Alzheimer's disease in the community
A recent study concerning the prevalence of Alzheimer's disease was reviewed and the results are addressed. The primary conclusion of this study was that the rate of occurrence of Alzheimer's disease is far greater than previous studies have indicated and incidence of this disease correlates with advancing age. The results of this study will most likely increase the fears of the general public and, hopefully, attract the interest and increase the awareness of physicians. The methodology of the study was reviewed and some limitations are observed. The first was that the investigators did not use the criteria that the Diagnostic and Statistical Manual of Mental Disorders, third edition, has recommended for confirming a diagnosis of Alzheimer's disease. The study omitted the portion of the definition which mentions functional impairment and relied instead strictly upon cognitive test results in making diagnoses. The community sampling which was used did not allow for cultural considerations which may have influenced the results. The majority of the patients had very low levels of education and, therefore, this may have distorted the cognitive test results. The fact that the survey did not include those already in nursing homes as a part of the general population probably also influenced the data. The study did point out some facts which physicians should consider in their practice and in diagnosing dementias. Cognitive impairment in individuals over 85-years-old is very common. Failure to recognize dementia may occur due to preoccupation with medical concerns by physicians. The older patient suffering from dementia may also be deprived of diagnosis for treatable medical problems as well. The reviewer emphasized that the diagnosis of Alzheimer's disease still remains very difficult and complicated. In terms of effective treatment strategies, nothing more can be done than merely treating the symptoms of Alzheimer patients. Priority should remain on patients who actually complain of symptoms, rather than making diagnoses for individuals who do not exhibit any major problems in the course of daily living.
Publication Name: JAMA, The Journal of the American Medical Association
Whither electronic fetal monitoring?
Although hopes were high that electronic fetal monitoring (EFM - continuous monitoring of the fetal heart) would reduce damage to the fetus during labor, these hopes have not been realized. In 1988, the American College of Obstetricians and Gynecologists declared that intermittent auscultation (listening to the fetal heart with the stethoscope) is as effective as EFM in detecting potential problems. A review is presented of the literature concerning this issue, with a proposal for solving the problems that surround EFM. Cerebral palsy (a chronic condition involving muscle spasticity and paralysis) has not been prevented by the use of EFM devices, nor have the devices reduced infant mortality or improved outcomes for low-birth-weight infants. EFM has led to an increased rate of cesarean section, increasing maternal risk, and higher costs for giving birth. Physicians who use EFM are at a higher risk for litigation; half of all claims made against obstetricians concern cases where EFM was used. Physicians' defenses are less effective in cases where plaintiffs possess such evidence. Therefore, a possible solution is to designate EFM an 'experimental' procedure. Until better evidence has been presented that it is effective, intermittent auscultation of the fetal heart can be performed. This should be done every 15 minutes during the first stage of labor, and every 5 minutes during the second stage. Protocols for high- and low-risk patients are presented. Nurses should be reminded by a timer when it is time to listen to the fetal heart; the preferred method is outlined. Emergency surgery should follow certain clearly specified changes in the fetal heart rate. The protocol was developed in two private community hospitals where all patients are private patients. Each laboring patient is assigned a single nurse; in most cases, the auscultation schedule can be adhered to. Patients, according to the protocol, are given a choice of intermittent auscultation or continuous EFM. (Consumer Summary produced by Reliance Medical Information, Inc.)
Publication Name: Obstetrics and Gynecology
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