreciation of the impact of parameter uncertainty on the statistical credibility of complex models with little internal state validation supports the use of more parsimonious approaches such as data-based mechanistic (DBM) modelling. The DBM approach combines physically based understanding with model structure identification based on transfer functions and objective statistical inference. Within this study, these approaches have been newly applied to rainfall-SSflux response. The dynamics of the sediment system, together with the rainfall-river flow system, were monitored at five nested contributory areas within a 44 ha headwater region in Malaysian Borneo. The data series analysed covered a whole year at a 5 min resolution, and were collected during a period some five to six years after selective timber harvesting had ceased. Physically based and statistical interpretation of these data was possible given the wealth of contemporary and past hydrogeomorphic data collected within the same region. The results indicated that parsimonious, three-parameter models of rainfall-river flow and rainfall-SSflux for the whole catchment describe 80 and 90% of the variance, respectively, and that parameter changes between scales could be explained in physically meaningful terms. Indeed, the modelling indicated some new conceptual descriptions of the river flow and sediment-generation systems. An extreme rainstorm having a 10-20 year return period was present within the data series and was shown to generate new mass movements along the forestry roads that had a differential impact on the monitored contributory areas. Critically, this spatially discrete behaviour was captured by the modelling and may indicate the potential use of DBM approaches for (i) predicting the differential effect of alternative forestry practices, (ii) estimating uncertainty in the behaviour of ungauged areas and (iii) forecasting river flow and SSflux in terrain with temporal changes in rainfall regime and forestry impacts.

Evaluating support services to seniors. A discussion of collaborative research.

The difficulties involved in attempting to turn collaboration into partnership are revealed in this article about the relationship between research funders and researchers, specifically government funders and university researchers. Some discussion revolves around the relationships between researchers and among the researchers, practitioners, and consumers. This article also discusses collaborative research relationships by using the evaluation of a support program to seniors as an illustration. Also addressed are how the research revealed the success of the program and the frustrations encountered when government would not act on the findings.

Health care service use by Chinese seniors in British Columbia, Canada.

This paper assesses whether the same factors are predictive of health service utilization among this ethnic group as is true of the general population of seniors. The data suggest that the health of Chinese elders is just as bad as other seniors, and their utilization is very similar. They have a strong preference for Western over Chinese medicine and for Western trained doctors over Chinese practitioners, and use services with Chinese staff, probably because of language. Similarly, the predictors of service use are strikingly similar to predictors revealed in utilization studies throughout the industrialized world. Ability to speak English, immigration history, and country of origin are unrelated to the use of these services. However, approximately half of Chinese seniors also engage in traditional Chinese care. Religious beliefs and a preference for traditional Chinese medicine are strongly predictive of the use of traditional care. It would appear that distinctive culture is related to the use of traditional care, but not the use of the western health care system.

Employer-based health insurance and seniors: the case of Bermuda.

This article examines the importance of economic factors in physician and other health service utilization among older adults living in Bermuda. Using data drawn from a national survey of 500 Bermudian elders, the findings reveal economic factors to be unrelated to the use of physician services directly, but to be significant determinants of the use of other health services. Need plus non-need factors are related to the use of both physician and other health services. The employer-based system does seem to provide universal access, but factors in addition to need influence the receipt of care.

The impact of cognitively impaired patients and shift on nursing assistant stress.

This study compared the stress experienced by nursing assistants (NAs) under four work conditions: high or low proportion of cognitively impaired patients and day or other shift. Five standard measures of caregiver stress served as the dependent variables in this study; burden, reaction to patient behaviors, workload, and two measures of burnout. A 2x2 multivariate analysis of variance found an interaction effect of type and shift on the stress measures. Univariate tests found that Burden and Depersonalization accounted for this effect. A further multivariate analysis of simple main effects found significant differences for each independent variable within each level of the other independent variable. Univariate analysis found that NAs who care for cognitively impaired patients on the day shift show significantly higher scores on specific stress measures. The article concludes with a discussion of how institutions can respond to the stresses faced by NAs who care for cognitively impaired patients.

Home care research: what does it tell us?

This article assesses the applied relevance of research on home care, reviewing the literature on predictors of use of home care services, the experience of receiving home care, and efficacy studies. Research to date informs us rather conclusively that functioning is a major predictor of use throughout the industrialized world, but does not inform us of the structural factors impacting on home care. Studies on the experience of home care, to date, have focused on program implementation issues, rather than more macro policy issues. Finally, efficacy studies by and large have not concluded that home care is less costly or necessarily better for the quality of life of seniors when compared with institutional care. This has led to questions about the raison d'être of home care. We do not have longitudinal research assessing the long-term preventive effects of home care.

Nursing assistant burnout and the cognitively impaired elderly.

This article employs the cognitive appraisal model to examine the experience of burnout in a random sample of nursing assistants (N = 245). The three subscales of Maslach's Burnout Inventory--Emotional Exhaustion, Personal Accomplishment, Depersonalization--serve as the dependent variables in this study. The study found that both stressor and appraisal variables influence feelings of burnout. The stressor variable, frequency of disturbing patient behaviors, best explained feelings of reduced Personal Accomplishment. The appraisal variable, reaction to patient behaviors, best explained Emotional Exhaustion and contributed to the explanation of reduced Personal Accomplishment. Age, minutes spent giving physical care, appraisal of work tasks, and reaction to patient behavior, explained Depersonalization. The study found support for the cognitive appraisal model in that appraisal played an important role in determining burnout. The article concludes with some suggestions for relief of nursing assistant burnout.

Implications of shifting health care policy for caregiving in Canada.

The health care system in Canada, like other industrialized countries, is undergoing a questioning and a change unlike any it has seen for many decades. This article begins with a brief description of the Canadian health care system, then discusses the shifts taking place in health care policy, the assumptions behind these shifts, and the choices that are being made. The current debate draws on knowledge about seniors and their caregivers. The shifts also have implications for caregiving, and these are examined. It is concluded that the new vision of an appropriate health care system that is emerging provides opportunity for greater recognition of and participation by caregivers. At the same time, however, it holds the danger that the burden of care will be shifted even more to their shoulders. It is not yet clear which direction it is going to take.

The role of support in alleviating stress among nursing assistants.

This paper provides a direct test of the buffering hypothesis that the negative effects of stressors (measured as burden, burnout, and perceived job pressure) on nursing assistants working in long-term care institutions are moderated by social support (at work and external to work). The buffering hypothesis was not confirmed, though some support for a main effects view was found. Social support at work, specifically training to work with residents with cognitive impairment, and support from family and friends can assist nursing assistants in dealing with burnout and perceived job pressure. However, major steps in alleviating burden, burnout, and perceived job pressure must be to decrease or change the workload and provide rewards on the job.

Living arrangements and sources of caregiving.

This study examined both the prevalence of different types of caregivers (in terms of the relation to the individual), and whether living with someone is more important for caregiving than the relation of an elder to an individual. Caregiving is examined in terms of IADL and emotional support. Analyses are conducted using three separate random samples of those who are married and living with a spouse, those who live alone, and those who live with nonspousal others in Winnipeg, Manitoba, Canada. The results confirm previous research pointing out that married people tend to receive assistance from their spouse. Among nonmarrieds, children are named most frequently as the primary caregiver. After children, however, those who live alone tend to receive assistance from friends, and those who live with nonspousal others receive assistance from siblings. The data further document the importance of the structural characteristic of living with someone, rather than marital status, for assistance with IADL.

Tenant resource coordinators: an experiment in supportive housing.

Supportive housing has been recognized as one option that allows older individuals to remain in the community. In this paper we examine the concept of a tenant resource coordinator (TRC) within an elderly persons' housing unit to link social and health services with housing as a type of supportive housing. Findings suggest that the TRC functions to convey information about services to tenants and vice versa. As such, the TRC fulfills the role of facilitator between two existing systems, community services and housing.

Social isolation and well-being.

We examined 10 common indicators of social isolation and assessed which, if any, are related to subjective well-being among elderly individuals. The quantitative measures (no daily contact and minimal weekly contact), no children, having no children plus being unmarried, and having no children plus living alone, were unrelated to either global happiness or life satisfaction. The combined indicators of living alone and being unmarried as well as single indicators of having no companions or having no confidants were related at the bivariate level to both measures of well-being. When controlling for demographic, economic, and health factors, having no confidants and no companions were significantly and independently related to subjective well-being. These findings suggest that practitioners who seek information on living arrangements or marital status as proxy measures of lower psychological well-being are utilizing the wrong predictors.