High-altitude exposure in patients with cardiovascular disease: risk assessment and practical recommendations

Because of the development of modern transportation facilities, an ever rising number of individuals including many patients with preexisting diseases visit high-altitude locations (>2500 m). High-altitude exposure triggers a series of physiologic responses intended to maintain an adequate tissue oxygenation. Even in normal subjects, there is enormous interindividual variability in these responses that may be further amplified by environmental factors such as cold temperature, low humidity, exercise, and stress. These adaptive mechanisms, although generally tolerated by most healthy subjects, may induce major problems in patients with preexisting cardiovascular diseases in which the functional reserves are already limited. Preexposure assessment of patients helps to minimize risk and detect contraindications to high-altitude exposure. Moreover, the great variability and nonpredictability of the adaptive response should encourage physicians counseling such patients to adapt a cautionary approach. Here, we will briefly review how high-altitude adjustments may interfere with and aggravate/decompensate preexisting cardiovascular diseases. Moreover, we will provide practical recommendations on how to investigate and counsel patients with cardiovascular disease desiring to travel to high-altitude locations.

Apraxia in neurorehabilitation: Classification, assessment and treatment

Apraxia is a higher-order motor disorder impairing the ability to correctly perform skilled, purposive movements as the result of neurological disorders most commonly stroke, dementia and movement disorders. It is increasingly recognised that apraxia negatively influences activities of daily living (ADL). Early diagnosis and treatment should be part of the neurorehabilitation programme. The aim of the present article is to describe the most important subtypes of apraxia such as ideational and ideomotor apraxia as well as their impact on ADL and outcome. Furthermore, the relationship to associated disorders such as aphasia is discussed. Finally, strategies concerning assessment, management and treatment of the disorder are presented.

The applicability of non-local LCI data for LCA

This study evaluated how applicable European Life Cycle Inventory (LCI) data are to assessing the environmental impacts of the life cycle of Brazilian triple superphosphate (TSP). The LCI data used for the comparison were local Brazilian LCI data, European LCI data in its original version from the ecoinvent database and a modified version of the European LCI data, which had been adapted to better account for the Brazilian situation. We compared the three established datasets at the level of the inventory as well as for their environmental impacts, i.e. at the level of Life Cycle Environmental Assessment (LCIA). The analysis showed that the European LCIs (both the original and the modified ones) considered a broader spectrum of background processes and environmental flows (inputs and outputs). Nevertheless, TSP production had in all three cases similar values for the consumption of the main raw materials. The LCIA results obtained for the datasets showed important differences as well. Therefore we concluded that the European data in general lead to much higher environmental impacts than the Brazilian data. The differences between the LCIA results obtained with the Brazilian and the European data can be basically explained by the methodological differences underlying the data. The small differences at the LCI level for selected inputs and outputs between the Brazilian and the European LCIs from ecoinvent indicate that the latter can be regarded as applicable for characterizing the Brazilian TSP.

A virtual environment for the assessment and the rehabilitation of the visuo-constructional ability in dementia patients

This study proposes a VE that offers a reliable diagnosis of the stage of cognitive decline in dementia patients and assists the delay of this decline in terms of the visuo-constructional ability. The proposed VE, in the case of the assessment, presents a visuo-constructional completion task, which requires spatial perception, motor memory and the perception of the target object. In the case of the rehabilitation the VE uses sound as audio-feedback that, with the aid of the music perception, tends to develop an enhancement in the visuo-construction ability of the dementia patients that can be generalized even outside of the VE. The study examined 30 subjects that were normal controls (N), 30 patients suffering from memory disorders (Age-Associated Memory Impairment--AAMI) and 30 suffering from Alzheimer's Disease (AD). The results showed that there is a significant correlation between the performance in the visuo-constructional task and the dementia diagnosis. It also seems that the visuo-constructional ability of the (AD) patients can be statistically improved by the audio experience in the VE. The empirical results of this study offer an alternative diagnosis and treatment of dementia patients and could share some light in the brain sub-systems that are responsible for the visuo-constructional ability. Further studies are required in order to investigate the nature of this phenomenon more.

A Preliminary Impact Assessment of Doha Round Results on Agricultural Policies in Turkey

Turkish agriculture has been experiencing a period of unique policy experiment over the last couple years. A World Bank-initiated project, called the Agricultural Reform Implementation Project (ARIP), has been at the forefront of policy change. It was initially promoted by the Bank as an exemplary reform package which could also be adopted by other developing countries. It was introduced in 2001 as part of a major International Monetary Fund (IMF)/World Bank-imposed program of “structural adjustment” after the country had been hit by a major financial crisis. The project has finally come to an end in 2009, and there is now an urgent need for a retrospective assessment of its overall impact on the agricultural sector. Has it fulfilled its ambitious objective of reforming and restructuring Turkish agriculture? Or should it be recorded as a failure of the neo-liberal doctrine? This book aims at finding answers to these questions by investigating the legacy of ARIP from a multi-disciplinary perspective.

Effect of Health Risk Assessment and Counselling on Health Behaviour and Survival in Older People: A Pragmatic Randomised Trial.

BACKGROUND Potentially avoidable risk factors continue to cause unnecessary disability and premature death in older people. Health risk assessment (HRA), a method successfully used in working-age populations, is a promising method for cost-effective health promotion and preventive care in older individuals, but the long-term effects of this approach are unknown. The objective of this study was to evaluate the effects of an innovative approach to HRA and counselling in older individuals for health behaviours, preventive care, and long-term survival. METHODS AND FINDINGS This study was a pragmatic, single-centre randomised controlled clinical trial in community-dwelling individuals aged 65 y or older registered with one of 19 primary care physician (PCP) practices in a mixed rural and urban area in Switzerland. From November 2000 to January 2002, 874 participants were randomly allocated to the intervention and 1,410 to usual care. The intervention consisted of HRA based on self-administered questionnaires and individualised computer-generated feedback reports, combined with nurse and PCP counselling over a 2-y period. Primary outcomes were health behaviours and preventive care use at 2 y and all-cause mortality at 8 y. At baseline, participants in the intervention group had a mean ± standard deviation of 6.9 ± 3.7 risk factors (including unfavourable health behaviours, health and functional impairments, and social risk factors) and 4.3 ± 1.8 deficits in recommended preventive care. At 2 y, favourable health behaviours and use of preventive care were more frequent in the intervention than in the control group (based on z-statistics from generalised estimating equation models). For example, 70% compared to 62% were physically active (odds ratio 1.43, 95% CI 1.16-1.77, p = 0.001), and 66% compared to 59% had influenza vaccinations in the past year (odds ratio 1.35, 95% CI 1.09-1.66, p = 0.005). At 8 y, based on an intention-to-treat analysis, the estimated proportion alive was 77.9% in the intervention and 72.8% in the control group, for an absolute mortality difference of 4.9% (95% CI 1.3%-8.5%, p = 0.009; based on z-test for risk difference). The hazard ratio of death comparing intervention with control was 0.79 (95% CI 0.66-0.94, p = 0.009; based on Wald test from Cox regression model), and the number needed to receive the intervention to prevent one death was 21 (95% CI 12-79). The main limitations of the study include the single-site study design, the use of a brief self-administered questionnaire for 2-y outcome data collection, the unavailability of other long-term outcome data (e.g., functional status, nursing home admissions), and the availability of long-term follow-up data on mortality for analysis only in 2014. CONCLUSIONS This is the first trial to our knowledge demonstrating that a collaborative care model of HRA in community-dwelling older people not only results in better health behaviours and increased use of recommended preventive care interventions, but also improves survival. The intervention tested in our study may serve as a model of how to implement a relatively low-cost but effective programme of disease prevention and health promotion in older individuals. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number: ISRCTN 28458424.

A systematic review of glomerular hyperfiltration assessment and definition in the medical literature.

BACKGROUND AND OBJECTIVES Evaluation of glomerular hyperfiltration (GH) is difficult; the variable reported definitions impede comparisons between studies. A clear and universal definition of GH would help in comparing results of trials aimed at reducing GH. This study assessed how GH is measured and defined in the literature. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Three databases (Embase, MEDLINE, CINAHL) were systematically searched using the terms "hyperfiltration" or "glomerular hyperfiltration". All studies reporting a GH threshold or studying the effect of a high GFR in a continuous manner against another outcome of interest were included. RESULTS The literature search was performed from November 2012 to February 2013 and updated in August 2014. From 2013 retrieved studies, 405 studies were included. Threshold use to define GH was reported in 55.6% of studies. Of these, 88.4% used a single threshold and 11.6% used numerous thresholds adapted to participant sex or age. In 29.8% of the studies, the choice of a GH threshold was not based on a control group or literature references. After 2004, the use of GH threshold use increased (P<0.001), but the use of a control group to precisely define that GH threshold decreased significantly (P<0.001); the threshold did not differ among pediatric, adult, or mixed-age studies. The GH threshold ranged from 90.7 to 175 ml/min per 1.73 m(2) (median, 135 ml/min per 1.73 m(2)). CONCLUSION Thirty percent of studies did not justify the choice of threshold values. The decrease of GFR in the elderly was rarely considered in defining GH. From a methodologic point of view, an age- and sex-matched control group should be used to define a GH threshold.