Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation.

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Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

Background: bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009. Objectives: to assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities. Search methods: studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013. Selection criteria: randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures. Data collection and analysis: data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument. Main results: twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment. All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data. Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB. No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications. Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group. One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group. One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence). QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation. Authors' conclusions: surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only. Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

Surgery for weight loss in adults

Placebo

Background: There is increasing recognition that the use of certain medications contributes to falls in seniors. Our objective was to update a previously completed meta-analysis looking at the association of medication use and falling to include relevant drug classes and new studies that have been completed since a previous meta-analysis. Methods: Studies were identified through a systematic search of English-language articles published from 1996 to 2007. We identified studies that were completed on patients older than 60 years, looking at the association between medication use and falling. Bayesian methods allowed us to combine the results of a previous metaanalysis with new information to estimate updated Bayesian odds ratios (ORs) and 95% credible intervals (95% CrIs) Results: Of 11 118 identified articles, 22 met our inclusion criteria. Meta-analyses were completed on 9 unique drug classes, including 79 081 participants, with the following Bayesian unadjusted OR estimates: antihypertensive agents, OR, 1.24 (95% CrI, 1.01-1.50); diuretics, OR, 1.07 (95% CrI, 1.01-1.14); -blockers, OR, 1.01 (95% CrI, 0.86-1.17); sedatives and hypnotics, OR, 1.47 (95% CrI, 1.35-1.62); neuroleptics and antipsychotics, OR, 1.59 (95% CrI, 1.37-1.83); antidepressants, OR, 1.68 (95% CrI, 1.47-1.91); benzodiazepines, OR, 1.57 (95% CrI, 1.431.72); narcotics, OR, 0.96 (95% CrI, 0.78-1.18); and nonsteroidal anti-inflammatory drugs, OR, 1.21 (95% CrI, 1.01-1.44). The updated Bayesian adjusted OR estimates for diuretics, neuroleptics and antipsychotics, antidepressants, and benzodiazepines were 0.99 (95% CrI, 0.78-1.25), 1.39 (95% CrI, 0.94-2.00), 1.36 (95% CrI, 1.13-1.76), and 1.41 (95% CrI, 1.20-1.71), respectively. Stratification of studies had little effect on Bayesian OR estimates, with only small differences in the stratified ORs observed across population (for -blockers and neuroleptics and antipsychotics) and study type (for sedatives and hypnotics, benzodiazepines, and narcotics). An increased likelihood of falling was estimated for the use of sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, and nonsteroidal anti-inflammatory drugs in studies considered to have “good” medication and falls ascertainment. Conclusion: The use of sedatives and hypnotics, antidepressants, and benzodiazepines demonstrated a significant association with falls in elderly individuals.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/485251/ira90005_1952_1960.pdf

Meta-analysis of the impact of 9 medication classes on falls in elderly persons.

The paper discusses the social and, particularly, the health consequences resulting from the expansion of the numbers of elderly people in Brazil over a short period. The data used were from the 1998 and 2003 Pesquisa Nacional por Amostra de Domicilios (PNAD, the national household sampling survey), and they express an improvement in elderly people's health conditions and similar distribution of chronic diseases across all income groups. If, on the one hand, elderly people present greater disease burden and incapacities and they use healthcare services more, on the other hand, the current models for healthcare for the elderly are shown to be inefficient and high-cost. Creative and innovative structures are required, such as social centers with health assessments and treatment. Foremost on the agenda for Brazilian public policy, priority should be given to maintaining elderly people's functional capacity, with monitoring of their health conditions; preventive and differentiated actions relating to health and education; and qualified care and multidimensional comprehensive attendance.

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Envelhecimento populacional contemporâneo: demandas, desafios e inovações

Ageing has now become a universal phenomenon, of increasing importance to developed and developing countries alike. In this, the first of a series of articles on ageing in developing countries, the actual demographic revolution is discussed, with special reference to Brazil. Estimates are provided up to the year 2025. The article analyses the factors which are responsible for this ageing process - such as the rapid decline in fertility and mortality rates that many Third Word countries have been experiencing over the last few years - and the various gradual stages of this process, which is usually referred to as the 'epidemiological transition', are discussed. The consequences for any society with a population that is gradually becoming older are considerable, and are of particular importance for the Health Sector. The article discusses the changing morbidity and mortality patterns and the concept of autonomy as a possible way to quantify quality of life is introduced. On this particular point a suggestion is made to redefine the concept of 'Ageing', in order to take into consideration the context in which senior adults in the Third World live. Finally, the article addresses itself to points relating to the interaction of ageing and social change. That there is such an interaction is apparent in developing countries and this raises questions to which answers could be found through the use of the epidemiological method.

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O envelhecimento da população mundial: um desafio novo

OBJETIVO: A Escala de Depressao Geriatrica, utilizada para o rastreamento de sintomas depressivos em idosos, ainda nao teve suas caracteristicas de medida avaliadas em ambulatorios gerais no Brasil. O objetivo foi estudar a validade da Escala, com 15 itens (EDG-15), na identificacao de episodio de Depressao Maior ou Distimia em idosos atendidos em ambulatorio geral. METODOS: A Escala foi aplicada em 302 individuos com 65 anos ou mais, que em seguida foram examinados, de maneira independente, por um geriatra que nao tinha conhecimento dos resultados da Escala. Os diagnosticos de Depressao Maior ou Distimia foram feitos utilizando-se os criterios do Diagnostic and Statistical Manual of Mental Disorders-IV. A sensibilidade e a especificidade nos varios pontos de corte foram expressas pela curva Receiver Operating Characteristic. RESULTADOS: O ponto de corte de melhor equilibrio foi 5/6, obteve sensibilidade de 81% e especificidade de 71%; e o valor da area sob a curva Receiver Operating Characteristic foi de 0,85 (IC 95%: 0,79-0,91). CONCLUSOES: A Escala de Depressao Geriatrica pode ser utilizada para o rastreamento de sintomas depressivos na populacao geriatrica ambulatorial brasileira. O ponto de corte 5/6, sugerido inicialmente por outros autores, mostrou-se adequado.

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Validação da escala de depressão geriátrica em um ambulatório geral

OBJETIVO: Avaliar as caracteristicas de medida do Mini-Exame do Estado Mental em idosos atendidos em um ambulatorio geral. METODOS: O total de 303 individuos (>65 anos) foi submetido a avaliacao geriatrica com varios instrumentos, inclusive o Mini-Exame do Estado Mental. Foram calculadas a sensibilidade, a especificidade, os valores preditivos positivo e negativo e a curva ROC. RESULTADOS: A sensibilidade, a especificidade, os valores preditivos positivo e negativo e a area sob a curva ROC foram 80,8%, 65,3%, 44,7%, 90,7% e 0,807, respectivamente (ponto de corte 23/24). O melhor ponto de corte para individuos analfabetos foi 18/19 (sensibilidade =73,5%; especificidade =73,9%), e para aqueles com instrucao escolar foi 24/25 (sensibilidade =75%; especificidade =69,7%). CONCLUSOES: Para o rastreamento cognitivo de idosos atendidos em ambulatorios gerais pelo Mini-Exame do Estado Mental, a escolaridade devera ser considerada para a adocao do ponto de corte mais adequado.

/pdf/mini-exame-do-estado-mental-caracteristicas-psicometricas-em-36qq5b57r6.pdf

Mini-Exame do Estado Mental: características psicométricas em idosos ambulatoriais

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Renato Peixoto Veras

Papers

Envelhecimento populacional contemporâneo: demandas, desafios e inovações

O envelhecimento da população mundial: um desafio novo

Validação da escala de depressão geriátrica em um ambulatório geral

Mini-Exame do Estado Mental: características psicométricas em idosos ambulatoriais

Saúde pública e envelhecimento