Dementia care initiative in primary practice – study protocol of a cluster randomized trial on dementia management in a general practice setting

<p>Abstract</p> <p>Background</p> <p>Current guidelines for dementia care recommend the combination of drug therapy with non-pharmaceutical measures like counselling and social support. However, the scientific evidence concerning non-pharmaceutical interventions for dementia patients and their informal caregivers remains inconclusive. Targets of modern comprehensive dementia care are to enable patients to live at home as long and as independent as possible and to reduce the burden of caregivers. The objective of the study is to compare a complex intervention including caregiver support groups and counselling against usual care in terms of time to nursing home placement. In this paper the study protocol is described.</p> <p>Methods/Design</p> <p>The IDA (Initiative Demenzversorgung in der Allgemeinmedizin) project is designed as a three armed cluster-randomized trial where dementia patients and their informal caregivers are recruited by general practitioners. Patients in the study region of Middle Franconia, Germany, are included if they have mild or moderate dementia, are at least 65 years old, and are members of the German AOK (Allgemeine Ortskrankenkasse) sickness fund. In the control group patients receive regular treatment, whereas in the two intervention groups general practitioners participate in a training course in evidence based dementia treatment, recommend support groups and offer counseling to the family caregivers either beginning at baseline or after the 1-year follow-up. The study recruitment and follow-up took place from July 2005 to January 2009. 303 general practitioners were randomized of which 129 recruited a total of 390 patients. Time to nursing home admission within the two year intervention and follow-up period is the primary endpoint. Secondary endpoints are cognitive status, activities of daily living, burden of care giving as well as healthcare costs. For an economic analysis from the societal perspective, data are collected from caregivers as well as by the use of routine data from statutory health insurance and long-term care insurance.</p> <p>Discussion</p> <p>From a public health perspective, the IDA trial is expected to lead to evidence based results on the community effectiveness of non-pharmaceutical support measures for dementia patients and their caregivers in the primary care sector. For health policy makers it is necessary to make their decisions about financing new services based on strong knowledge about the acceptance of measures in the population and their cost-effectiveness.</p> <p>Trial registration</p> <p>ISRCTN68329593</p

Derivation of Rapamycin: Adventures in Natural Product Chemistry

The macrolide rapamycin was first described as an antifungal agent in 1975. It attracted our interest in the early 90s based on its reported immunosuppressive activity in transplantation models and based on indications that its mechanism of action was different from those of the known immunosuppressive agents ciclosporin and FK506, although the biological target and the molecular details were yet to be discovered. In this review we describe our efforts to chemically modify this complex and chemically very sensitive natural product. Despite the limitations regarding the reaction conditions compatible with rapamycin we discovered ways of selectively modifying specific functional groups. This allowed us, among others, to improve the stability of the parent molecule towards ring-opening. Our efforts culminated in the discovery and development of the 40-O-alkylated derivative everolimus which became a useful drug in solid organ transplantation, in various cancer indications and as the active principle of the market leading drug-eluting stent

Behavioral dynamics of conversation and (mis)communication in noisy environments

While communication is an essential part of life, it is not always easy and effortless. This is especially true when talking with someone in a noisy environment. Although communicating in noise is often the rule rather than the exception, very little research has investigated the behavioral processes individuals might use to minimize miscommunication when listening becomes challenged. Here we explored synergistic speech and movement processes that 22 pairs of adults used to hear and be heard when (mis)communicating in noise. The results revealed intricate dynamics both with respect to acoustic optimization of the speech produced and heard, as well as how individuals modulate interpersonal distance and behavioral coordination patterns

Cocktail-party behavior: dynamics of conversation and (mis)communication in noisy environments

During conversations people effortlessly coordinate simultaneous channels of verbal and nonverbal information to hear and be heard. But the presence of common background noise levels such as those found in cafes and restaurants can be a barrier to conversational success. Here, we used speech and motion-tracking to reveal the behavioral processes that talkers use to communicate effectively during conversations in noisy environments. Natural speech communication of twenty-two pairs of normal- hearing adults was elicited under different conditions of realistic background noise, while standing freely or sitting around a table. The results revealed how the behavior of conversing partners entail three phases of adaptive behavior. First, with the onset of background noise, pairs rapidly adjusted their interpersonal distance and speech level, with the degree of initial change dependent on noise level and talker configuration. Following this transient phase of behavioral adaptation, pairs settled into a steady- state or sustaining phase of behavioral coordination, in which reciprocal speech and movement-based coordination processes operated to synergistically maintain effective communication, again with the magnitude of stability of these coordination processes covarying with noise level and talker configuration. Finally, as communication breakdowns started to increase at high levels of background noise, pairs exhibited intermittent resetting behaviors to help restore communication. That is, individuals further decreased interpersonal distance and/or increased speech levels in direct response to communication breakdowns. The findings show that approximately 78 dB SPL defines a critical noise threshold where behavioral coordination processes are no longer sufficient for maintaining effective conversation and communication breakdowns rapidly increase