Inappropriate Drugs in Elderly Patients with Severe Cognitive Impairment: Results from the Shelter Study

Background

It has been estimated that Nursing Home (NH) residents with impaired cognitive status receive an average of seven to eight drugs daily. The aim of this study was to determine prevalence and factors associated with use of inappropriate drugs in elderly patients with severe cognitive impairment living in NH in Europe.

Methods

Cross-sectional data from a sample of 1449 NH residents with severe cognitive impairment, participating in the Services and Health for Elderly in Long TERm care (SHELTER) study were analysed. Inappropriate drug use was defined as the use of drugs classified as rarely or never appropriate in patients with severe cognitive impairment based on the Holmes criteria published in 2008.

Results

Mean age of participating residents was 84.2±8.9 years, 1087 (75.0%) were women. Inappropriate drug use was observed in 643 (44.9%) residents. Most commonly used inappropriate drugs were lipid-lowering agents (9.9%), antiplatelet agents (excluding Acetylsalicylic Acid – ASA –) (9.9%), acetylcholinesterase, inhibitors (7.2%) and antispasmodics (6.9%). Inappropriate drug use was directly associated with specific diseases including diabetes (OR 1.64; 95% CI 1.21–2.24), heart failure (OR 1.48; 95% CI 1.04–2.09), stroke (OR 1.43; 95% CI 1.06–1.93), and recent hospitalization (OR 1.69; 95% CI 1.20–2.39). An inverse relation was shown between inappropriate drug use and presence of a geriatrician in the facility (OR 0.55; 95% CI 0.39–0.77).

Conclusion

Use of inappropriate drugs is common among older EU NH residents. Determinants of inappropriate drug use include comorbidities and recent hospitalization. Presence of a geriatrician in the facility staff is associated with a reduced rate of use of these medications.     

Enhancement of TCE Attenuation in Soils by Natural Amendments

The objective of this study was to identify low-cost natural amendments that could be used as carbon sources and sustain a bioactive zone to promote biodegradation of TCE in contaminated shallow groundwater. The natural amendments were compared based on their geophysical characteristics as well as TCE adsorption capacities. The amendments studied included low-cost natural and agricultural materials such as eucalyptus tree mulch, pine bark mulch, muck from the Florida Everglades, SRS wetland peat, commercial compost, and peat humus. These natural substrates have relatively high organic fractions that can retard the movement of TCE while serving as carbon sources. Batch sorption studies were conducted to determine the sorption and retardation characteristics of the amendments for TCE. The experimental results were analyzed in relation to the geophysical characteristics of the amendments and compared with those of natural soils.     

Photon transmission study on swelling of kappa-carrageenan gels prepared in various concentrations

κ-Carrageenan gels prepared with various carrageenan concentrations in pure water were completely dried and then swelled in pure water. Photon transmission measurements were performed using a UV-Vis (UVV) spectrometer during the swelling of κ-carrageenan gels. Transmitted photon intensity, I_tr, increased exponentially as swelling time is increased for all gel samples. The behaviour of I_tr was interpreted by Monte-Carlo Simulation. The increase in I_tr was quantified by employing Li-Tanaka equation, from which time constants τ₁ and collective diffusion coefficients, D_o were determined for the gels in various carrageenan concentrations. Gravimetric and volumetric measurements were also carried out during swelling of gels. It is observed that gel with high carrageenan content possess more double helices and more lattice dislocations and swell slower than gels with low carrageenan content which may contain less double helices and less lattice imperfections. Increase in I_tr was interpreted by the homogeneous distribution of double helices in the carrageenan gel system.     

4'-deoxy iridoid glycosides from Centranthus longiflorus

The new iridoid glycosides, 4'-deoxykanokoside A and 4'-deoxykanokoside C, were isolated from the methanolic root extract of Centranthus longiflorus ssp. longiflorus. They were accompanied by the three known iridoid glycosides, kanokoside A, kanokoside C and valerosidatum, and two known phenylpropanoid glycosides, coniferin and isoconiferinoside. The structures were elucidated mainly by spectroscopic methods. The presence of 4-deoxy glucose as a part of plant glycosides is rather unusual. Cytotoxic effects of the isolated compounds were also investigated.     

T cells require TRAIL for optimal graft-versus-tumor activity

Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is a member of the TNF superfamily that exhibits specific tumoricidal activity against a variety of tumors. It is expressed on different cells of the immune system and plays a role in natural killer cell-mediated tumor surveillance. In allogeneic hematopoietic-cell transplantation, the reactivity of the donor T cell against malignant cells is essential for the graft-versus-tumor (GVT) effect. Cytolytic activity of T cells is primarily mediated through the Fas-Fas ligand and perforin-granzyme pathways. However, T cells deficient for both Fas ligand and perforin can still exert GVT activity in vivo in mouse models. To uncover a potential role for TRAIL in donor T cell-mediated GVT activity, we compared donor T cells from TRAIL-deficient and wild-type mice in clinically relevant mouse bone-marrow transplantation models. We found that alloreactive T cells can express TRAIL, but the absence of TRAIL had no effect on their proliferative and cytokine response to alloantigens. TRAIL-deficient T cells showed significantly lower GVT activity than did TRAIL-expressing T cells, but no important differences in graft-versus-host disease, a major complication of allogeneic hematopoietic cell transplantation, were observed. These data suggest that strategies to enhance TRAIL-mediated GVT activity could decrease relapse rates of malignancies after hematopoietic cell transplantation without exacerbation of graft-versus-host disease.     

Correlation of serum tumor necrosis factor-alpha,interleukin-4 and soluble interleukin-2 receptor levels with radiologic and clinical manifestations in active pulmonary tuberculosis

The precise clinical manifestations of tuberculosis are likely to result from a complex interaction between the host and the pathogen. We took serum samples from a group of patients with a variety of clinical and radiological stages of pulmonary tuberculosis in order to characterize tumor necrosis factor-alpha (TNF-alpha), interleukin-4 (IL-4) and soluble interleukin-2 receptor (sIL-2R) response. We further evaluated whether the levels of TNF-alpha, IL-4 and soluble IL-2R are related with each other, and also evaluated the levels of TNF-alpha, IL-4 and sIL-2R after anti-tuberculosis therapy and relation with radiologic scores. Forty-three inpatients with active pulmonary tuberculosis and 19 healthy controls participated in the study. Patients were divided into four categories radiologically on chest X-ray (minimal, moderate-advanced, far-advanced and with miliary infiltration). Concentrations of TNF-alpha (20.9+/-10/15.4+/-8 pg/ml) and sIL-2R (2569+/-842/1444+/-514 pg/ml) were statistically different between patients and controls (p=0.02 and p=0.0001, respectively). Before chemotherapy there was a positive correlation between TNF-alpha and sIL-2R (r=0.34), but there was no correlation between IL-4 and TNF-alpha, and between IL-4 and sIL-2R (r=-0.23 and r=-0.22). The TNF-alpha level was not statistically different in four groups before and after chemotherapy. Results of this study provided some evidence confirming the previously reported role of TNF-alpha, IL-4 and sIL 2R in the control of tuberculosis, but these cytokines were not found related with disease severity.     

Hyperoxic conditions inhibit airway smooth muscle myosin phosphatase in rat pups

Exposure of rat pups to 100% oxygen is a model for studying neonatal lung injury. Airway reactivity is increased in this model, in part due to impaired airway smooth muscle (ASM) relaxation. We compared biochemical determinants of ASM contractility in rat pups exposed to 100% oxygen for 7 days vs. littermates raised in room air. The baseline quantities of ASM contractile proteins, extent of phosphorylation of the 20-kDa myosin regulatory light chain (LC(20)), and amount of the myosin-binding subunit of smooth muscle myosin phosphatase (MYPT) were all comparable between the two groups. Bethanechol-induced contraction increased the extent of phosphorylation of both LC(20) and MYPT in the hyperoxic group (45% and 70% over control, respectively). Relaxation after electrical field stimulation demonstrated greater phosphorylation of both LC(20) and MYPT in the hyperoxic group compared with controls (67% and 84%, respectively). To determine if hyperoxia induced changes in the isoforms of MYPT, isoform expression was also compared but differences were not found. To determine potential mechanisms whereby MYPT phosphorylation was increased by hyperoxia, separate tracheas were treated with the Rho kinase inhibitor Y-27632. This treatment completely eliminated differences in MYPT phosphorylation between the groups. Because phosphorylation of MYPT impairs the phosphatase activity of myosin phosphatase, these data suggest that hyperoxic conditioning during early postnatal life impairs relaxation through prolonging LC(20) phosphorylation. This mechanism might contribute to increased ASM reactivity seen in bronchopulmonary dysplasia.     

Effect of Time on Endothelium-Dependent Relaxations in Mice and Rat Thoracic Aortas

Temporal variations in the endothelium-dependent relaxant effects of acetylcholine (ACh) in mice and histamine (HA) in rat thoracic aorta have been studied. The relaxations induced by higher concentrations of ACh and HA were significantly dependent on the time the tissues were obtained. However, neither EC 50 (the concentration inducing half of the maximum response) values for ACh and HA, nor K B (antagonist dissociation constant) values for atropine and diphenhydramine were found to be statistically significant depending upon the time of obtaining aorta preparations. These results show that the in vitro responsiveness of mice and rat thoracic aortas to endothelium-dependent relaxant effects of ACh and HA, respectively, changes over a 24-h period. These variations might be dependent on a temporal rhythm in post-receptor events, i.e., guanylate cyclase-cGMP-phosphodiesterase system which mediates responses to endothelium-derived relaxing factor(s).