Determining the Efficacy of Liquid Sporicides Against Spores of Bacillus subtilis on a Hard Nonporous Surface Using the Quantitative Three Step Method: Collaborative Study

A collaborative study was conducted to validate the quantitative Three Step Method (TSM), a method designed to measure the performance of liquid sporicides on a hard nonporous surface. Ten laboratories agreed to participate in the collaborative study; data from 8 of 10 participating laboratories were used in the final statistical analysis. The TSM uses 5 5 1 mm glass coupons (carriers) upon which spores have been inoculated and which are introduced into liquid sporicidal agent contained in a microcentrifuge tube. Following exposure to a test chemical and a neutralization agent, spores are removed from carriers in 3 fractions: passive removal (Fraction A), sonication (Fraction B), and gentle agitation (Fraction C). Liquid from each fraction is serially diluted and plated on a recovery medium for spore enumeration. Control counts are compared to the treated counts, and the level of efficacy is determined by calculating the log10 reduction (LR) of spores. The main statistical goals were to evaluate the repeatability and reproducibility of the LR values, to estimate the components of variance for LR, and to assess method responsiveness. AOAC Method 966.04Method II was used as a reference method. The scope of the validation was limited to testing liquid formulations against spores of Bacillus subtilis, a surrogate for virulent strains of B. anthracis, on a hard nonporous surface (glass). The test chemicals used in the study were sodium hypochlorite, a combination of peracetic acid and hydrogen peroxide, and glutaraldehyde. Each test chemical was evaluated at 3 levels of presumed efficacy: high, medium, and low. Three replications were required. The TSM was validated as it successfully met the statistical parameters for quantitative test methods. Satisfactory validation parameters, such as the repeatability standard deviation (Sr) and reproducibility standard deviation (SR), were obtained for control carrier counts and LR values. Both the TSM and the reference method were responsive to the efficacy levels of the test chemicals. For the 72 total TSM tests conducted, the mean ( standard error of the mean) log density of spores per control carrier was 6.86 ( 0.08); the Sr and SR were low at 0.15 and 0.27, respectively. Across the range of test chemicals, the Sr and SR estimates associated with LR were also acceptably low. The Sr rangedfrom 0.17 to 0.72 and the SR ranged from 0.34 to 1.43. Overall, the Sr and SR estimates associated with the efficacy data were within the ranges published for other quantitative methods and meet the performance characteristics necessary for validation.

Effects of physical activity on exercise tests and respiratory function

BACKGROUND

Exercise is an important component of pulmonary rehabilitation for patients with chronic lung disease.

OBJECTIVE

To explore the role of physical activity in maintaining cardiac and respiratory function in healthy people.

METHODS

Cardiorespiratory fitness was measured by a maximal treadmill test (MTT), and respiratory function was tested by spirometry. The cross sectional study included data from 24 536 healthy persons who were examined at the Cooper Clinic between 1971 and 1995; the longitudinal study included data from 5707 healthy persons who had an initial visit between 1971 and 1995 and a subsequent visit during the next five years. All participants were aged 25-55 years and completed a cardiorespiratory test and a medical questionnaire.

RESULTS

In the cross sectional study, after controlling for covariates, being active and not being a recent smoker were associated with better cardiorespiratory fitness and respiratory function in both men and women. In the follow up study, persons who remained or became active had better MTT than persons who remained or became sedentary. Men who remained active had higher forced expiratory volume in one second (FEV(1)) and forced vital capacity (FVC) than the other groups. Smoking was related to lower cardiorespiratory fitness and respiratory function.

CONCLUSIONS

Physical activity and non-smoking or smoking cessation is associated with maintenance of cardiorespiratory fitness. Change in physical activity habits is associated with change in cardiorespiratory fitness, but respiratory function contributed little to this association during a five year follow up.

One-leg standing balance and functional status in an elderly community-dwelling population in northeast Italy

BACKGROUND AND AIMS

Development of simple and accurate indicators of frailty is an important research goal in aging societies. One-leg standing balance (OLSB) has been proposed as a component of a clinical index of frailty.

METHODS

We analyzed relationships between results of OLSB testing and multiple health risk factors and impairment/disability indicators in a sample of elderly subjects (N=102) participating in the Anchyses Project. Subjects were aged >65, lived in a home for the aged in Rovigo, Italy, and had no ADL dependencies or recent acute illnesses.

RESULTS

More than half (53%) failed the OLSB test while 36% were able to balance without difficulty. Significant differences were observed among OLSB performance groups in forced vital capacity (p=0.025), dynamometry (p=0.001), age, physical activity, and IADL dependency (all p<0.001).

CONCLUSIONS

OLSB performance is a marker of frailty and thus a potentially useful predictor of functional decline.

Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics

BACKGROUND

Without family caregivers, many frail elders who live at home would require nursing home care. However, providing care to frail elders requires a large time commitment that may interfere with the caregiver's ability to work. Our goal was to determine the patient and caregiver characteristics associated with the reduction of employment hours in caregivers of frail elders.

METHODS

This was a cross-sectional study of 2806 patients (mean age 78, 73% women, 29% African American, 12% Hispanic, 54% with dementia) with at least one potentially working caregiver (defined as one who is either currently employed or who would have been employed if they had not been providing care) and their 4592 potentially working caregivers. Patients were enrollees at 11 sites of the Program of All-Inclusive Care for the Elderly (PACE). Social workers interviewed patients and caregivers at the time of PACE enrollment. Caregivers were asked if they had reduced the hours they worked or had stopped working to care for the patient. Nurses interviewed patients and caregivers to assess independence in activities of daily living (ADLs) and the presence of behavioral disturbances. Comorbid conditions were assessed by physicians during enrollment examinations.

RESULTS

A total of 604 (22%) of the 2806 patients had at least one caregiver who either reduced the number of hours they worked or quit working to care for the patient. Patient characteristics independently associated with a caregiver reducing hours or quitting work were ethnicity, 95% confidence interval [CI] 1.14-1.78 for African American;, 95% CI 1.43-2.52 for Hispanic), ADL function below the median (, 95% CI 1.44-2.15), a diagnosis of dementia (, 95% -2.17 if associated with a behavioral disturbance;, 95% CI 1.06-1.63 if not associated with a behavioral disturbance), or a history of stroke (OR = 1.42, 95% CI 1.16-1.73). After controlling for these patient characteristics, caregiver characteristics associated with reducing work hours included being the daughter or daughter-in-law of the patient (OR = 1.69, 95% CI 1.37-2.08) and living with the patient (OR = 4.66, 95% CI 3.65-5.95 if no other caregiver lived at home, OR = 2.53, 95% CI 2.03-3.14 if another caregiver lived at home).

CONCLUSIONS

Many caregivers reduce the number of hours they work to care for frail elderly relatives. The burden of reduced employment is more likely to be incurred by the families of ethnic minorities and of patients with specific clinical characteristics. Daughters and caregivers who live with the patient are more likely to reduce work hours than other caregivers. Future research should examine the impact of lost caregiver employment on patients' families and the ways in which the societal responsibility of caring for frail elders can be equitably shared.

Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics

BACKGROUND

Without family caregivers, many frail elders who live at home would require nursing home care. However, providing care to frail elders requires a large time commitment that may interfere with the caregiver's ability to work. Our goal was to determine the patient and caregiver characteristics associated with the reduction of employment hours in caregivers of frail elders.

METHODS

This was a cross-sectional study of 2806 patients (mean age 78, 73% women, 29% African American, 12% Hispanic, 54% with dementia) with at least one potentially working caregiver (defined as one who is either currently employed or who would have been employed if they had not been providing care) and their 4592 potentially working caregivers. Patients were enrollees at 11 sites of the Program of All-Inclusive Care for the Elderly (PACE). Social workers interviewed patients and caregivers at the time of PACE enrollment. Caregivers were asked if they had reduced the hours they worked or had stopped working to care for the patient. Nurses interviewed patients and caregivers to assess independence in activities of daily living (ADLs) and the presence of behavioral disturbances. Comorbid conditions were assessed by physicians during enrollment examinations.

RESULTS

A total of 604 (22%) of the 2806 patients had at least one caregiver who either reduced the number of hours they worked or quit working to care for the patient. Patient characteristics independently associated with a caregiver reducing hours or quitting work were ethnicity, 95% confidence interval [CI] 1.14-1.78 for African American;, 95% CI 1.43-2.52 for Hispanic), ADL function below the median (, 95% CI 1.44-2.15), a diagnosis of dementia (, 95% -2.17 if associated with a behavioral disturbance;, 95% CI 1.06-1.63 if not associated with a behavioral disturbance), or a history of stroke (OR = 1.42, 95% CI 1.16-1.73). After controlling for these patient characteristics, caregiver characteristics associated with reducing work hours included being the daughter or daughter-in-law of the patient (OR = 1.69, 95% CI 1.37-2.08) and living with the patient (OR = 4.66, 95% CI 3.65-5.95 if no other caregiver lived at home, OR = 2.53, 95% CI 2.03-3.14 if another caregiver lived at home).

CONCLUSIONS

Many caregivers reduce the number of hours they work to care for frail elderly relatives. The burden of reduced employment is more likely to be incurred by the families of ethnic minorities and of patients with specific clinical characteristics. Daughters and caregivers who live with the patient are more likely to reduce work hours than other caregivers. Future research should examine the impact of lost caregiver employment on patients' families and the ways in which the societal responsibility of caring for frail elders can be equitably shared.

Hospitalization in the Program of All-Inclusive Care for the Elderly (PACE): rates, concomitants, and predictors

BACKGROUND

The Program of All-Inclusive Care for the Elderly (PACE) replicates the model of comprehensive, community-based geriatric care pioneered by On Lok, that enrolls frail older adults who meet states' criteria for nursing home care, and that uses interdisciplinary teams to assess the participants and to deliver care in appropriate settings. As managed care, PACE receives capitated payment from Medicare and Medicaid. Thus, PACE's fiscal incentives are thought to be aligned with the goals of optimizing health, function, and quality of life through the delivery of effective primary, preventive, restorative, supportive, and palliative care and through the avoidance of inappropriate and expensive hospital and nursing home utilization.

OBJECTIVES

To describe short-term hospital utilization, hospital discharge diagnoses, time from enrollment to first hospitalization and its clinical predictors, and hospitalization in relation to mortality among PACE participants.

METHODS

Data on short-term hospitalization and participants were recovered from PACE's minimum data set. Bed use was evaluated in annual cross-sections of current participants. Primary hospital discharge diagnoses were available for discharges from September 1, 1993 through March 31, 1997. The time from enrollment to hospitalization was calculated for the participants (n = 5478) who were admitted between January 1, 1990 and March 31, 1997. The characteristics of this inception cohort were used to develop a Cox regression model of hospitalization. All PACE deaths were identified and the place of death was recovered, together with the medical records used in the hospital during PACE enrollment or 6 months before death.

RESULTS

Bed-days per 1,000 PACE participants per year were comparable with the general Medicare (fee-for-service) population, at 2,046 (in 1998) versus 2014 (in 1997) despite the greater morbidity and disability for PACE participants, as reflected in their enrollment characteristics and primary hospital discharge diagnoses. The time to hospitalization was 773 days (median); 95% confidence interval, 725, 814, and was predicted by disease, treatment, social and demographic factors. Whereas 8% of PACE deaths occurred in acute hospitals, less than one-third of the decedents spent any time in the hospital in the 6-month interval before death.

CONCLUSIONS

Overall, short-term hospital utilization among PACE participants is low in contrast with that for other older and disabled populations. Participant predictors of hospitalization in PACE are generally consistent with other studies in older clinical and community populations. Both utilization and risk vary considerably across PACE sites, independent of participant-level risk factors, hence suggesting that further investigation is required to study PACE's management of acute illness and hospitalization decisions. Critical to maintaining PACE's success is an understanding of the independent impact of the organization and the environment of health care on this management.

Abuse of older persons: an overview

As demographics in the United States indicate that by 2050 older persons will constitute one-fourth of the population, statistics indicating abuse of older persons will also increase. As a serious social problem, nurses will need to assess and intervene with families where this type of family violence occurs. The types of abuse of older persons include physical, psychological, sexual, and financial abuse; neglect, self-neglect; and other types such as violation of rights, denial of privacy, and denial of participation in decision making. This article examines types of abuse, who is at risk, identifying characteristics of abusers, and nursing assessment and nursing interventions related to abuse of older persons.

Participants in the Program of All-Inclusive Care for the Elderly (PACE) demonstration: developing disease-impairment-disability profiles

The Program of All-Inclusive Care for the Elderly (PACE) builds on On Lok's community-based care and financing model for disabled elderly people who are state certified as eligible for nursing home care. Yet PACE's diverse population has not been fully described. We obtained data for a complete cross-section of PACE participants from early 1997 (N = 2,917). Using grade-of-membership analysis, we classified participants on the basis of their specific diseases, impairments, and disabilities. The classification was reviewed by a physician panel to produce clinical profiles, which were then validated against participants' PACE tenure, demographics, supports, and health. Cognitive impairment, incontinence, and activities of daily living disabilities were influential in producing eight types, which correspond predictably to responses in tenure (the more disabled, ill types likely to be in PACE longer), demographics, health, and informal support.

Population-based survey of complementary and alternative medicine usage, patient satisfaction, and physician involvement. South Carolina Complementary Medicine Program Baseline Research Team

BACKGROUND

With an increasing proportion of Americans using complementary or alternative medicine (CAM), physicians need to know which patients are using CAM to effectively manage care.

METHODS

In this cross-sectional study, telephone interviews were conducted with 1,584 South Carolina adults (ages 18 and older); 66% responded to the survey of demographics, general health, frequency of CAM use, perceived CAM effectiveness, and physician knowledge of CAM use.

RESULTS

A total of 44% had used a CAM during the past year. Increasing age and higher education were significantly associated with CAM use. More than 60% perceived CAM therapy as very effective, and 89% said they would recommend CAM to others. Physicians were unaware of CAM use in 57% of their patients using CAM.

CONCLUSION

Complementary or alternative medicine use in this rural Southern state is similar to national usage. Users view CAM as effective. Physicians are frequently unaware of patients' CAM use. More research is needed to establish CAM effectiveness and how CAM affects medical care, training, and public health.

Comparing two dinoprostone agents for preinduction cervical ripening at term. A randomized trial

OBJECTIVE

To compare the safety, efficacy and cost of two methods of administering commercially available dinoprostone for preinduction cervical ripening at term.

STUDY DESIGN

Sixty-nine women admitted for labor induction were randomized to receive one of two commercially available agents for cervical ripening. Half the patients received a gel containing 0.5 mg of dinoprostone placed intracervically every four hours. The other half received a polymer insert containing 10 mg of dinoprostone intravaginally. After 12 hours of cervical ripening, oxytocin was given and amniotomy performed to induce labor.

RESULTS

Among 69 women randomized, 35 received the gel and 34 the polymer. No significant differences were noted between the two groups in starting characteristics or indication for induction. Both groups were similar with respect to change in Bishop score, start-to-delivery interval, amount of oxytocin required, mode of delivery and success of induction. A slightly higher rate of hyperstimulation was noted in the polymer group, although this did not lead to fetal or maternal morbidity. The average costs per patient for the two agents were similar.

CONCLUSION

The two dinoprostone agents are similar with respect to efficacy. The polymer group had slightly more complications but without adverse fetal or maternal outcomes. A larger, multicenter trial would be required to determine actual differences in the efficacy, safety and cost of these two agents.

Brain uptake of iodine-131 metaiodobenzylguanidine following therapy of malignant pheochromocytoma

Intracranial metaiodobenzylguanidine (MIBG) uptake is occasionally and only faintly visualized on diagnostic studies. Recently, intense normal cerebellar uptake was described on posttherapy MIBG images. Experience at the University of Michigan with posttherapy MIBG scintigraphy of pheochromocytoma was reviewed. The patterns and correlates of intracranial uptake after therapeutic 1-131 MIBG in 25 patients (61 patient treatment encounters) were evaluated by review of records and blinded consensus interpretation of diagnostic and posttherapeutic MIBG scans. Thirty-nine (64%) patient treatment encounters demonstrated at least faint (grade 1) MIBG uptake in one or more brain sites; the most common site was the cerebellum. There was a statistically significant relation between intracranial uptake and 1) size of therapeutic dose and 2) patient age, but no relation between intracranial uptake and gender, body mass index, plasma epinephrine level, plasma norepinephrine level, urine metanephrine level, or the therapy-to-imaging interval. Although the influence of age on the pattern and intensity of intracranial uptake is unexplained, the relation to therapy dose may be explained by the possible generation of MIBG metabolites that can cross the blood-brain barrier (high activity administered and the delay until imaging). Further studies are needed to define mechanisms of intracranial uptake and relation to responses and toxicity after MIBG therapy of neuroendocrine tumors.

The art and science of targeting geriatrics programs

"Targeting" in geriatrics is the selection from a wider screened group of frail elderly patients for specific geriatrics programs designed to meet their particular multidimensional health needs. Targeting has been advocated as a means of improving the overall cost-effectiveness of health services for elderly people, both through improvement of the measurable health outcomes in patients served, and limiting futile/inappropriate care (both in patients admitted, and in others by virtue of their exclusion) which adds cost but does not improve health or quality of life. While research supports targeting for improving health outcomes, work to improve targeting practices and criteria is somewhat underdeveloped. These issues are discussed in reference to the contribution of Karppi and Tilvis (1) and other current literature.

What do we know about patient targeting in geriatric evaluation and management (GEM) programs?

Evidence indicates that institution-based programs for interdisciplinary geriatric evaluation and management (GEMs) improve outcomes of care, but results vary considerably between studies. Targeting (i.e., selective admission of frail elderly patient subgroups who are thought particularly to benefit) has been advocated as a means to improve the cost-effectiveness of GEM programs, and results from meta-analysis give this concept some support. Our review has several objectives: 1) describing approaches to GEM targeting and development of selection criteria; 2) assessing evidence from randomized trials concerning effects of targeting on outcome; and 3) suggesting an agenda for further research and development on GEM targeting.

Successful and unsuccessful approaches to imaging carcinoids: comparison of a radiolabelled tryptophan hydroxylase inhibitor with a tracer of biogenic amine uptake and storage, and a somatostatin analogue

A mouse mastocytoma model was used to determine the biodistribution and tumour uptake of four radiopharmaceuticals developed to target the serotonin synthetic pathway in carcinoid tumours. Three of the compounds were competitive inhibitors of the rate-limiting enzyme of serotonin synthesis, tryptophan hydroxylase. Radiolabelled iodo-dL-phenylalanine (iodine-131 PIPA) was found to have the highest uptake and tumour-to-liver ratio. Four patients with known carcinoid tumours were then injected with 0.5 mCi 131I-PIPA and imaged at 1, 4, 24 and 48 h post-injection. The radiopharmaceutical, however, failed to localize in the known tumour sites. This result was in contrast to the authors experience of 131I- and 123I-MIBG imaging of carcinoid tumours. Seven patients with known metastatic carcinoid tumours, two patients with symptoms of recurrence following tumour resection, one patient with completely resected disease, and two patients with a flushing syndrome of uncertain aetiology were studied with 131I-MIBG. Three of the seven patients with known metastatic disease had positive 131I-MIBG scans. Both patients with clinical evidence of recurrent disease had negative scans, as did the patient who was considered to have had complete resection of her primary tumour. The two patients with idiopathic flushing syndrome also had negative scans. Among seven patients imaged with 123I-MIBG there were four true-negative scans and one false-negative, the latter in a patient with biochemical and CT evidence of recurrence. In a seventh patient with distant metastases there was variable uptake in some of the lesions. Four patients were studied with indium-111 pentetreotide . Two patients with metastatic carcinoid disease had positive scans, although hepatic metastases were not seen in one. Another two with idiopathic flushing syndrome had normal studies. The literature suggests that up 50% of carcinoid tumour cases are detected with 131I-MIBG, compared to a sensitivity of 87% reported with somatostatin receptor imaging using 111In-pentetreotide. The experience with 123I-MIBG is much less extensive. The mechanisms of carcinoid tumour localization for each of the three classes of radiotracers are discussed and contrasted to their varying sensitivities. The relative success of 131I-MIBG and 111In-pentetreotide relative to 131I-PIPA may be related to the fact that 131I-MIBG is actively taken up and stored by the enterochromaffin cells of the tumours and 111In-pentetreotide binds to cell surface receptors, whereas 131I-PIPA binds to tryptophan hydroxylase, which may be present in quantities too small to permit tumours to be imaged.

Meta-analytic methods for health services research--an example from geriatrics

The authors recently published a meta-analysis of controlled trials of comprehensive geriatric assessment (CGA). The results supported the view that efficacy of CGA is strongly related to the patients, objectives, and basic design of CGA programs, and that particular program models and design features are associated with important health outcome improvements (e.g., survival, living at home, and functional improvement at follow-up). Present objectives include the outline of methods and how they were developed given the condition of the trial database and scientific context. Aspects of the approach, such as (a) survey of primary trialists to recover unpublished information and standardize data, (b) development of a program typology to guide the principal analysis, and (c) incorporation of program design features as covariates where statistical heterogeneity was detected, proved extremely useful, and have implications for other systematic reviews of similarly complex primary trials of new health care technologies, health services, and organizational interventions.

Depression in users of depo-medroxyprogesterone acetate

Prevalence of depression is high among poor, young, Hispanic inner city women. Depot-medroxyprogesterone acetate (DMPA) is a popular contraceptive choice in this group. DMPA labelling suggests that depression may worsen with use. In order to identify any association of DMPA use with worsening depression, we surveyed an English-speaking subset of DMPA users in a Title-X funded family planning clinic. Eighty women completed the CES-D scale on two occasions: once about four weeks after a DMPA injection when the subject would have been exposed to the highest blood levels, and once immediately prior to an injection when recent blood levels of the drug would be somewhat lower (or absent preceding the first injection). The median CES-D score was 14. The scores were not related to timing of the test (pre- or post-injection). The depression scores were somewhat higher among those women receiving their first DMPA injection during the study period (i.e., unexposed women) and among those women who had received four or more injections. Scores were unrelated to age or parity, but were somewhat higher in women who reported fewer years of education or a recent adverse pregnancy outcome. These data provide little evidence of increasing depression with long-term use of DMPA and no evidence of a short-term effect of dose (within the contraceptive range) on mood. Women at risk of depression should not be denied DMPA as a contraceptive choice.

The Sepulveda GEU Study revisited: long-term outcomes, use of services, and costs

The randomized controlled trial of the Geriatric Evaluation Unit (GEU) at the Sepulveda Veterans Hospital was the first to document the clinical and cost-effectiveness of hospital-based comprehensive geriatric assessment (CGA). Frail elderly inpatients were assigned randomly to the GEU for CGA, therapy, rehabilitation, and placement (N = 63), or to standard hospital care (N = 60). At one year, GEU patients had much lower mortality (24% vs 48%) and were less likely to have been discharged to a nursing home (NH) (13% vs 30%), or to have spent any time in NHs (27% vs 47%). GEU patients were more likely to improve in personal self-maintenance and morale. Further, controls had substantially more acute-care hospital days, NH days, and hospital readmissions, resulting in higher direct institutional care costs, especially after survival adjustment. Here, we report the results of long-term follow-up. There was a significant survival effect through two years. Despite prolongation of life, there was no indication that quality of life was worse for survivors in the GEU group. In fact, the proportion of persons independent in > or = 2 ADLs at two years was somewhat higher for GEU patients (0.44) than controls (0.33) (z = 1.27; p = 0.056). By three years, 43% of GEU subjects and 38% of controls were still alive. Over the entire 3-year period, the per capita direct cost difference was not significant, either before or after survival adjustment (unadjusted: $37,091 GEU vs $34,205 control; survival-adjusted: $54,315 GEU vs $63,362 control; p = 0.17).(ABSTRACT TRUNCATED AT 250 WORDS)

Health outcomes of post-hospital in-home team care: secondary analysis of a Swedish trial

OBJECTIVE

To determine patient and treatment-related factors predictive of health outcomes.

DESIGN

Secondary analysis of a randomized trial with 6-month follow-up. After using bivariate and three-way analysis in the total sample to screen outcome predictors and interactions among baseline variables, multivariate logistic regression was used to model outcomes.

SETTING

A county general hospital in central Stockholm, and patients' homes nearby.

PATIENTS

Hospital inpatients stable for discharge from acute care, having at least one chronic condition, and dependent in 1 to 5 Katz activities of daily life (ADLs) were included. Subjects (mean age = 81.1 years) were randomized to "team" (n = 150) or "usual care" (n = 99).

INTERVENTIONS

Team patients were eligible for in-home primary care by an interdisciplinary team that included a physician, physical therapist, and 24-hour nursing services and geriatric consultation where necessary. "Usual-care" patients received standard district nurse-administered services at home upon hospital discharge.

MEASUREMENTS

Demographic, functional status, and medical characteristics were measured at randomization. Outcomes included survival and higher ADL, instrumental ADL (IADL), and outdoor ambulation scores.

MAIN RESULTS

Multiple medical, social, behavioral, and functional factors were associated with outcomes. Primary cardiac disease, number of prescription drugs, alcohol abstinence, and baseline mental status all impacted 6-month survival. Controlling for other factors, team care improved the likelihood of ambulation independent of personal assistance at follow-up (P = .027), treating an estimated 10 patients per 1 benefiting. Further, rehabilitative in-home team care neutralized mortality and functional risk factors (low number of baseline contacts and coresidence) apparent in usual care.

CONCLUSIONS

Heterogeneous clinical populations of older patients contain many prevalent characteristics important to outcomes. Secondary analysis of trials including interactions identifies treatable and untreatable risks, what program components may be effective, and who benefits.

A geriatric assessment and intervention team for hospital inpatients awaiting transfer to a geriatric unit: a randomized trial

The objective of this study, designed as a randomized controlled trial, was to decrease the length-of-stay (LOS) of hospitalized patients on a waiting list for admission to an inpatient geriatric assessment unit (GAU), and to optimize use of the GAU and other hospital services. The participants included 108 elderly, functionally impaired inpatients referred for geriatric consultation, and appropriate for GAU admission, stratified into high and low ADL functioning groups. They were admitted to a 354-bed acute hospital, with a 31-bed long-stay ward and a 15-bed GAU; a 25-30 day delay occurred between screening and admission of inpatients to the GAU. Experimental subjects (N = 25) received the consultative services of a geriatric assessment and intervention team (GAIT) immediately after being qualified for GAU admission, in place of waiting for GAU services. Controls (N = 52) received usual hospital care until admitted to the GAU. While high-function patients randomized to the GAIT had significantly shorter hospital LOS than comparable controls (41.4 vs 56.5 days; p = 0.03), LOS reduction was even greater in the low-function stratum (44.5 vs 74.5 days; p = 0.001). Further, significantly more GAIT than control patients were discharged home (28% vs 11%; p = 0.044). A trend toward reduced mortality in the GAIT group was non-significant. We conclude that for Canadian hospitals in which extensive stays of frail elderly patients, "bed blockage", and thus access to unit-based geriatric services are common problems, the GAIT can efficiently decrease hospital LOS, increase home placement, and may improve outcomes.

Inpatient geriatric evaluation and management units: organization and care patterns in the Department of Veterans Affairs

Geriatric evaluation and management units (GEMs) are designed to improve the functional health and placement of frail elderly hospital inpatients. We surveyed Department of Veterans Affairs (VA) GEMs to describe their care patterns and organization. GEMs meeting consensus standards (n = 46) varied considerably. Hospital, GEM, and patient-admission factors (e.g., hospital psychiatric mix, GEM location, proportion of GEM admissions from nursing homes) predicted length-of-stay, readmission rate, and discharge status. Ongoing monitoring may improve the effectiveness of VA GEMs systemwide.

Inpatient geriatric evaluation and management units (GEMs) in the veterans health system: diamonds in the rough?

BACKGROUND

Research suggests that inpatient geriatric evaluation and management units (GEMs), which undertake interdisciplinary diagnosis to improve the health of frail elderly patients, are effective. The Department of Veterans Affairs (VA) helped pioneer U.S. GEMs and mandates that every facility shall have a GEM by 1996. We conducted a population survey of VA GEMs in 1991 to assess their dissemination.

METHODS

Various organizational and performance characteristics of GEMs were entered in a data base derived from a piloted questionnaire and administrative records. Basic criteria from consensus reports were used to classify and compare "standard" and "nonstandard" GEMs. The criteria covered performance of assessment, team structure, patient selection, GEM location, and treatment functions. We analyzed the effect of GEM type and other factors on length of stay and placement. Reasons for closure of GEMs inactive in 1991 were recovered, and GEMs active in 1991 but later closed are described.

RESULTS

As of 1991, 41 of 73 GEMs were classified as standard, and 32 nonstandard. Standard compared to nonstandard GEMs had shorter stays (25.4 vs 69.9 days; p < .001), higher home discharge rates (63.4% vs 40%; p < .001), and lower nursing home placement rates (19.1% vs 40.3%; p < .001). Eleven hospitals had closed their programs by 1991. By 1993, 6 additional GEMs had closed; all were nonstandard in 1991.

CONCLUSIONS

Most VA GEMs are organized according to basic consensus standards, and appear to be discharging most patients back to the community after reasonably short stays. However, various resource constraints are common, apparently reflected in nonstandard organization and GEM closure. Additional work is needed to monitor GEM proliferation, implementation, and performance in and out of the VA system.

Endothelin-1 potentiates ADP-induced platelet aggregation in chronic renal failure

The effect of preincubation of heparinized whole blood with endothelin-1 (ET-1) on the ADP (adenosine diphosphate) and epinephrine-induced platelet aggregation was examined in 20 healthy donors compared with 20 patients with chronic renal failure (CRF). ET-1 significantly stimulated ADP-induced aggregation in CRF: EC (effective concentration)25 = 2.3 +/- 0.20 with ET-1 vs. 2.7 +/- 0.22 mumol/L without ET-1; EC50: 3.8 +/- 0.18 with ET-1 vs. 4.4 +/- 0.24 mumol/L without ET-1; and EC75: 5.7 +/- 0.22 with ET-1 vs. 6.4 +/- 0.21 mumol/L without ET-1). In healthy donors only the EC25 was significantly increased: EC25 = 2.5 +/- 0.13 with ET-1 vs. 2.8 +/- 0.20 mumol/L without ET-1. No significant influence of ET-1 in epinephrine-induced aggregation was observed in CRF or in healthy donors. The basal values of determined ET-1 were significantly elevated in CRF: 6.99 +/- 0.29 pmol/mL vs. 5.65 +/- 0.33 pmol/mL in healthy donors. The high endogenous level of ET-1 in CRF patients together with an observed higher endogenous plasma level of cAMP (58 +/- 5.2 nmol/L compared to 29 +/- 2.0 nmol/L in healthy donors) may explain the enhanced pharmacological interaction of ET-1 and ADP in CRF patients. The data suggest that positive agonist interaction between ET-1 and ADP may result from effects on the concentrations of cAMP within the platelet rather than from direct interaction on the membrane receptors or the transmembrane coupling mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between scintigraphic evidence of regional sympathetic neuronal dysfunction and ventricular refractoriness in the human heart

BACKGROUND

Denervation supersensitivity has been proposed as a mechanism for the relation between ventricular arrhythmias and the sympathetic nervous system. Evaluation of this phenomenon in humans has become feasible only recently with the development of noninvasive scintigraphic methods for evaluating the pattern of sympathetic innervation. The purpose of this study was to determine if scintigraphic evidence of sympathetic neuronal dysfunction correlates with measurements of ventricular refractoriness and to evaluate the phenomenon of denervation supersensitivity in humans.

METHODS AND RESULTS

Eleven patients with a history of sustained ventricular tachycardia or sudden cardiac death who were referred for placement of an implantable defibrillator participated in this study (seven men and four women; age, 51 +/- 18 years). Preoperative scintigraphic evaluation of the pattern of sympathetic innervation was performed with 11C-hydroxyephedrine in conjunction with positron emission tomography. At the time of surgery, ventricular refractoriness was determined in regions of myocardium demonstrating normal and reduced 11C-hydroxyephedrine retention in the baseline state and during an infusion of norepinephrine. Scintigraphic evaluation demonstrated regions of reduced 11C-hydroxyephedrine retention in each patient. The effective refractory period in areas of myocardium that demonstrated reduced 11C-hydroxyephedrine retention was significantly longer than in areas of myocardium demonstrating normal 11C-hydroxyephedrine retention (273 +/- 32 versus 243 +/- 32 msec, p < 0.001). Norepinephrine shortened the effective refractory period in regions of myocardium demonstrating normal and reduced 11C-hydroxyephedrine retention to a similar degree.

CONCLUSIONS

There is a correlation between scintigraphic evidence of sympathetic neuronal dysfunction and ventricular refractoriness in the human heart. These observations help validate the use of scintigraphic techniques for evaluation of sympathetic innervation and may assist in the further evaluation of the relation between the sympathetic nervous system and ventricular arrhythmias.

Scintigraphic pattern of regional cardiac sympathetic innervation in patients with familial long QT syndrome using positron emission tomography

BACKGROUND

The purpose of this study was to determine whether scintigraphic evidence of cardiac sympathetic neuronal dysinnervation is present in patients with the familial long QT syndrome. The "sympathetic imbalance" hypothesis for the familial long QT syndrome proposes that the long QT syndrome results from a congenital imbalance of sympathetic innervation of the heart caused by lower-than-normal right cardiac sympathetic activity. Although the majority of clinical features of the long QT syndrome can be understood according to this hypothesis, its validity has never been shown. Noninvasive scintigraphic evaluation of the pattern of sympathetic innervation of the heart has recently become possible with catecholamine analogues that can be taken up by sympathetic nerve terminals: radioiodinated metaiodobenzyl guanidine or C-11 hydroxyephedrine (HED).

METHODS AND RESULTS

Nine affected patients, each from a separate family with familial long QT syndrome, were enrolled in this study (three men, six women; mean age, 39 +/- 16 years). Scintigraphic evaluation of the pattern of cardiac sympathetic innervation in each patient was performed with HED in conjunction with positron emission tomography. The results of scintigraphic imaging in these patients were compared with those obtained in 14 asymptomatic volunteers. Scintigraphic evaluation demonstrated that HED retention index and HED uptake normalized to blood flow were no different in patients with the familial long QT syndrome than in normal control patients.

CONCLUSIONS

Patients with the long QT syndrome have normal cardiac sympathetic innervation as assessed by HED. This finding, although not incompatible with the sympathetic imbalance hypothesis of the long QT syndrome, suggests that if a decrease in right sympathetic activity is present in patients with familial long QT syndrome, it is unlikely to be attributed to an abnormal distribution of cardiac sympathetic nerves.

Response of vasoactive substances to reduction of blood volume during hemodialysis in hypotensive patients

Hypotension is a frequent complication in patients subjected to regular hemodialysis. Insufficient regulation of blood pressure following dialysis with ultrafiltration has been attributed to a lack in hormone activation. To determine whether altered production of vasoactive hormones is involved in the breakdown of blood pressure regulation during hemodialysis (HD), blood volume (BV), atrial natriuretic peptide (ANP), plasma renin activity (PRA), aldosterone (Aldo), norepinephrine (NE), epinephrine (Epi), intact immunoreactive parathyroid hormone (iPTH) and arginine vasopressin (AVP) were examined. The relative BV was measured by continuous hemoglobinometry during the HD period of about 240 min. The total decrease in BV at the end of treatment was 23.5 +/- 4.8% of the pretreatment value. Systolic blood pressure (SBP) was 99.6 +/- 23.0 mmHg before dialysis compared with 74.6 +/- 18.8 mmHg at the end of dialysis and heart rate (HR) increased from 76.3 +/- 5.5/min before to 92.0 +/- 10.0/min at the end of dialysis. Despite the wide range of interindividual variance, the hormonal changes indicate that hypotensive patients under HD develop reduced sensitivity of the angiotensin-renin, adrenergic and AVP systems to volumetric stimuli. A paradoxical activation in iPTH and PRA independent Aldo secretions is apparent.

Response of vasoactive substances to intermittent ultrafiltration in normotensive hemodialysis patients

The changes in blood volume (BV), atrial natriuretic peptide (ANP), plasma renin activity (PRA), aldosterone (Aldo), norepinephrine (NE), epinephrine (Epi), parathyroid hormone (PTH), arginine vasopressin (AVP) and the cyclic nucleotides cAMP and cGMP were measured during a fluctuating BV cycle in 15 patients with end-stage renal failure maintained on chronic hemodialysis (HD). HD consisted of 4 periods of about 60 min each. The first half of each HD period consisted of ultrafiltration (UF) greater than 1,000 ml/h, and the second half consisted of no UF. Changes in relative BV were measured using continuous hemoglobinometry. Total BV at the end of treatment was 74.3 +/- 6.9% of the pretreatment volume. A significant positive correlation between BV and the levels of ANP, PTH, Epi and cGMP and an inverse correlation between BV and PRA, Aldo, AVP and NE were demonstrated. While mean values of NE and AVP levels were directly related to actual changes in BV, individual values did not homogeneously reflect this relationship. The cyclic nucleotides cGMP and cAMP did not follow immediate BV changes, but showed a significant decrease correlated with diminished BV. Based on a pre-postdialysis analysis, significant changes in PRA and Aldo were missing. It seems possible that vascular stability in dialysis patients may be maintained by the response of NE and AVP, and not by the renin-aldosterone system. The changes in ANP and cGMP values correlated most significantly (r = 0.38 and r = 0.51, p < 0.005) with the changes in BV, but no single variable could explain the blood pressure regulation during HD with intermittent rapid UF.

Immunoreactive parathyroid hormone after volume change in normo- and hypotensive hemodialysis patients

The effects of reduced blood volume during hemodialysis on circulating immunoreactive parathyroid hormone (PTH) were determined in relation to changes in blood pressure and heart rate in normo- and hypotensive patients with end stage renal failure. During dialysis the plasma concentration of PTH did not change in normotensives, while PTH increased significantly in patients with a fall in blood pressure during a 25% reduction in effective intravascular volume. The blood volume was measured continuously during hemodialysis using the authors' hemoglobin measurement system. The decrease in blood volume in both groups was comparable. The results suggest that secretion of PTH during hemodialysis may play a role in hemodynamic instability during hemodialysis.

Geriatric home health care. Conceptual and demographic considerations

This article has explored conceptual and demographic aspects of HHC and the distinction between formal and informal care. HHC for elderly persons is shown to be mainly an informal, familial activity with important formal professional, skilled, and unskilled components. Formal home health care in the United States has undergone a historic transformation with the rise of third-party payment as a principal, defining force and with demographic and epidemiologic transition of the general population. Recent national studies demonstrate that the principal population group receiving HHC services--the chronically ill, functionally limited, noninstitutionalized elderly--is growing in number and as a proportion of the group with home and community service needs. Although diverse formal service innovations are being explored to meet these growing needs, current involvement of medical professionals in formal HHC emphasizes relatively short-term, post-acute therapeutic and restorative care offered through Medicare-certified home health agencies.

Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence

Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations. In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta-analysis. In this initial meta-analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta-analysis of 6-month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46-0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42-0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55-0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61-1.49).(ABSTRACT TRUNCATED AT 250 WORDS)

Working group recommendations: methods for geriatric evaluation and management research

Methodological issues relating to multi-site studies of inpatient geriatric evaluation and management units were the focus of this working group's deliberations. The group favored a randomized clinical trial in which the inpatient geriatric evaluation and management unit was coupled with outpatient geriatric care. Inclusion of a broad spectrum of patients stratified according to risk for poor hospital outcomes was proposed in order to obtain information on the types of patients that would be most likely to benefit. The need for a detailed definition and description of care in the unit and of "usual care" was emphasized. Serious concerns were raised about including both VA medical centers and private hospitals in the same trial due to differences in the implementation of such a program. Furthermore, fears of contamination of the control group suggested that hospitals could be randomized either to provide usual care or have a GEM unit. However, this strategy would necessitate that hospitals that have already developed inpatient GEM units would be excluded from the trial and could be costly because of the number of hospitals that would be required.

Evidence for regional catecholamine uptake and storage sites in the transplanted human heart by positron emission tomography

Positron emission tomography in combination with the newly introduced catecholamine analogue [11C]hydroxyephedrine ([11C]HED) enables the noninvasive delineation of sympathetic nerve terminals of the heart. To address the ongoing controversy over possible reinnervation of the human transplant, 5 healthy control subjects and 11 patients were studied after cardiac transplant by this imaging approach. Regional [11C]HED retention was compared to regional blood flow as assessed by rubidium-82. Transplant patients were divided into two groups. Group I had recent (less than 1 yr, 4.4 +/- 2.3 mo) surgery, while group II patients underwent cardiac transplantation more than 2 yr before imaging (3.5 +/- 1.3 yr). [11C]HED retention paralleled blood flow in normals, but was homogeneously reduced in group I. In contrast, group II patients revealed heterogeneous [11C]HED retention, with increased uptake in the proximal anterior and septal wall. Quantitative evaluation of [11C]HED retention revealed a 70% reduction in group I and 59% reduction in group II patients (P less than 0.001). In group II patients, [11C]HED retention reached 60% of normal in the proximal anterior wall. These data suggest the presence of neuronal tissue in the transplanted human heart, which may reflect regional sympathetic reinnervation.

Growth of the teaching nursing home. The Veterans Administration experience

Nursing homes are becoming increasingly involved with medical education, and the Veterans Administration (VA) has been particularly active in this movement. We conducted a system-wide survey of VA nursing home facilities to determine the degree to which they participate in medical and other professional training and the features associated with such training. Of the 116 VA nursing homes in 1987, 113 (97.4%) returned completed questionnaires. Compared to "standard" VA facilities (n = 85), "teaching" nursing homes (n = 28)--those in which physicians received at least 20 hours of training per capita annually--were significantly larger, admitted and discharged significantly more patients per occupied bed, and placed a significantly larger proportion of discharged patients in noninstitutional community settings. Care costs in the teaching nursing homes were slightly but not significantly higher, despite significant increases in levels of professional staffing and amounts of training activities in all disciplines. During the survey year, teaching nursing homes provided training experiences for 440 students, residents, and fellows in internal and rehabilitation medicine, as well as for 2,700 other health professionals. The growth of teaching nursing homes in the VA system appears to be associated with positive changes in the pattern of health-care delivery, and it is increasing the number of health-care professionals trained in long-term care.

Comprehensive geriatric assessment: toward understanding its efficacy

Comprehensive geriatric assessment (CGA) offers health care professionals a technique for multidimensional diagnosis of frail elderly people to plan medical, psychosocial, and rehabilitative care. In the present paper, we provide a brief history of geriatric assessment, a description of the varied organization of geriatric assessment programs (GAPs), and a review of published effectiveness studies of programs worldwide performing comprehensive geriatric assessment. Program diversity has complicated drawing conclusions about the efficacy of CGA from a literature reporting generally positive, but not uniformly significant, results. We suggest that sample size limitations explain much of the variability in findings. Using the techniques of meta-analysis, we evaluate the effect of GAPs on mortality when all controlled trials are considered cumulatively. Meta-analysis of six-month mortality demonstrates a statistically significant 36% reduction of mortality for inpatient CGA programs (odds ratio = 0.64; 95% confidence interval = 0.50 to 0.83), and a 32% mortality reduction for all CGA programs (odds ratio = 0.68; 95% confidence interval = 0.57 to 0.80). Further use of meta-analytic techniques can be employed to clarify the effect of GAPs on other important outcomes (e.g., reduced hospital and nursing home use, improved functional status), and to identify program characteristics best promoting these benefits.

Evaluating humanistic attributes of internal medicine residents

OBJECTIVE

Methods of assessing humanism in internal medicine residents have not been completely designed or evaluated. This study used patient satisfaction as a measure of humanism, and assessed the validity of using faculty physicians to evaluate residents' humanistic behavior. Residents' ability to assess themselves was also evaluated.

SETTING

A university-affiliated internal medicine training program.

SUBJECTS

Forty-seven internal medicine residents were evaluated by patients, faculty, and themselves.

DESIGN

Faculty physicians were given standard faculty evaluation and patient satisfaction forms, and were asked to evaluate residents. These evaluations were compared with the patients' responses on the same satisfaction forms. Residents performed self-assessment using identical forms; these responses were compared with those of the faculty and patients.

RESULTS

There was no correlation between patients' responses and those of the faculty or residents. There was a significant inverse correlation between resident and faculty responses, especially for the female residents (r = 0.71).

CONCLUSION

These findings suggest the need for further study of the evaluation process, including what factors influence individuals to respond as they do. It appears that the use of one rating group is not sufficient to achieve an accurate assessment of residents' humanistic skills. The present status of the process of evaluating humanism is discussed.

Dynamics and clinical implications of the nursing home-hospital interface

Nursing homes and hospitals are dynamically interrelated, and there is much that the clinician can do to optimize patient transitions between institutions. This article approaches this topic in three sections: epidemiology of movement between hospitals and nursing homes, impacts of policy changes and financial incentives on patient transfers, and clinical strategies to reduce unnecessary hospitalizations of nursing home patients.

Organizing an academic nursing home. Impacts on institutionalized elderly

In March 1984, a program for an academic nursing home was established at the Sepulveda Veterans Administration Medical Center. The program was designed to improve care of nursing home patients, provide interdisciplinary training for medical house staff and allied health students, and stimulate research. Geriatric faculty physicians were appointed, medical house staff were assigned as primary physicians to groups of patients, and geriatric nurse practitioners were hired to provide day-to-day care. A two-phase evaluation of the impact of the academic nursing home on patient care was conducted. Beneficial developments associated with the program in concurrent comparison with the standard nursing home unit included a significant decrease in patient transfers to the acute-care hospital and significant improvements in functional status, patient satisfaction, and morale. A trend toward improved survival was nonsignificant. Longer-term follow-up revealed a significantly increased rate of discharge for patients completing long-term rehabilitation. Overall, the costs of nursing home care were only minimally increased by the program. Results suggest that programs like the academic nursing home can lead to improved process and outcomes of nursing home care.