Proxies' decisions about clinical research participation for their charges

OBJECTIVE

To examine the process by which proxies decide about their charges' participation in clinical research.

DESIGN

Using eight hypothetical research studies encompassing a variety of risks and benefits, we interviewed 315 competent persons > or = 65 years old (charges) and, separately, the individuals who would be designated as their proxies if the charges were to become incompetent. The proxies were asked what they thought their charges would decide and what decisions they would make for their charges and for their own participation.

SETTINGS

A medical house-call program, two apartment complexes, and three nursing homes.

PARTICIPANTS

Charges > or = 65 years old and their proxies.

MAIN OUTCOME MEASURE

Comparison of decisions made by charges and by proxies for their charges.

RESULTS

The agreement between the proxies' and charges' decisions was not significantly different from random agreement (range of kappa statistics, 0.05-0.15). Rather, proxies' decisions for their charges were significantly related to the proxies' decisions for themselves (kappas, 0.52-0.86). When the paired proxies' and charges' decisions differed, the proxies were protective, more frequently refusing their charges' participation in the perceived riskier research studies.

CONCLUSIONS

Proxies did not know what their charges would decide. Their choices for the charges related more to the proxies' decisions about their own participation (which they knew) than to the decisions of their charges (which they didn't know). This is similar to the process of a reasonable person making the decision, a characteristic of decisions made in the best interests of the patient.

Organ-limited autopsies. Obtaining permission for postmortem examination of the urinary tract

OBJECTIVE

To develop a systematic pre- and postmortem program for obtaining permission for autopsies limited to the urinary tract.

DESIGN

Comparison versus historical control of autopsy permission using a new process comprising premortem education, modification of the permission process, and autopsy limited to the urinary tract.

PARTICIPANTS AND SETTING

Patients, family members, and healthcare providers associated with a nursing home.

INTERVENTION

Education of healthcare providers and family members and modification of autopsy consent and performance.

MAIN OUTCOME MEASURE

Permission rate and demographic characteristics of patients and family members giving permission.

RESULTS

Of the 361 patients who died during the study, we received permission for postmortem examination of the urinary tract for 129 (36%). This was substantially better than the autopsy rate in the year prior to the study, 0.6%. A significantly higher permission rate was associated with patients and contact persons of white race, a higher level of education of the contact person, a nonrelative contact person, and two or fewer individuals making the decision.

CONCLUSION

Permission for organ-limited autopsies can be obtained with a systematic approach.

Family medicine residents' knowledge and attitudes about drug-nutrient interactions

OBJECTIVE

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that health professionals recognize the importance of drug-nutrient interactions and educate patients to prevent adverse effects. Drug-nutrient interactions are an important issue in medical practice, but it is not clear how or if physicians are trained in this issue.

METHODS

This investigation was a needs assessment that examined attitudes and knowledge about drug-nutrient interactions that was examined in a national sample of 834 family medicine residents in 56 residency programs.

RESULTS

Most reported they had little or no formal training in drug-nutrient interactions in medical school (83%) or residency (80%). However, 79% believed it was the physician's responsibility to inform patients about drug-nutrient interactions, although many thought pharmacists (75%) and dietitians (66%) share this responsibility. Overall, residents correctly answered 61% +/- 19 of fourteen drug-nutrient interaction knowledge items. There was a slight increase in drug-nutrient knowledge as year of residency increased.

CONCLUSIONS

Physicians' knowledge of drug-nutrient interactions may be improved by including nutrition education in the topics taught by physicians, nutritionists, and pharmacists using several educational strategies. Nutrition educators in particular can play a role in curriculum development about drug-nutrient interactions by developing, refining, and evaluating materials and educational tools. Nutrition educators need to provide this information in academic settings for the training of all health professionals as well as in patient education settings such as hospitals and public health clinics.

Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation

OBJECTIVE

To determine the prevalences of chronic pyelonephritis and chronic renal inflammation in elderly nursing home patients at the time of death and to assess correlation with urethral catheterization and other putative risk factors.

DESIGN

Prospective assessment of risk factors with the prevalences of chronic pyelonephritis and renal inflammation at autopsy.

SETTING

A 240-bed long-term care facility.

PARTICIPANTS

All residents > or = 65 years old who died and were autopsied during a 2-year period.

MEASUREMENTS

Antemortem assessment of risk factors for renal inflammation, including a search for any urethral catheterization in the person's life. Prospective assessment of urethral catheterization, catheter obstruction, and use of anti-inflammatory medications and urine cultures. Urinary tract pathology was assessed for gross and microscopic evidence of inflammation and urinary tract stones.

RESULTS

The duration of catheterization was significantly associated with increasing prevalence of bacteriuria, polymicrobial bacteriuria, chronic pyelonephritis, and chronic renal inflammation. The prevalence of chronic pyelonephritis at death was 10 percent (5/52) for patients catheterized > 90 days during their last year of life and zero (0/65) when catheterized < or = 90 days (P < 0.02; Fisher's exact test). Chronic pyelonephritis was significantly associated with renal stones and hydronephrosis. The prevalence of chronic renal inflammation without chronic pyelonephritis was significantly greater than that of chronic pyelonephritis: the prevalence was 43 percent (20/47) when catheterized > 90 days and 18 percent (12/65) when < or = 90 days (P < 0.05). Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension.

CONCLUSION

Chronic pyelonephritis and chronic renal inflammation are associated with long-term catheterization.

Prevalence and characteristics of nursing home-acquired infections in the aged

OBJECTIVES

This study provides estimates of the prevalence of infections in all patients from a representative sample of 53 Maryland nursing homes; identifies risk factors for these infections; and describes diagnostic procedures carried out.

METHODS

The records of 4,259 patients in a stratified random sample of 53 Maryland nursing homes were reviewed for diagnostic procedures, medical, functional, and behavioral status. Infections were identified by signs, symptoms, and laboratory findings.

RESULTS

Study patients were characteristic of aged patients in US nursing homes. The prevalence of infections actually acquired in the nursing home (80% of all infections) was 4.4%. Multivariate analysis revealed that skin infections (35% of nursing home-acquired infections) were associated with skin ulcers and inversely with urine incontinence. Fevers of uncertain source (13%) were associated with bladder catheters. Symptomatic urinary infections (12%) and lower respiratory infections (12%) were associated with bedfast status, and the latter with tracheostomy and lung disease. Skin ulcers, urethral catheters, and bedfast status were markers for nursing home-acquired infection. The prevalence of infection in patients with all three markers was 32%; in patients with none, 2%. Fewer than a quarter of the four most common nursing home-acquired infections received an evaluation which met minimal diagnostic criteria established by a panel of infectious disease specialists and geriatricians. Patients with dementia, those in large homes (greater than 150 beds), and those in urban homes were less likely to be evaluated in a manner meeting these criteria.

CONCLUSIONS

Use of three characteristics (ie skin ulcers, urethral catheters, bedfast status) to identify patients at risk for nursing home-acquired infections may allow targeted infection surveillance and prevention programs. In addition, nursing home-acquired infections are not evaluated uniformly across patients and facilities, suggesting the need to establish, through further study, guidelines for such evaluations.

An external urine collection device for incontinent women. Evaluation of long-term use

Urinary incontinence is common in aged women, may precipitate nursing home admission, and may prompt use of a urine collection device, usually an indwelling urethral catheter. The safety and efficacy of a new external urine collection device for women that is affixed to the perineum by an adhesive developed for ostomy bags was evaluated. Applied to 26 aged women, 78% of 2,264 devices were leak-free for 24 hours and 49% for 48 hours. The incidence of new bacteriuria was less than half that found in our earlier studies of long-term urethral catheters in the same institution. Perineal erythema was infrequent and preexisting decubitus ulcers improved or did not change. Four patients were withdrawn, one each because of periurethral itching, diminished urine output, recurrent wetness, and fracture of the proximal femur associated with severe osteoporosis. This device may offer an alternative to urethral catheters for management of urinary incontinence but should not be used on women with urine retention and should be used with care on women with severe osteoporosis. Controlled trials must determine effects upon bacteriologic complications and health-care costs.

Reasons for replacement of long-term urethral catheters: implications for randomized trials

On any given day more than 100,000 nursing home patients have indwelling urethral catheters in place. We prospectively followed 47 such patients for almost 18 patient-years and observed 249 catheter replacements. The mean number of replacements per 100 days of catheterization was 3.1 (71% of the catheters were replaced within 30 days of insertion). Nonprescribed removal by the patient or nursing staff was the most frequent cause of replacement (43%), followed by leakage (33%) and obstruction (24%). Catheter replacements followed patient-specific patterns, with each reason for replacement being associated significantly with the reason for the prior replacement (p less than 0.001). To minimize the effect of patient-specific replacement patterns, studies of complications of catheterization that may be affected by catheter obstruction or replacement should use cross-over designs.

NAPCRG abstracts 1977-1987: analysis of research designs and methods

Research techniques reflect the approach of a discipline to the issues it faces. The annual North American Primary Care Research Group (NAPCRG) meeting has been a forum for family medicine research since 1973. A cross-sectional content analysis was conducted on all 1,295 printed NAPCRG abstracts from 1977 to 1987, classifying the research design and methods. The number of abstracts per meeting increased from 58 in 1977 to 149 in 1987. The predominant research design was cross-sectional (58%), followed by prospective (15%), experimental (15%), and retrospective (3%). The major methods were surveys (34%), chart reviews (24%), or surveys combined with chart reviews (7%). One fourth of all abstracts were cross-sectional surveys. NAPCRG research designs and methods have not changed substantially during these 11 years.

Diflunisal and ibuprofen: effects on gastric and duodenal mucosa in patients with osteoarthritis

Patients with osteoarthritis make up the largest group of users of nonsteroidal anti-inflammatory drugs (NSAIDs), but the effects of these agents on the gastrointestinal mucosa of such patients have not been well studied. This article describes a short-term comparison of two widely used NSAIDs, diflunisal and ibuprofen, in patients requiring these medications for their osteoarthritis. Efficacy, tolerability, and endoscopically documented effects of these drugs on the gastric and duodenal mucosa were assessed. Consenting, eligible patients were randomly assigned to one of the two study drugs for a two-week course. Clinical assessments were made after each week of treatment. Fiberoptic endoscopy and laboratory tests were performed before and after the treatment period. Thirty patients completed the study: 16 received diflunisal and 14 received ibuprofen. Similar improvements in pain, joint mobility, functional capacity, and joint swelling and tenderness were observed in both treatment groups. Transient, mild abdominal cramping was reported by two patients in each group; one patient receiving ibuprofen complained of transient dizziness. No patient withdrew from the study because of side effects. Follow-up endoscopy revealed slight (grade 1) changes in the gastric mucosa of two patients in each treatment group. An additional patient in the ibuprofen group had gastric erosions (grade 2) at the end of the study. Endoscopic changes were not correlated with symptoms. Diflunisal and ibuprofen were found to be similarly effective and well tolerated in the treatment of osteoarthritis. Their use may be associated with some gastrointestinal side effects even during short-term use.

Dietary habits, weight history, and vitamin supplement use in elderly osteoarthritis patients

Osteoarthritis is a chronic disabling disease in the elderly, but few studies have examined nutritional parameters of osteoarthritis patients. For 82 ambulatory elderly osteoarthritis patients, a registered dietitian assessed the following: consumption of 72 food items, using a food-frequency questionnaire; weight history, by measuring current weight and asking the weight at age 20, maximum adult weight, and minimum adult weight; dietary habits; and vitamin supplement consumption. Joint pain and activities of daily living (ADL) were assessed by a physician. On the basis of the Four Food Group guidelines, dietary intakes were suboptimal in the dairy and grain groups, which are important sources of calcium, vitamin D, thiamin, iron, and riboflavin. Eighty percent of the sample were obese (BMI greater than or equal to 27). The average weight change since early adulthood was a gain of 59 lb. Current joint pain and ADL restrictions were not related to obesity or weight gain. Vitamin/mineral supplements were consumed by 37% of the sample.

Once-daily irrigation of long-term urethral catheters with normal saline. Lack of benefit

Urinary incontinence is often managed with a long-term urethral catheter after other methods have failed. Such urethral catheterization is associated with polymicrobial bacteriuria, catheter obstruction, fever, bacteremia, urinary tract stones, and death. Periodic catheter irrigation is a common but untested management procedure intended to prevent catheter obstruction, fevers, and/or bacteremia. To evaluate this technique, we performed a randomized crossover trial comparing ten weeks of once-daily normal saline irrigation with ten weeks of no irrigation in 32 long-term catheterized women. The incidence of catheter obstructions and febrile episodes and the prevalence and species of bacteriuria were similar whether examined as completed crossover patients (N = 23) or as partially completed trials (N = 9). Once-daily irrigation with normal saline of long-term urethral catheters is a time-consuming and costly procedure that is unlikely to have an impact on the morbidity associated with such catheters.

Acute pyelonephritis associated with bacteriuria during long-term catheterization: a prospective clinicopathological study

Bacteriuria is virtually universal in long-term catheterized patients. This blinded autopsy study of 75 aged nursing home patients demonstrated that acute inflammation of the renal parenchyma was present in 38% of patients with a urinary catheter in place at death versus 5% of noncatheterized patients (P = .004). Of a number of clinical and demographic variables studied, only catheterization was significantly related to acute renal inflammation. Acute cystitis was uncommon, but each case was associated with inflammation of at least one kidney. The majority of kidneys showing acute inflammation (21 [68%] of 31) were not accompanied by acute pyelitis. Acute renal inflammation with or without pelvic inflammation is a common finding in nursing home patients dying with urethral catheters in place. This finding provides additional support for the development of alternatives to the indwelling urethral catheter.

Self-reported referral patterns in practices of family/general practitioners, internists, and obstetricians/gynecologists

A profile of referrals can help to define the characteristics of a physician's practice. Self-reported referral patterns in the practices of Family/General Practitioners (FP/GP), Internists (IM), and Obstetricians/Gynecologists (OB/GYN) in Maryland were assessed with a questionnaire mailed to an area sample of 1,715 physicians. A 65% response rate was obtained after three mailings (weighted N = 1,487). Self-reported referrals received per month averaged 16% of patients seen (six percent FP/GP, 13% OB/GYN, 23% IM), and were more frequent among self-employed, younger, metropolitan and female physicians who spent less time in patient care. Self-reported referrals made per month averaged ten percent (10% FP/GP), 11% IM, and eight percent OB/GYN), and were higher for physicians in metropolitan areas. The correlation between percentage referrals received and percentage referrals made was r = .19 (r = .03 FP/GP, r = .21 IM, r = .25 OB/GYN). Self-reported practice referral patterns are similar to referrals reported in prior studies, and can be used to consider specialty differences in referral behavior of physicians.

Long-term urethral catheters in older women

If other methods of managing urinary incontinence fail, a long-term urethral catheter may be considered. Bacteriuria invariably develops in patients with a catheter in place for 30 days or more. With long-term catheterization, bacteriuria becomes polymicrobial, including familiar and unfamiliar uropathogens. Some febrile episodes, particularly those with high temperatures, can be fatal.

Fever, bacteremia, and death as complications of bacteriuria in women with long-term urethral catheters

Numbers of nursing home beds now exceed hospital beds in the United States and are usually occupied by women. Urinary incontinence is very common and may be managed with long-term urethral catheters. Bacteriuria invariably results, yet its clinical consequences are not well known. We studied 47 catheterized and bacteriuric women for almost 25 patient-years. The incidence of febrile episodes of possible urinary origin was 1.1 episodes/100 patient-days. Because these were diagnoses of exclusion, even this low incidence may be an overestimate. Most of these episodes were of less than or equal to 38.3 C (101.0 F), lasted for less than one day, and resolved without antibiotic therapy. Six deaths, half the total from all causes, occurred during these episodes, an incidence 60 times that during afebrile periods. Deaths and bacteremias were significantly associated with episodes of greater than or equal to 38.8 C (102.0 F). In the individual patient, these risks should be weighed against benefits of patient comfort, family satisfaction, and prevention and management of decubitus ulcers.

A practical method of estimating stature of bedridden female nursing home patients

Accurate measurement of stature is important for the determination of several nutritional indices as well as body surface area (BSA) for the normalization of creatinine clearances. Direct standing measurement of stature of bedridden elderly nursing home patients is impossible, and stature as recorded in the chart may not be valid. An accurate stature obtained by summing five segmental measurements was compared to the stature recorded in the patient's chart and calculated estimates of stature from measurement of a long bone (humerus, tibia, knee height). Estimation of stature from measurement of knee height was highly correlated (r = 0.93) to the segmental measurement of stature while estimates from other long-bone measurements were less highly correlated (r = 0.71 to 0.81). Recorded chart stature was poorly correlated (r = 0.37). Measurement of knee height provides a simple, quick, and accurate means of estimating stature for bedridden females in nursing homes.

Informed consent by proxy. An issue in research with elderly patients

The need for clinical study of patients in nursing homes is growing as this population grows; yet many of these patients are mentally incompetent to give informed consent for such research, and the decision must therefore be left to family members or other proxies. We studied the decisions by the proxies for 168 patients in nursing homes about whether to permit the patients' participation in a study involving minimal risk. The proxies were family members in all but one case, and 78 of 168 (46 percent) refused consent. Refusal was significantly associated (P less than 0.001) with the views that research should not be done in nursing homes, that the study would disturb the patient, that the patient, if able, would refuse to participate in the study, and that the proxy would refuse to participate in such a study if asked. Of the 55 proxies who believed that the patient would refuse consent, however, 17 (31 percent) gave consent, in apparent opposition to the patient's wishes. We conclude that refusal by family members to allow incompetent elderly patients to participate in studies may be an important obstacle to research among the elderly. Both the selection of proxies and the bases for their decisions require further study and definition.

Prescribing postpartum iron supplementation: a survey of practicing obstetricians

Supplemental iron (excluding the amount in prenatal vitamins) is routinely recommended post partum by standard obstetric textbooks. We surveyed practicing obstetricians in Maryland to examine their indications for and prescription of postpartum iron supplements. The survey was returned by 201 physicians (33% response rate). Iron was prescribed by 25% of the physicians always, 12% never, and 63% depending upon the patient. An average of 37% of postpartum patients were given iron. The most frequently cited indication for prescribing iron was the postpartum hematocrit level (used by 90% of the physicians), followed by high blood loss (41%), operative delivery (15%), mean corpuscular volume (12%), and toxemia (9%). The postpartum iron dosage (325 mg) was prescribed as a single daily dose by 22%, twice daily by 37%, and three times daily by 32%. These practices do not correspond to the current recommendation that postpartum iron should always be prescribed.

Health promotion: physicians' beliefs, attitudes, and practices

There is a paucity of research describing the health-promotion beliefs, attitudes, and practices of physicians. Self-reported data from a survey of 1,040 primary care physicians showed that a majority of physicians (97 percent) believed they should modify patients' behaviors to minimize risk factors and rated a variety of health behaviors as important in promoting health. While most physicians gathered information about risk factors and believed they were prepared to counsel patients, only a small percentage (3-18 percent) reported being very successful in helping patients achieve behavioral change. However, given appropriate support, physicians reported that they could be up to six times more successful in influencing behavioral change. This study indicated that physicians have strong beliefs and interests in health promotion, are interested in continuing education about health promotion topics, and desire a variety of new skills to help patients modify their health behaviors.

Nutritional supplement use by patients in a rural family practice

The use of nutritional supplements (vitamins, minerals) has been reported to be as high as 66% for individuals and 54% for households. Among medical patients in metropolitan areas, 66% of suburban private patients and 31% of urban clinic patients use supplements. Reported here are results of a survey to assess the use of nutritional supplements by rural family medicine patients. A sample of patients (N = 199) in one practice completed a standardized questionnaire, and 54% reported that they had taken supplements (primarily multivitamins) during the previous 6 months. The desire to assure good nutrition and less fatigue were the major reasons cited for supplement use; 50% were daily users, and 42% had used supplements for longer than 3 years.

Physicians' beliefs about the importance of 25 health promoting behaviors

A mail survey of 1,040 primary care physicians in Maryland examined their beliefs about the importance of 25 behaviors for promoting the health of the average person. Physician consensus existed across specialties in rating most health behaviors as very important and few as very unimportant. Eliminating smoking was most important and taking vitamin supplements least important.

Nutritional supplement utilization in an urban family practice center

A survey of 128 patients in an urban family health center examined their use of nutritional supplements and found that 31 percent currently used supplements, primarily multivitamins and other vitamins. The patients' desire to increase their energy and to ensure good nutrition were the major reasons for their taking supplements, along with prevention of illness, desire for strength, and dealing with stress. Patients reported that they were influenced by their physicians' advice and were willing to change their supplement use upon physician recommendation. The resident physicians who cared for these patients were also surveyed, and they estimated that an average of 23 percent of their patients used nutritional supplements. Residents did not consider discussion of nutritional supplements to be of high priority, nor did they usually discuss them with their patients. Discussion about the use of nutritional supplements can contribute to the role family physicians play in nutrition education.

Developing a cancer prevention elective course

A comprehensive course on cancer prevention was developed for medical students at the University of Maryland School of Medicine. This course was developed under a three-year contract with the National Cancer Institute during the period from 1979 to 1982. The course development team was multidisciplinary and consisted of faculty members from the departments of pathology, epidemiology and preventive medicine, and family medicine and the Office of Medical Education. The finished course consisted of 20 instructional modules which can be used individually, in groups, or as a complete course in cancer prevention. During the developmental process, all educational objectives were subjected to intensive review and critique by faculty members from the University of Maryland School of Medicine and several other medical schools. The course was pilot tested as a four-week "minimester" elective, revised, and field tested again. This innovative, multidisciplinary, modular curriculum package is now considered complete and appropriate for use by other health sciences institutions.

Ineffectiveness of cephalexin in treatment of cephalexin-resistant bacteriuria in patients with chronic indwelling urethral catheters

Catheterized patients not only are subject to risks of bacteriuria but the catheter also may act as reservoirs for nosocomial infections. Antibiotics that are concentrated in the urine, even those to which the organisms are nominally resistant, have been advocated as a means of treatment and infection control. During a randomized study of repetitive 10-day courses of cephalexin in chronically catheterized patients we observed the impact of such treatment upon susceptible, moderately resistant and highly resistant strains of bacteria. Cephalexin diminished the persistence of cephalexin-susceptible strains. However, its effect upon moderately resistant (inhibited by 200 micrograms per ml.) was not different than its effect upon highly resistant (not inhibited by 200 micrograms per ml.) strains. Indeed, the persistence of strains of moderately and highly resistant organisms during cephalexin courses was similar to that of such organisms during comparable periods in patients not receiving cephalexin. The administration of cephalexin to chronically catheterized patients with moderately or highly resistant organisms causing bacteriuria does not clear these organisms from the urine.

A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters

Bacteriuria is common in chronically catheterized patients and is associated with both acute and chronic complications. Of 605 consecutive weekly urine specimens from 20 chronically catheterized patients, 98% contained bacteria at high concentrations and 77% were polymicrobial. The mean interval between new episodes of bacteriuria was 1.8 weeks. Most species of bacteria caused five to seven new episodes of bacteriuria per 100 weeks of catheterization. Even though access to the catheter lumen was similar, the duration of bacteriuric episodes varied greatly by species. Of the episodes of bacteriuria caused by nonenterococcal gram-positive cocci, greater than 75% lasted less than one week. Mean durations of episodes of bacteriuria due to Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa were four to six weeks, whereas those due to Providencia stuartii averaged 10 weeks and ranged up to 36 weeks. Thus, the very high prevalence of bacteriuria--virtually 100%--was a result of a high incidence caused by many different species combined with the prolonged residence of some gram-negative bacilli in the catheter and urinary tract.

Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients

Patients with long-term indwelling urethral catheters are subject to acute and long-term complications of bacteriuria. To evaluate the common practice of short-course antibiotic therapy in such patients, we performed a randomized controlled trial of ten-day courses of cephalexin monohydrate repeated whenever a susceptible bacteriuria was present. We observed 17 cephalexin group patients for 545 patient-weeks (160 cephalexin courses) and 18 control group patients for 477 patient-weeks. Throughout the study, the groups were comparable in regard to incidence and prevalence of bacteriuria, number of bacterial strains per weekly urine specimen, incidence of febrile days, and incidence of obstructed catheters. In the cephalexin group, the frequency of fever during periods when antibiotics were being used was similar to that during periods when antibiotics were not being used. More cephalexin-resistant bacteria were isolated from cephalexin group patients. Routine treatment with cephalexin of asymptomatic long-term catheterized patients, even for susceptible organisms, does not seem to be warranted.

Prevalence of protein-calorie malnutrition in an extended care facility

The prevalence of protein-calorie malnutrition has been documented in the acute care hospital. Thirty randomly selected patients at an extended care facility were studied as to their nutritional status. Anthropometric measurements of height, weight, arm circumference, and triceps skin fold were obtained as well as laboratory studies of hematocrit, while blood cell count, albumin, and transferrin. Between 47 and 66 percent of the patients had moderate or severe protein-calorie malnutrition by anthropometric measurements, and 60 percent had a serum albumin level less than 3.5 g/100 mL. There was a significant correlation (r greater than .5) between the percent of standard weight/height and arm muscle circumference (r = .601, P less than .001) as well as triceps skin fold (r = 6.13, P less than .001). Serum albumin was highly correlated to hematocrit (r = .721, P less than .001). Sixty percent of the patients were anemic and 24 percent were leukopenic. There was no correlation between length of stay and serum albumin. Physicians will need to increase their awareness and observation of this problem in patients in extended care facilities and become cognizant of the potential detrimental effects protein-calorie malnutrition may have on the rehabilitative process.