Debate: Should the elderly receive thrombolytic therapy or primary angioplasty?

Thrombolysis and primary angioplasty are both recommended reperfusion strategies for elderly patients presenting with myocardial infarction (MI). Primary angioplasty is most beneficial in high-risk patients. While the elderly have a high absolute risk of dying or developing complications after MI, they also have an increased risk of intracranial haemorrhage if they are given thrombolytic therapy. It could therefore be reasonably argued that primary angioplasty is the reperfusion strategy of choice in the elderly. However, primary angioplasty has not been shown to have a greater relative benefit than thrombolytic therapy in the elderly. Recent data from the Fibrinolytic Therapy Trialists' (FTT) Collaborative Group show that thrombolytic therapy significantly reduces mortality compared with control treatment in patients over 75 years of age presenting within 12 h of symptom onset, with ST-segment elevation or bundle branch block. Future advances in adjunctive therapies may improve myocyte perfusion and hence the outcomes achieved by both invasive and noninvasive reperfusion strategies. Better thrombolytic regimens incorporating adjunctive agents such as bivalirudin may reduce the risk of intracranial haemorrhage. Few hospitals can provide a 24-h primary angioplasty service with door-to-balloon times consistently less than 90 min, and thrombolytic therapy is therefore a far more practical option in most instances.     

Domiciliary care for the elderly sick--economy or neglect?

This paper reports an investigation of the costs of domiciliary care for 139 elderly sick patients under the care of the home nursing service. The data suggest that there may be little economic advantage in home care for seriously disabled elderly people. The revenue cost of domiciliary care was equal to or greater than the average associated with residential or hospital custodial care in such patients. Even so, the cost of services received at home did not disclose the real need for domiciliary care, since at present this is obscured by compulsory rationing and the separation of responsibility between health and social services. It is suggested that the supposed economic advantage of domiciliary care will depend increasingly on restricting such services, thus increasing the degree of neglect to some patients.     

Predator odor recognition and antipredatory response in fish: does the prey know the predator diel rhythm?

We studied in a laboratory experiment using stream tanks if two percid prey fish, the perch (Perca fluviatilis) and the ruffe (Gymnocephalus cernuus), can recognize and respond to increased predation risk using odors of two piscivores, the pike (Esox lucius) and the burbot (Lota lota). Burbot is night-active most of the year but pike hunts predominantly visually whenever there is enough light. Perch is a common day-active prey of pike and dark-active ruffe that of burbot. We predicted that besides recognizing the predator odors, the prey species would respond more strongly to odors of the predator which share the same activity pattern. Both perch and ruffe clearly responded to both predator fish odors. They decreased movements and erected the spiny dorsal fins. Fin erection showed clearly the black warning ornamentation in the fin and thus erected fin may function besides as mechanical defense also as warning ornament for an approaching predator. No rapid escape movements were generally observed. Both perch and ruffe responded more strongly to pike odor than to burbot. There were no clear differences in response between day and night. In conclusion, we were able to verify clear predator odor recognition by both prey fish. Both perch and ruffe responded to both predator odors and it seemed that pike forms a stronger threat for both prey species. Despite of diel activity differences both perch and ruffe used the same antipredatory strategies, but the day-active perch seemed to have a more flexible antipredatory behavior by responding more strongly to burbot threat during the night when burbot is active.     

Male care in primates: does it ever reflect paternity?

Female mammals have internal fertilization, long gestation, and lactation. These basic facts of reproductive biology have important social consequences. Internal fertilization (accompanied by sperm competition) forces males either to face considerable uncertainty about paternity or to invest heavily in mate guarding. Long gestation increases the benefits of mate desertion for males. And because only females lactate, males have relatively less to contribute to rearing the young. Hence, it is not surprising that male mammals rarely assist their mates in caring for their young: Direct infant care by males occurs in fewer than 5 percent of all mammalian species.^1,2 In fact, many mammalian mothers attack males, even possible father of their offspring.³     

Tolerating herbivory: does the plant care if the herbivore has a backbone?

Differences in size-related ecology and behaviour between vertebrate and invertebrate herbivores lead to differences in the rates, tissue specificity, and spatial distribution of their damage, as well as in their indirect effects. As a result, many features of tolerance to herbivory by these groups also may differ. Tolerating vertebrate herbivory may demand the ability to tolerate sporadic non-specific impacts; this may be achieved by broad responses promoting regrowth and resource acquisition. In contrast, the diversity of different types of invertebrate damage seems likely to demand a correspondingly great variety of responses. These conclusions suggest that tolerance to invertebrates may involve a broader set of responses than tolerance to vertebrates; conversely, the greater specificity of these responses may make it more difficult for arthropod-tolerant plants to achieve cross-tolerance to other types of damage. This revised version was published online in July 2006 with corrections to the Cover Date.     

Separation of housing and care: more or less care? Consequences for health care services utilization by the elderly

The Dutch policy for the care of the elderly has been mainly characterised by the aim to improve the possibility for elderly people to live independently for as long as possible. One measure that has been taken to achieve this goal is the separation of the financing of care from the accommodation in which care is given. Recent discussions have brought to light some possible positive and negative effects of this separation on the use of care. It is, however, largely unknown to what extent there are differences concerning the nature and intensity of care and the type of caregivers provided to dwellers of houses where care and housing are separated (so-called 'life-time houses') and the elderly who live in homes for residential care and nursing homes. To gain insight in this matter an explorative study was conducted in Rotterdam of the use of several health facilities by matching 35 dwellers of 'life-time houses' on the criteria age, health needs and social status with 35 dwellers of residential care homes and nursing homes. On the basis of interviews, questionnaires and patient records data were collected and analysed on the nature and amount of help that has been given (per minute per week) and the kind of caregiver. The main finding is that the use pattern differs between the research groups. Dwellers of 'life-time houses' generally make more use of some care facilities and make more use of different types of care and caregivers. These differences however do not seem to be exclusively caused by the separation of housing and care.     

CBO guidelines to prevent accidental falls in the elderly: how can it be used in the institutionalized elderly?

Fall incidents occur frequently in the community dwelling elderly and even more in the institutionalised elderly. Fall-related research data indicate positive effects of a multifactorial intervention targeted on prevention of falls and fall-related injuries. In November 2004 the guideline "Prevention of fall incidents in the elderly" developed by The Dutch Institute for Healthcare Improvement (CBO) was published. This guideline pays attention to the risk factors for falling and the prevention of fall incidents in all settings. The highlights for nursing homes are: all nursing home patients are at risk; perform a fall risk assessment to direct fall preventive activities; together with specific fall prevention for the patient general fall prevention for the institute has to be undertaken; a multifactorial approach is indicated. In nursing homes it is possible to perform such approach multidisciplinary.     

What does the public want to know in the event of a terrorist attack using plague?

We used formative research to assess the information needs and information-seeking strategies with general public audience segments in response to a hypothetical attack using plague, and we pretested informational materials about plague. Twelve focus groups were conducted across the country, with 129 individuals being purposively sampled by ethnicity and place of residence. Across groups, participants wanted to understand: the nature of the threat of plague, how to protect themselves from transmission, how to detect exposure and symptoms, how to treat infection, and progress in apprehending perpetrators. Participants reported that they would seek information from both the news media and local authorities. Based on the findings and the challenges posed by a terrorist attack using plague, the authors recommend that message materials answer key questions, provide clear action steps, be clear and easily understood, include sources for credibility, and reflect full government disclosure. A dissemination plan is required to ensure that critical information will be available when people need it and where they look.     

Regeneration in the metazoans: why does it happen?

Why does regeneration occur? And why, when it manifests itself, does it do so in some but not all metazoan species? Hence, what are the permissive or inhibitory factors operating behind this phenomenon? When it comes to regeneration, many questions, such as these, remain unanswered. In fact, the problem of animal regeneration has withstood the probing of scientific inquiry for over 250 years and still awaits a satisfactory mechanistic explanation. In this essay, I will review the distribution and the modes of regeneration that are found in the different metazoan phyla. Also, I will re-examine ideas on its evolutionary origins, and discuss its possible relationship to both asexual reproduction and embryogenesis. This endeavor has two objectives. First, to bring forward an interpretation of regeneration which integrates evolutionary and developmental considerations into its discussion. And second, to suggest a comparative experimental approach to this problem that may bring us closer to understanding the molecular basis of this long-standing biological problem. BioEssays 22:578-590, 2000.