Surgery for endometriomas before IVF: what are the benefits and risks?

Endometriosis is present in up to one-third of infertility patients. In a subset of these patients, work-up will reveal the presence of an endometrioma. When the endometrioma is causing pelvic pain or dysmenorrhea, removal can greatly improve pain and quality of life. However, in the patient preparing for an in-vitro fertilization (IVF) cycle removal of an endometrioma can delay treatment. It is critical to know the benefits and risk of such a procedure prior to proceeding with surgical endometrioma removal. A great deal of literature had been published on the effect of endometriomas on fertility and IVF outcomes. In this review, we will summarize the current literature addressing the effects of endometrioma removal on ovarian response and pregnancy rates following IVF.

The role of T helper type 17 cells in inflammatory arthritis.

While T cells have been implicated in the pathogenesis of inflammatory arthritis for more than three decades, the focus on the T helper type 17 (Th17) subset of CD4 T cells and their secreted cytokines, such as interleukin (IL)-17, is much more recent. Proinflammatory actions of IL-17 were first identified in the 1990s, but the delineation of a distinct Th17 subset in late 2005 has sparked great interest in the role of these cells in a broad range of immune-mediated diseases. This review summarizes current understanding of the role of Th17 cells and their products in both animal models of inflammatory arthritis and human immune-driven arthritides.

Effects of exercise intervention on myocardial function in type 2 diabetes.

OBJECTIVE: To identify the effects of a 1-year exercise intervention on myocardial dysfunction in patients with type 2 diabetes mellitus (T2DM). DESIGN: Randomised controlled trial, the Diabetes Lifestyle Intervention Study. SETTING: University hospital. PATIENTS: 223 T2DM patients without occult coronary artery disease, aged 18-75 were randomised to an exercise training group (n = 111) or a usual care group (n = 112). Complete follow-up data were available in 176 (88 exercise, 88 usual care). INTERVENTIONS: Exercise training consisted of gym, followed by telephone-monitored home-based exercise training. MAIN OUTCOME MEASURES: Tissue Doppler-derived myocardial velocities, strain-rate and strain, body composition, glycated haemoglobin (HbA(1c)), maximum oxygen consumption (VO(2max)) and physical activity. RESULTS: Overall changes in myocardial function were not different between groups despite improvements in waist circumference, fat mass, blood glucose, HbA(1c), insulin sensitivity, VO(2max) and 6-minute walk distance in the intervention group (p<0.05). The latter also spent significantly more time in vigorous activity (p<0.05). A post-hoc analysis revealed that intervention patients who spent more time in both moderate and vigorous activity showed a significant improvement in myocardial tissue velocity (p<0.01), HbA(1c) (p = 0.03) and VO(2max) (p = 0.03) compared to controls. Myocardial strain rate (p = 0.03) and HbA(1c) improved in intervention patients with the greatest increase in moderate activity (p = 0.03). CONCLUSIONS: In patients with T2DM, current exercise recommendations led to an improvement in metabolic function, but failed to improve myocardial function in the overall group. Patients with greater increases in both moderate and vigorous activity showed improvements in myocardial function, glycaemic control and cardiorespiratory fitness. TRIAL REGISTRATION NUMBER: ACTRN12607000060448.

Changes in risk factors for cardiovascular disease with body fat loss in obese women.

BACKGROUND: Current guidelines for obesity management emphasize the improvements in health risks associated with weight losses of 5-10% initial weight. However, most of the data is derived from periods of acute weight loss and may not represent the true effect in the longer term or in obese but otherwise healthy individuals. This study examines the temporal changes in risk factors for cardiovascular disease with weight change over 52 weeks. METHODS: In total, 57 overweight women (age 43.7 +/- 9.1 years, mean BMI of 31.7 kg/m2, range 27.2-38.5 kg/m2) with no other significant medical history, entered a milk-based, low-energy weight loss programme for 12 weeks and were then monitored without further intervention until 52 weeks. Weight, fat mass, fasting plasma insulin, lipids and blood pressure were measured at 0, 12, 24 and 52 weeks. RESULTS: The mean weight change in sequential periods was -11.6% (p < 0.0001), +1.1% (p = 0.02) and +5.2% (p < 0.0001). The change from baseline to 1 year being -6.0% (p < 0.0001) an 11% (p < 0.0001) reduction in initial body fat mass. Initial weight loss (0-12 weeks) was positively correlated with greater longer term weight loss (0-52 weeks, r = 0.75, p < 0.0001) and not with weight regain (12-52 weeks, r = 0.14, p = 0.28). Despite significant improvements in insulin sensitivity, lipid profile and blood pressure (BP) with acute weight loss, in the group overall, only benefits in BP were maintained after 52 weeks. However, improvements in insulin sensitivity were sustained in those who maintained more than 5% weight loss, and those with higher baseline metabolic risk had greater benefits with weight loss. Change in waist circumference was better than BMI or fat mass in predicting improvements in metabolic risk in these obese women. CONCLUSIONS: This study suggests, in otherwise apparently healthy obese women, the rationale of targeting individuals most likely to benefit from weight management. Most importantly it highlights the need to focus on achieving initial weight losses of greater than 10% to maintain longer term losses of at least 5% and the associated health benefits.

Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings.

BACKGROUND: Nurses play a key role in recognition of delirium, yet delirium is often unrecognized by nurses. Our goals were to compare nurse ratings for delirium using the Confusion Assessment Method based on routine clinical observations with researcher ratings based on cognitive testing and to identify factors associated with underrecognition by nurses. METHODS: In a prospective study, 797 patients 70 years and older underwent 2721 paired delirium ratings by nurses and researchers. Patient-related factors associated with underrecognition of delirium by nurses were examined. RESULTS: Delirium occurred in 239 (9%) of 2721 observations or 131 (16%) of 797 patients. Nurses identified delirium in only 19% of observations and 31% of patients compared with researchers. Sensitivities of nurses' ratings for delirium and its key features were generally low (15%-31%); however, specificities were high (91%-99%). Nearly all disagreements between nurse and researcher ratings were because of underrecognition of delirium by the nurses. Four independent risk factors for underrecognition by nurses were identified: hypoactive delirium (adjusted odds ratio [OR], 7.4; 95% confidence interval [CI], 4.2-12.9), age 80 years and older (OR, 2.8; 95% CI, 1.7-4.7), vision impairment (OR, 2.2; 95% CI, 1.2-4.0), and dementia (OR, 2.1; 95% CI, 1.2-3.7). The risk for underrecognition by nurses increased with the number of risk factors present from 2% (0 risk factors) to 6% (1 risk factor), 15% (2 risk factors), and 44% (3 or 4 risk factors; P(trend)<.001). Patients with 3 or 4 risk factors had a 20-fold risk for underrecognition of delirium by nurses. CONCLUSIONS: Nurses often missed delirium when present, but rarely identified delirium when absent. Recognition of delirium can be enhanced with education of nurses in delirium features, cognitive assessment, and factors associated with poor recognition.

The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program.

OBJECTIVES: To describe the Hospital Elder Life Program, a new model of care designed to prevent functional and cognitive decline of older persons during hospitalization. PROGRAM STRUCTURE AND PROCESS: All patients aged > or =70 years on specified units are screened on admission for six risk factors (cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment). Targeted interventions for these risk factors are implemented by an interdisciplinary team-including a geriatric nurse specialist, Elder Life Specialists, trained volunteers, and geriatricians--who work closely with primary nurses. Other experts provide consultation at twice-weekly interdisciplinary rounds. INTERVENTION: Adherence is carefully tracked. Quality assurance procedures and performance reviews are an integral part of the program. PROGRAM OUTCOMES: To date, 1,507 patients have been enrolled during 1,716 hospital admissions. The overall intervention adherence rate was 89% for at least partial adherence with all interventions during 37,131 patient-days. Our results indicate that only 8% of admissions involved patients who declined by 2 or more points on MMSE and only 14% involved patients who declined by 2 or more points on ADL score. Comparative results for the control group from the clinical trial were 26% and 33%, and from previous studies 14 to 56% and 34 to 50% for cognitive and functional decline, respectively. Effectiveness of the program for delirium prevention and of the program's nonpharmacologic sleep protocol have been demonstrated previously. CONCLUSIONS: These results suggest that the Hospital Elder Life Program successfully prevents cognitive and functional decline in at-risk older patients. The program is unique in its hospital-wide focus; in providing skilled staff and volunteers to implement interventions; and in targeting practical interventions toward evidence-based risk factors. Future studies are needed to evaluate cost-effectiveness and longterm outcomes of the program as well as its effectiveness in non-hospital settings.

Consequences of driving cessation: decreased out-of-home activity levels.

OBJECTIVES: Increasing age, socioeconomic factors, and declining function and health have been linked to driving cessation, but little is known about the consequences of stopping driving. This study was designed to test the hypothesis that driving cessation leads to a decline in out-of-home activity levels. METHODS: In 1989 a survey of driving practices was administered to surviving noninstitutionalized members of the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort. Of 1,316 respondents, 502 were active drivers as of 1988, 92 had stopped driving between 1982 and 1987, and 722 never drove or stopped before 1982. Information on sociodemographic and health-related variables came from in-home EPESE interviews in 1982, 1985, and 1988, and from yearly phone interviews. Activity was measured at all three in-home interviews, and an activity measure was created based on self-reported participation in nine out-of-home activities. A repeated measures random-effects model was used to test the effect of driving cessation on activity while controlling for potential confounders. RESULTS: Driving cessation was strongly associated with decreased out-of-home activity levels (coefficient-1.081, standard error 0.264, p < .001) after adjustment for sociodemographic and health-related factors. DISCUSSION: The potential consequences of driving limitations or cessation should be taken into account when advising older drivers and developing alternative transportation strategies to help maintain their mobility.

A multicomponent intervention to prevent delirium in hospitalized older patients.

BACKGROUND: Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium. METHODS: We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge. RESULTS: Delirium developed in 9.9 percent of the intervention group as compared with 15.0 percent of the usual-care group, (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 90, P=0.03) were significantly lower in the intervention group. However, the severity of delirium and recurrence rates were not significantly different. The overall rate of adherence to the intervention was 87 percent, and the total number of targeted risk factors per patient was significantly reduced. Intervention was associated with significant improvement in the degree of cognitive impairment among patients with cognitive impairment at admission and a reduction in the rate of use of sleep medications among all patients. Among the other risk factors per patient there were trends toward improvement in immobility, visual impairment, and hearing impairment. CONCLUSIONS: The risk-factor intervention strategy that we studied resulted in significant reductions in the number and duration of episodes of delirium in hospitalized older patients. The intervention had no significant effect on the severity of delirium or on recurrence rates; this finding suggests that primary prevention of delirium is probably the most effective treatment strategy.

Shoulder pain in older people.

Shoulder pain is encountered commonly in older people. Most of the conditions are amenable to nonoperative treatment, but a clear understanding of the anatomy and those conditions encountered most commonly is essential. A careful history and physical examination, as well as limited diagnostic tests, point to a clear diagnosis in the majority of patients. Most often, conservative measures are effective. Steroid injections are often helpful for both diagnostic and therapeutic reasons. A small percentage of patients do not respond to conservative management and require operative intervention.

Development of a test battery to identify older drivers at risk for self-reported adverse driving events.

OBJECTIVES: The purposes of this study were (1) to develop a battery of tests that assessed a wide range of functional abilities relevant to driving yet could be performed in a clinician's office and (2) to determine which of these tests were most closely associated with self-reported adverse driving events. DESIGN: A cohort study. SETTING: An urban community. PARTICIPANTS: Participants were drawn from the Project Safety cohort, a probability sample of noninstitutionalized older persons in New Haven, Connecticut, initiated in 1989. The current study included surviving, active drivers in the cohort (N=125). MEASURES: The test battery assessed visual, cognitive, and physical abilities potentially relevant to driving, and was administered in participants' homes by trained interviewers between October 1994 and July 1995. Outcome measures included the self-report of a crash, moving violation, or being stopped by police in any Project Safety interview since the inception of the cohort. Analyses compared performance on the elements of the test battery with participants' histories of adverse driving events. RESULTS: Of the 125 drivers, 50 (40%) had reported an adverse event in a mean period of 5.76 (+/-.25) years before the current interview. The elements of the test battery independently associated with a history of events, adjusting for driving frequency, included near visual acuity worse than 20/40 (adjusted odds ratio 11.90), limited neck rotation (OR 6.10), and poor performance on a test of visual attention, the number cancellation task (OR 3.00). The resulting regression equation yielded a sensitivity of 80%, a specificity of 55%, and an area under the curve of .75 by receiver operating characteristic analysis. CONCLUSION: These findings suggest it may be possible to identify individuals potentially at risk for self-reported adverse driving events using simple tests of functional ability. If validated, such an approach could be used to identify individuals who need a more detailed assessment of functional abilities to determine the severity and etiology of impairments, and their effect on driving performance, as well as possible interventions to correct or compensate for the impairments.

Self-report versus state records for identifying crashes among older drivers.

BACKGROUND: There is growing concern about the potential safety implications of the increasing number of older drivers. A primary consideration in determining risk is the method of outcome ascertainment. In the case of motor vehicle crashes, the two most common methods are self-report and state records of events. METHODS: The self-report of motor vehicle crashes was compared to state records among all active drivers (n = 358) in a representative cohort of community-living individuals age 72 years and older in New Haven, Connecticut, in 1989. In the baseline interview, participants who reported driving were asked if they had had any crashes in the previous year. This was compared to state-recorded crashes over the same period. RESULTS: Of the 358 drivers, 33 either reported or had a state record of a crash in the previous year. Of the 33, 20 were identified by self-report only, 9 by both self-report and state records, and 4 by state records only. In the two cases where license reexamination was requested by the officer at the scene, both drivers reported the event in the interview. CONCLUSIONS: Self-report and state records provide complementary information for the ascertainment of crashes among older drivers, although in this sample self-report yielded more events.

Driving cessation and increased depressive symptoms: prospective evidence from the New Haven EPESE. Established Populations for Epidemiologic Studies of the Elderly.

OBJECTIVES: The purpose of this study was to determine the association between driving cessation and depressive symptoms among older drivers. Previous efforts in this area have focused on the factors associated with cessation, not the consequences of having stopped. DESIGN: Cohort study. SETTING: Urban community. PARTICIPANTS: A driving survey was administered in 1989 to surviving noninstitutionalized members of the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort. Of 1316 respondents, 502 were active drivers as of 1988, 92 had stopped driving between 1982 and 1987, and the remainder had either never driven or had stopped before 1982. MEASUREMENTS: Information about independent and dependent variables other than driving status came from the in person EPESE interviews in 1982, 1985, and 1988, except for medical conditions, which were updated yearly. Depressive symptoms were assessed by the Centers for Epidemiologic Studies-Depression (CES-D) scale. Analyses focused on the changes in depressive symptoms before and after driving cessation. Repeated measures multivariable analysis accounted for the effect of cessation on the outcome adjusting for the potential confounding due to sociodemographic and health-related factors. RESULTS: Individuals who stopped driving exhibited substantial increases in depressive symptoms during the 6-year interval. Driving cessation was among the strongest predictors of increased depressive symptoms (Coefficient 2.464, SE 0.758, P = .001) even when adjusting for sociodemographic and health-related factors. CONCLUSIONS: Driving cessation was associated with an increase in depressive symptoms even when accounting for sociodemographic and health-related factors. These consequences need to be taken into account when advising older drivers and when developing alternative transportation strategies.

Predictors of automobile crashes and moving violations among elderly drivers.

OBJECTIVE: To identify the factors associated with automobile crashes, moving violations, and being stopped by police in a cohort of elderly drivers. DESIGN: Prospective cohort study. SETTING: Urban community. PARTICIPANTS: All 283 persons who drove between 1990 and 1991, selected from a representative cohort of community-living persons aged 72 years and older in New Haven, Connecticut. MEASUREMENTS: Data on independent variables in five domains (demographic, health, psychosocial, activity, and physical performance) were collected in structured interviews before events occurred. The outcome measure was the self-report of involvement in automobile crashes, moving violations, or being stopped by police in a 1-year period. RESULTS: Of the 283 drivers, 13% reported a crash, a moving violation, or being stopped by police in 1 year. The baseline factors associated with the occurrence of adverse events in multivariable analysis (with adjustment for driving frequency and housing type) were the following: poor design copying on the Mini-Mental State Examination (relative risk, 2.7; 95% CI, 1.5 to 5.0), fewer blocks walked (relative risk, 2.3; CI, 1.3 to 4.0), and more foot abnormalities (relative risk, 1.9; CI, 1.1 to 3.3). These risk factors were combined for assessment of their ability to predict the occurrence of adverse driving events. If no factors were present, 6% of drivers had events; if 1 factor was present, 12% had events; if 2 factors were present, 26% had events; and if 3 factors were present, 47% had events. CONCLUSIONS: In this urban population, several simple clinical measures correlated with the risk for adverse driving events.

Predictors of mortality and institutionalization after hip fracture: the New Haven EPESE cohort. Established Populations for Epidemiologic Studies of the Elderly.

OBJECTIVES: Hip fractures can have devastating effects on the lives of older individuals. We determined the frequency of occurrence of hip fracture and the baseline factors predicting death and institutionalization at 6 months after hip fracture. METHODS: A representative cohort of 2812 individuals aged 65 years and older was followed prospectively for 6 years. Hip fractures were identified, and the occurrence of death and institutionalization within 6 months of the fracture was determined. Prefracture information on physical and mental function, social support, and demographic features and in-hospital data on comorbid diagnoses, fracture site, and complications were analyzed to determine predictors of death and institutionalization after hip fracture. RESULTS: Of 120 individuals suffering a hip fracture, 22 (18%) died within 6 months and 35 (29%) were institutionalized at 6 months. The predictors of death in multiple logistic regression included fracture site, a high number of comorbid conditions, a high number of complications, and poor baseline mental status. The primary predictor of institutionalization was poor baseline mental status. CONCLUSIONS: The frequency of death, institutionalization, and loss of function after hip fracture should prompt a reevaluation of the current approach to this problem.

The Yale Geriatric Care Program: a model of care to prevent functional decline in hospitalized elderly patients.

OBJECTIVE: To describe the structure and implementation of the Yale Geriatric Care Program, an innovative, nursing-centered model for developing geriatric nursing expertise throughout an acute-care hospital. DESIGN: Descriptive study of an intervention in a prospective cohort of patients. SETTING: University teaching hospital. PATIENTS: Two hundred forty four patients aged 70 years and older on four non-intensive care intervention units during the study period (July 9, 1990 to July 31, 1991). INTERVENTION: The Geriatric Care Program involved an integrated model of primary nurses, specially trained unit-based geriatric resource nurses, gerontological nurse specialists, and geriatric physicians. The intervention included surveillance and identification of frail older patients, unit-based geriatric educational programs for all nurses, special education and support for the geriatric resource nurses, and twice-weekly rounds of the Geriatric Care Team. RESULTS: The Geriatric Care Program has been successfully implemented on four units. The interventions ranged from general clarification of goals in 226 (92%) to specific recommendations for management of immobility in 100 (41%), bladder/bowel problems in 99 (41%), pressure ulcer treatment or prevention in 61 (25%), confusion evaluation or management in 62 (25%), and adjustment of medications in 43 (18%). Overall, 68% of the specific recommendations were documented to have been implemented. Barriers to implementation of the program have included initial difficulties with recruitment and retainment of geriatric resource nurses (due to high nursing turnover and the increased time commitment required), breakdown in communication and carryover of recommendations between nursing shifts, and obstacles to communication between the nursing and medical staff. CONCLUSIONS: An innovative model of care, in which geriatric nursing was integrated as part of standard nursing care on selected medical and surgical units, has been designed and implemented. Evaluation of the effectiveness and costs of this intervention are currently underway.

A controlled trial of a nursing-centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program.

OBJECTIVE: To test the effectiveness of a nursing-centered intervention to prevent functional decline among hospitalized elderly medical patients. DESIGN: Prospective cohort study with stratified and matched cohort analyses. SETTING: General medicine wards of a university teaching hospital. PATIENTS: Two hundred sixteen patients aged > or = 70 years (85 intervention and 131 control patients). INTERVENTION: The intervention included identification and surveillance of frail older patients, twice-weekly rounds of the Geriatric Care Team, and a nursing-centered educational program. MAIN OUTCOME MEASURE: Functional decline, defined as a net decline in five activities of daily living (ADLs). RESULTS: In stratified analyses, the intervention resulted in a beneficial effect with a relative risk of 0.82 (95% confidence interval [CI] 0.54 to 1.24) in patients (n = 106) with one of four geriatric target conditions at baseline (eg, delirium, functional impairment, incontinence, and pressure sores). The intervention had no effect in patients without target conditions at baseline (n = 110); thus, this subgroup was excluded from further analyses. When patients were matched on number of target conditions and risk for functional decline at baseline (n = 66), the intervention resulted in a significant beneficial effect, with a reduction in functional decline from 64% in controls to 41% in the intervention group, for a relative risk of 0.64 (95% CI, 0.43 to 0.96). The intervention group had significantly less decline in ADL score and in individual ADLs than control subjects. Specific interventions aimed at maximizing function, such as physical therapy, were received more often by intervention patients; however, the beneficial effects of the intervention were achieved without increasing per-day hospital costs. CONCLUSIONS: The intervention appears effective to decrease functional decline in targeted elderly hospitalized medical patients.