How well are the diagnosis and symptoms of dementia recorded in older patients admitted to hospital?

Introduction: In the United Kingdom dementia is generally diagnosed by mental health services. General hospitals are managed by separate healthcare trusts and the handover of clinical information between organisations is potentially unreliable. Around 40% of older people admitted to hospital have dementia. This group have a high prevalence of psychological symptoms and delirium. If the dementia diagnosis or symptoms are not recognised, patients may suffer unnecessarily with resulting negative outcomes. Methods: To understand areas of unmet need we have described the prevalence of dementia in over 75 year olds admitted to a general hospital, the accuracy of diagnostic recording, and the prevalence of recorded psychological symptoms and delirium. To achieve this we conducted a retrospective review of 116 patients admitted to hospital with known dementia. Psychiatric and medical notes were reviewed, identifying the accuracy dementia diagnosis recording by the hospital and all episodes of documented psychological symptoms and delirium. Results: The prevalence of documented dementia in the population was estimated at 15%; 74% of dementia diagnoses were recorded in the medical notes; 10% had documented psychological symptoms (depression 4%, anxiety 3%, hallucinations 3%, delusions 4%); and 11% had documented delirium. There were no associations between the specialty providing care and the recognition of dementia or the reporting of symptoms. Discussion: This work suggests an under reporting of dementia and symptoms associated with it in the general hospital. Improving this requires closer collaboration between metal health and hospital healthcare services and training for staff on how to access diagnostic information and recognise common psychological symptoms.

Sensing iron availability via the fragile [4Fe-4S] cluster of the bacterial transcriptional repressor RirA.

Rhizobial iron regulator A (RirA) is a global regulator of iron homeostasis in many nitrogen-fixing Rhizobia and related species of α-proteobacteria. It belongs to the widespread Rrf2 super-family of transcriptional regulators and features three conserved Cys residues that characterise the binding of an iron-sulfur cluster in other Rrf2 family regulators. Here we report biophysical studies demonstrating that RirA contains a [4Fe-4S] cluster, and that this form of the protein binds RirA-regulated DNA, consistent with its function as a repressor of expression of many genes involved in iron uptake. Under low iron conditions, [4Fe-4S] RirA undergoes a cluster conversion reaction resulting in a [2Fe-2S] form, which exhibits much lower affinity for DNA. Under prolonged low iron conditions, the [2Fe-2S] cluster degrades to apo-RirA, which does not bind DNA and can no longer function as a repressor of the cell's iron-uptake machinery. [4Fe-4S] RirA was also found to be sensitive to O2, suggesting that both iron and O2 are important signals for iron metabolism. Consistent with this, in vivo data showed that expression of RirA-regulated genes is also affected by O2. These data lead us to propose a novel regulatory model for iron homeostasis, in which RirA senses iron via the incorporation of a fragile iron-sulfur cluster that is sensitive to iron and O2 concentrations.

Noninvasive positive pressure ventilation for acute respiratory failure in delirious patients: understudied, underreported, or underappreciated? A systematic review and meta-analysis.

BACKGROUND: We performed a systematic review and meta-analysis of the literature to determine the prevalence of delirium in patients receiving noninvasive positive pressure ventilation (NPPV) for acute respiratory failure and to quantify the prognostic impact of delirium with respect to NPPV failure. METHOD: We searched the databases EMBASE (1996 to present), MEDLINE (1996 to present), PsycINFO(®) (2002 to present) and CINAHL (1992 to present). A Google™ search and hand searching of bibliographies or relevant articles were also performed. We searched for prospective observational studies conducted in a setting where patients with acute respiratory failure receiving NPPV were screened for delirium. All authors independently assessed references for inclusion and extracted data. Information was collated regarding study design, baseline characteristics of included patients, and the prevalence of delirium. Where prognostic information regarding NPPV failure was reported, a risk ratio for the association between delirium and NPPV failure was derived. These values were pooled in the meta-analysis. RESULTS: Three articles were retrieved by the search strategy. These included 239 patients receiving noninvasive ventilation who were assessed for delirium. The prevalence of delirium was recorded at between 33 and 38 % with a pooled prevalence of 37 %. Two studies reported prognostic data and the risk ratios for noninvasive ventilation failure in delirium were calculated as 1.79 (95 % CI 1.09-2.94) and 3.28 (95 % CI 1.60-6.73). A meta-analysis was performed and the pooled risk ratio was found to be 2.12 (95 % CI 1.41-3.18). CONCLUSIONS: The data in this context was scarce and of low quality. A diagnosis of delirium was made in 9 patients and inferred in 80. Despite the current lack of high-quality data and studies, the high reported prevalence of delirium and the association with noninvasive ventilation failure lends support for more awareness amongst health-care professionals and more routine screening. More focused primary research is necessary in this area. Adherence to NICE guidelines regarding delirium in these patients should be a standard of care.

Sickness presenteeism in a New Zealand hospital.

AIMS: The aim of this study was to assess the attitudes of hospital clinical staff to acute personal illness. METHODS: A self-reported questionnaire was developed. Four hundred clinical staff employed by the district health board (DHB) who met the inclusion criteria who were randomly selected. Data were collected and analysed using SPSS software. Ethical approval was obtained from the Lower South Regional Ethics Committee and from the DHB Health Research Office. RESULTS: Doctors were more likely to exhibit sickness presenteeism (SP)--i.e. working despite being sick--than any other occupational group at the DHB. Two main reasons were given for not taking sick leave: staff did not believe they were unwell enough to justify taking leave and they did not want to increase the workload of others. The majority of study participants would not contact anyone for advice about whether to take leave. CONCLUSION: This study provides evidence that SP, especially in doctors, is prevalent in the DHB and is similar to findings from elsewhere. Low rates of clinical staff contacting someone for advice on coming to work whilst ill could be targeted to improve infection control.

Plasma angiotensin-converting enzyme in Alzheimer's disease.

The insertion allele in the gene encoding angiotensin-converting enzyme (ACE) is a risk factor for Alzheimer's disease (AD) and ACE is one of several peptidases that have the ability to degrade the neurotoxic amyloid-beta peptide. ACE is a membrane-bound peptidase that is also present in a soluble form in plasma as a result of a zinc metalloprotease-mediated shedding event. Here we aimed to determine whether there is a difference in ACE in the plasma of late-onset clinically diagnosed AD patients (n = 94) as compared to age-matched non-demented control subjects (n = 188). Plasma ACE was lower in the AD subjects as compared to the controls both at baseline (p = 0.072) and after two years (p = 0.05). There was a greater reduction in plasma ACE in the AD subjects as compared to the control subjects over the two years. Plasma ACE did not correlate with cognitive function. The observed reduction in plasma ACE in AD may reflect a general decrease in the zinc metalloprotease-mediated shedding of a subset of membrane-bound proteins.

Nail gun injuries to the hand.

BACKGROUND: Aberdeen Royal Infirmary is a teaching hospital serving a population of over 500,000. A number of nail gun injuries to the hand prompted a review of our management of these injuries and a review of the literature. These are deep penetrating injuries, often contaminated by particles of skin, oil, paper or glue, or caused by nails that are barbed. METHODS: Fifty-five cases of nail gun injury to the hand were reviewed in a retrospective study of injuries presenting to the hospital between January 2000 and June 2004. RESULTS: The population at risk is almost entirely men and involved in the construction industry. Twenty-five percent of cases were found to have tendon, nerve or joint involvement at operation. None of the injuries required anything more than meticulous wound toilet. CONCLUSIONS: To our knowledge, this is the first large study to clinically document the actual hand injuries caused by nail guns. An analysis of our treatment patterns suggests a low risk from surgical exploration with several potential benefits.

Increased circulating insulin-like growth factor-1 in late-onset Alzheimer's disease.

BACKGROUND: Insulin-like growth factor (IGF)-1 has been implicated in the pathogenesis of Alzheimer's disease (AD). METHODS: We compared the level of circulating total and bioavailable IGF-1, by simultaneous measurements of IGF-1 and IGF binding protein (IGFBP)-3, between 87 patients diagnosed with AD and 126 age and sex matched control subjects without cognitive impairment. Blood samples were collected and IGF-1 and IGFBP-3 measured by ELISA. Subjects were also genotyped for apolipoprotein E. RESULTS: Total circulating IGF-1 levels were significantly raised in the AD group as compared to the control group (p=0.022). There was no significant difference in the circulating level of IGFBP-3 between the two groups. When the IGF-1 levels were ratioed against IGFBP-3 levels as an indicator of unbound, bioavailable circulating IGF-1, there was a significant increase in the molar IGF-1:IGFBP-3 ratio in the AD subjects (0.181 +/- 0.006) as compared to the controls (0.156 +/- 0.004) (p< 0.001). Logistic regression analysis revealed that an increase in the IGF-1:IGFBP-3 molar ratio increased the risk of AD significantly. CONCLUSION: The results of increased total and free circulating IGF-1 support the hypothesis that in its early stages late-onset AD reflects a state of resistance to IGF-1.

Occurrence and outcome of delirium in medical in-patients: a systematic literature review.

BACKGROUND: Despite the acknowledged clinical importance of delirium, research evidence for measures to improve its management is sparse. A necessary first step to devising appropriate strategies is to understand how common it is and what its outcomes are in any particular setting. OBJECTIVE: To determine the occurrence of delirium and its outcomes in medical in-patients, through a systematic review of the literature. METHOD: We searched electronic medical databases, the Consultation-Liaison Literature Database and reference lists and bibliographies for potentially relevant studies. Studies were selected, quality assessed and data extracted according to preset protocols. RESULTS: Results for the occurrence of delirium in medical in-patients were available for 42 cohorts. Prevalence of delirium at admission ranged from 10 to 31%, incidence of new delirium per admission ranged from 3 to 29% and occurrence rate per admission varied between 11 and 42%. Results for outcomes were available for 19 study cohorts. Delirium was associated with increased mortality at discharge and at 12 months, increased length of hospital stay (LOS) and institutionalisation. A significant proportion of patients had persistent symptoms of delirium at discharge and at 6 and 12 months. CONCLUSION: Delirium is common in medical in-patients and has serious adverse effects on mortality, functional outcomes, LOS and institutionalisation. The development of appropriate strategies to improve its management should be a clinical and research priority. As delirium prevalent at hospital admission is a significant problem, research is also needed into preventative measures that could be applied in community settings.

Recovery of the Decorin-Enriched Fraction, Extract (D), From Human Skin: An Accelerated Protocol.

The original extraction procedure of Engel and Catchpole [1] has often been used to recover decorin-enriched material from the skin. This material has a strong inhibitory effect on fibroblast proliferation, and clearly suppresses it in skin except after the first 5-6 days of wounding when new scaffold material is required. The aim of our present study has been to find and evaluate the product of a faster recovery method, and to check its consistency as a more reliable means of regularly obtaining sufficient material for topical application in wounds that might become hypertrophic. Modifications of the original Toole and Lowther [2] extraction procedure have been carefully evaluated in an attempt to cut preparation time without compromising biological activity of the inhibitory extract. We have devised a faster recovery procedure without compromising biological activity, even if initial recovery has been somewhat reduced. The latter problem could be offset by repeated cycles of the final extraction step. The main inhibitory activity is shown to be within the decorin-enriched "extract D," as the core protein and DSPG II. Adjustment of the extract towards neutrality after dialysis against water keeps most of the extracted protein in solution and yielded a decorin-enriched preparation that had a specific activity equivalent to that of the old method. It also yielded a fraction that was readily lyophilised to give a small amount of material that could be stored indefinitely without loss of activity and readily redissolved in aqueous solution. A reliable and relatively quick method is presented for the production, from human skin, of a decorin-enriched preparation that has strong fibroblast inhibitory action. The value of the procedure is that it is inexpensive and can produce the quantities that might be used topically in reducing hypertrophic scarring of wounds.