Protein-energy undernutrition among elderly hospitalized patients: a prospective study

CONTEXT

Numerous studies have identified strong correlations between the severity of nutritional deficits and an increased risk of subsequent morbid events among the hospitalized elderly, but whether inadequate nutrient intake during hospitalization contributes to such nutritional deficits or the risk of adverse outcomes is not known.

OBJECTIVES

To identify the distribution of average daily nutrient intake among the nonterminally ill hospitalized elderly, ascertain what factors contribute to persistently low intakes, and determine whether the adequacy of nutrient intake correlates with the risk of mortality.

DESIGN

Prospective cohort study conducted from 1994 to 1997.

SETTING

University-affiliated Department of Veterans Affairs hospital.

PATIENTS

A total of 497 patients 65 years or older (mean [SD] age, 74 [6] years; 97% male; 86% white) with a length of stay of 4 days or more.

MAIN OUTCOME MEASURES

Daily in-hospital nutrient intake, in-hospital mortality, and 90-day mortality.

RESULTS

A total of 102 patients (21%) had an average daily in-hospital nutrient intake of less than 50% of their calculated maintenance energy requirements. Admission illness severity, average length of stay, and admission albumin and prealbumin levels for this low nutrient group did not differ significantly from those of the remaining patients. However, the low nutrient group had lower mean (SD) discharge serum total cholesterol (154 [44] mg/dL [4 [1.1] mmol/L] vs 173 [42] mg/dL [4.5 [1.1] mmol/L]; P=.001), albumin (29.1 [6.7] vs 33.2 [6.1] g/L, P=.001), and prealbumin (162 [69] vs 205 [68] mg/L; P=.001) concentrations and a higher rate of in-hospital mortality (relative risk, 8.0; 95% confidence interval, 2.8-22.6) and 90-day mortality (relative risk, 2.9; 95% confidence interval, 1.4-6.1). Contributing to the problem of inadequate nutrient intake, patients were frequently ordered to have nothing by mouth and were not fed by another route. Neither canned supplements nor nutritional support were used effectively.

CONCLUSIONS

Throughout their hospitalization, many elderly patients were maintained on nutrient intakes far less than their estimated maintenance energy requirements, which may contribute to an increased risk of mortality. Given the difficulties reversing established nutritional deficits in the elderly, greater efforts should be made to prevent the development of such deficits during hospitalization.

Protein-energy undernutrition and the risk of mortality within six years of hospital discharge

OBJECTIVE

The primary objective was to determine whether protein-energy undernutrition among elderly patients discharged from the hospital remains a significant risk factor for mortality beyond 1 year.

DESIGN

Prospective Survey (cohort study).

SETTING

Outpatient follow-up of patients discharged from a Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital.

PARTICIPANTS

Of 350 randomly selected admissions to the GRU, 322 were discharged alive from the hospital. These 322 patients represented the study population of whom 99% were male, and 75% were white. The average age of the study patients was 76 (range 58 to 102) years.

MEASUREMENTS

At admission and again at discharge, each patient completed a comprehensive medical, functional, neuro-psychological, socioeconomic, and nutritional assessment. Subsequent to discharge, each subject was tracked for an average of 6 years. In addition to including serum albumin and other putative nutrition indicators in the data set, a "nutrition-risk" indicator variable was created. Subjects were stratified into the nutrition "high-risk" group if their albumin was less than 30 g/L or BMI was less than 19; and, "low-risk" group if albumin was equal to or greater than 35 g/L and BMI equal to or greater than 22. All others represented the "moderate-risk" group.

RESULTS

Within the 6-year post-hospital-discharge follow-up period, 237 study subjects (74%) died. Based on the Cox proportional hazards survival model, the variable most strongly associated with mortality was discharge "nutrition-risk" followed by the Katz Index of ADL Score, diagnosis of congestive heart failure, discharge location (home vs. institution), age, and marital status. Within the first 4.5 years of follow-up, the relationship between "nutrition-risk" and mortality remained constant. After 4.5 years, the strength of the correlation began to diminish.

CONCLUSIONS

Among the elderly, protein-energy undernutrition present at hospital discharge appears to be a strong independent risk factor for mortality during the subsequent 4.5 years or longer.

Mini radial keratotomy reduces ocular integrity. Axial compression in a postmortem porcine eye model

OBJECTIVE

This study aimed to examine ocular rupture force in pig eyes after "minimally invasive radial keratotomy" (MRK) and standard radial keratotomy (SRK).

DESIGN

Experimental study.

MATERIALS

A total of 71 pairs of pig eyes (51 control eyes) were examined.

INTERVENTION

An axial-torsional Materials Testing System (MTS, Eden Prairie, MN) was used to apply blunt force to the corneal surface. A force transducer measured the rupture forces in control eyes and in eyes with MRK or SRK. Five groups of paired eyes were compared: 2.0-mm MRK versus control (N = 12), 3.5-mm MRK versus control (N = 21), 6.5-mm SRK versus control (N = 18), SRK versus 3.5-mm MRK versus 2.0-mm MRK (N = 10).

MAIN OUTCOME MEASURE

Ocular rupture force (newtons) was measured.

RESULTS

The mean rupture force in newtons was 746.3 for control eyes, 514.2 for 2.0-mm MRK, 353.1 for 3.5-mm MRK, and 246.2 for SRK. Analysis of variance showed a statistically significant difference (P < or = 0.04) between paired comparisons.

CONCLUSION

The MRK and SRK significantly weakened ocular integrity compared with control eyes not operated on. MRK required significantly more force to rupture than SRK. MRK eyes, however, ruptured at 50% to 70% of the force required to rupture eyes not operated on. Any patient considering radial keratotomy should be counseled about the risk of greater ocular damage in trauma.

Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial

OBJECTIVE

This non-blinded randomized controlled trial was the first phase of a planned series of investigations designed to test the efficacy of aggressive post-operative enteral nutrition support to decrease the rate of post-operative complications or improve long-term outcomes in specifically defined subgroups of elderly patients who have sustained a hip fracture requiring surgery.

METHODS

Eighteen patients (17 males) were randomized to the treatment (eight male subjects) or control groups. The control group (mean age 76.5+/-6.1 years) received standard post-operative care. Subjects in the treatment group (mean age 74.5+/-2.1 years) received 125 cc/hour of nasoenteral tube feedings over 11 hours each night in addition to standard post-operative nutritional care.

RESULTS

Both the treatment and control groups had reduced volitional nutrient intakes for the first 7 post-operative days (3,966+/-2,238 vs. 4,263+/-2,916 kJ/day [948+/-535 vs. 1019+/-697 kcal/day], p=0.815), but the treatment subjects had a greater total nutrient intake (7,719+/-2,109 vs. 4,301+/-2,858 kJ/day [1845+/-504 vs. 1028+/-683 kcal], p=0.012). On average, treatment subjects were tube fed for 15.8+/-16.4 days. There was no difference between the groups (treatment vs. controls) in the rate of post-operative life-threatening complications (25 vs. 30%, p=1.00) or in-hospital mortality (0 vs. 30%, p=0.216). Mortality within 6 months subsequent to surgery was lower in the treatment group compared to the controls (0 vs. 50%, p=0.036).

DISCUSSION

We conclude that nightly enteral feedings are a safe and effective means of supplementing nutrient intake. The greatest impact of nutrition support may be to reduce mortality.

Improving dressing behavior in cognitively impaired nursing home residents

This study tested the extent to which a behavioral intervention, Strategies to Promote Independence in Dressing (SPID), improved dressing independence among 90 cognitively impaired nursing home residents (average score on Mini Mental Status Exam = 7.35 +/- .69). The effect of SPID on caregiving efficiency, the time required for nursing assistants to use the strategies, was also examined. The results showed improved independence (decrease in assistance) from 6.08 +/- .12 at baseline to 4.93 +/- .19 following 6 intervention weeks. This significant improvement in dressing independence occurred without a clinically relevant increase in caregiver time (less than 1 min). Seventy-five percent of the subjects improved one or more levels of dressing independence, and more than 20% achieved their maximum intervention effect during the first week of treatment.

Holmium:YAG laser-assisted capsular shift in a canine model: intraarticular pressure and histologic observations

The purpose of this study was to determine the initial effects of Holmium:YAG laser energy on the shoulder joint capsule. A new surgical procedure to correct shoulder joint instability uses Holmium:YAG laser energy to cause "shrinkage" of joint capsular tissues. To date there has been no information concerning an intraoperative measurable end point for the application of laser energy at surgery or the resultant depth and degree of tissue alteration. Seven greyhound dogs were used in this study. Preoperative intraarticular pressures (IAP) were measured on entry and after injection of 10 ml of solution. Laser energy was applied to the cranial medial glenohumeral ligament and joint capsule of all right shoulders with arthroscopic visualization. The unoperated left shoulders served as the control group. Six weeks after surgery pressure measurements were performed on both shoulders. A "second look" arthroscopy was performed on the shoulders. After euthanasia was performed, the anterior capsular tissues were harvested from both shoulders for histologic examination. The specimens were inspected by three blinded examiners. After 6 weeks the postoperative laser-treated IAP were higher than the same joint preoperative IAP in four of six dogs for both static nondistension and 10 ml distension measurements. At this same interval the marked tissue damage of the treated capsule was easily discerned by blinded observers. On histologic evaluation the laser-treated capsule showed synovitis and pericapsular tissue reactivity. The depth of the injury was beyond the joint capsule into the pericapsular tissue. It was not possible to determine the end point of the capsular "shrinkage" operation by combined pressure/volume intraoperative measurements. There was no uniform joint capsule compliance at 6 weeks. The histologic changes were extensive in both magnitude and depth. Future studies in this animal should include decreased laser energy plus other means of monitoring the intraoperative effects of laser use.

Time quantified detection of fetal movements using a new fetal movement algorithm

Primarily, the objective is to develop an automated ultrasound fetal movement detection system that will better characterize fetal movements. Secondarily, the objective is to develop an improved method of quantifying the performance of fetal movement detectors. We recorded 20-minute segments of fetal movement on 101 patients using a UAMS-developed fetal movement detection algorithm (Russell algorithm) and compared this to a Hewlett-Packard (HP) M-1350-A. Movements were recorded on a second-per-second basis by an expert examiner reviewing videotaped real-time ultrasound images. Videotape (86,592 seconds) was scored and compared with the electronic movement-detection systems. The Russell algorithm detected 95.53% of the discrete movements greater than 5 seconds, while the HP system (M-1350-A) detected only 86.08% of the discrete movements (p = 0.012). Both devices were less efficient at detecting the short discrete movements, obtaining sensitivities of 57.39 and 35.22, respectively. Neither system fully identifies fetal movement based on the second-per-second system. Improved methods of quantifying performance indicated that the Russell algorithm performed better than the HP on these patients.

Effect of light on the prevalence of simple anisocoria

PURPOSE

Because simple anisocoria is believed to decrease in bright light, the authors determined the prevalence of simple anisocoria under different lighting conditions.

METHODS

The authors measured the pupil size of 104 healthy subjects with infrared videography at four clinically accessible light levels: darkness; darkness with a hand-held light shining from below; room light; and room light with the hand light shining from below.

RESULTS

Of the 104 subjects, 40 (38%) were men and 64 (62%) were women. The ages ranged from 12 to 71 years (mean, 36.3 +/- 12.5 years). The mean decrease in pupillary diameter from darkness to the brightest condition was 1.89 mm. Based on the traditional definition of a pupillary diameter difference of 0.4 mm or greater, the prevalence of simple anisocoria decreased from 18% in darkness to 8% in room light with the hand-held light shining from below. The prevalence of anisocoria varied considerably when other definitions were used. Repeated measures analysis of variance showed that pupillary area difference decreased with brighter conditions (P = 0.026). However, the ratio of the pupillary areas did not change with brighter conditions (P = 0.666).

CONCLUSIONS

The prevalence of simple anisocoria decreases with brighter conditions based on pupillary diameter difference. However, this decrease is not apparent when anisocoria is expressed as pupillary area ratio. Those clinicians who measure pupils will find that simple anisocoria decreases in bright light. However, with gross observation where perception of an anisocoria may be related more to the ratio of the pupillary areas, simple anisocoria may not seem to change much with brighter conditions.

The change in serum protein concentration in response to the stress of total joint surgery: a comparison of older versus younger patients

OBJECTIVE

To investigate whether the physiological response to surgery-induced stress, as measured by changes in serum secretory proteins, is more profound on older than in younger total joint arthroplasty patients.

DESIGN

Retrospective study.

SETTING

A 267-bed teaching hospital.

PARTICIPANTS

A total of 220 ambulatory patients with normal admission serum albumin levels, of whom 106 were 65 years of age or older (mean age 73.3 +/- 6.2 years) and 114 less than age 65 (mean age 48.8 +/- 12.2 years).

METHODS

Serum albumin and transferrin levels obtained at admission an on the fifth and tenth postoperative days were compared in the two age groups.

RESULTS

In both age groups, admission serum albumins were significantly higher than on the corresponding postoperative Day 5 levels (40.4 +/- 3.7 g/L vs 25.0 +/- 3.3 g/L, P < .0001 and 39.5 +/- 2.5 g/L vs 23.9 +/- 3.1 g/L, P < .001 in older and younger patients, respectively). The drop in the serum concentration of albumin by postoperative Day 5 in the older patients was not significantly different from that of the younger patients (a drop of 15.6 +/- 3.3 g/L in older vs 15.4 +/- 4.4 g/L for the younger, P = .740). Among the 64 patients who remained in the hospital 10 days subsequent to surgery, the average postoperative Day 10 serum albumin concentration was significantly lower in the older patients when compared with the younger (26.2 vs 29.1 g/L P = .016). Similar results were obtained for serum transferrin.

CONCLUSIONS

Subsequent to elective arthroplasty, the magnitude of change in serum albumin and transferrin concentrations is similar in older compared with younger, patients, suggesting that this stress response to surgery is nor age dependent. In contrast, the rate of recovery of the serum protein concentrations to preoperative levels may be slower in the older patients. However, this issue needs to be investigated further.

Tensile strength of insertional suture techniques in strabismus surgery

BACKGROUND

The "lost" extraocular muscle is a serious adverse outcome of seemingly uncomplicated strabismus surgery. One potential cause of this complication is suture slippage in the operated muscle or tendon. The purpose of this study was to determine the relative tensile strengths of three suture techniques commonly used in strabismus surgery and to compare the incidence of suture slippage in the tendon or muscle among these techniques.

METHODS

The horizontal rectus muscles of 18 adults pigs were assigned to undergo either recession or resection and were randomized to one of three suture techniques studies. Tension applied to the free ends of the suture was incrementally increased until failure occurred. The two techniques were compared in terms of the mean applied tensions at the time of failure and the incidence of slippage.

RESULTS

No statistically significant difference in mean tension at failure between the three techniques used in recessed or resected muscles was found. Suture slippage in the tendon or muscle occurred in 25% of the trials and was almost evenly distributed among the techniques. Mean tension at slippage did not differ significantly between the techniques. No failure of any kind occurred at less than 100 g applied tension.

CONCLUSION

Each suture technique appeared to adequately secure to tendon or muscle for recession and resection procedures. Changing techniques is unlikely to alter the incidence of lost muscles in strabismus surgery.

Effects of holmium: YAG laser energy on cartilage metabolism, healing, and biochemical properties of lesional and perilesional tissue in a weight-bearing model

Comparison of perilesional cartilage, lesional repair tissue, and subchondral bone activity 6 months after application of holmium-yttrium-aluminum-garnet (Ho:YAG) laser energy to chronic (10 week) induced 10-mm full-thickness (FT) circular articular cartilage craters followed by 6 months' intermittent active motion (IAM) in a free exercise environment was investigated. The 2.1-microns wavelength was delivered in hand-controlled near-contact mode by arthroscopic surgery in a saline medium. Bilateral arthroscopy was performed on normal antebrachiocarpal, intercarpal, and metacarpophalangeal joints of six adult horses. Full-thickness craters were created in nine sites per limb on weight-bearing articular surfaces with a motorized bur. Right limb craters served as sham operated controls. Animals were killed at 10 weeks after FT crater creation (n = 2), and at 24 weeks (6 months) after laser energy application (n = 4). Histological analysis using hematoxylineosin (HE) and Safranin-O staining consisted of a modified Mankin grading of perilesional cartilage and lesional repair tissue scoring. Biochemical analysis was performed for cellularity and glycosaminoglycan (GAG) synthesis. Histological analysis showed clustering of chondrocytes or perilesional zonal cloning (PZC) in 83% of laser-treated lesions and in no control lesions. No differences were observed between treated and control lesional repair activity. Laser-treated perilesional cartilage showed a significant (P < .02) decrease in GAG synthesis. No adverse effects to distant cartilage were observed after application of laser energy regarding cell proliferation or GAG synthesis. Significance of decreased GAG synthesis in treated perilesional cartilage and perilesional zonal cloning of chondrocytes in treated cartilage is unknown. Additional study of Ho:YAG laser energy application to cartilage and subchondral bone is needed before its application in the surgical management and repair of cartilage damage.

Prevalence of palpebral fissure asymmetry in white persons

PURPOSE

Because palpebral fissure asymmetry in horizontal gaze is reportedly common in otherwise normal persons, we determined the prevalence of physiologic palpebral fissure asymmetry for primary and horizontal gazes.

METHODS

We measured the palpebral fissure height of both eyes of 88 healthy white subjects. Measurements were obtained with high-resolution videography, with the eyes in primary position, in 45-degree right gaze, and in 45-degree left gaze.

RESULTS

Of the 88 subjects, 36 (41%) were male and 52 (59%) were female. The ages ranged from 12 to 50 years, with a mean of 32.5 +/- 9.0 years. When a criterion of equal to or greater than 1 mm was used, the prevalence of physiologic palpebral fissure asymmetry was 5.7% (five of 88) in primary gaze, 18.2% (16 of 88) in right gaze, and 14.8% (13 of 88) in left gaze. The largest observed palpebral fissure asymmetry was 2.1 mm. After correcting for any existing fissure asymmetry in primary gaze, two-tailed trivariate analysis of variance showed that the fissure of the adducting eye tended to be wider. The mean increase in the palpebral fissure of the adducting eye was 0.12 mm for right gaze (P = .052) and 0.13 mm for left gaze (P = .034). Additionally, a chi 2 test indicated that the occurrence of wider adducting eye in both right and left gazes was highly significant (P = .0023).

CONCLUSIONS

In this sample of white subjects, palpebral fissure height asymmetry increased in horizontal gaze to the right and to the left, which is in part because of a tendency of the adducting eye to widen slightly. In contrast to previous reports, the prevalence of palpebral fissure asymmetry was low, and the abducting eye did not widen significantly.

Time-quantified fetal movement detection with two-transducer data fusion

OBJECTIVE

Our purpose was to develop an automated ultrasound-based fetal movement detection system to better define fetal movements.

STUDY DESIGN

One hundred one patients had fetal movements recorded over a 20-minute period. Results of movement detection by a single-transducer system (Russell 1) and a two-transducer fusion system (Russell 2) were compared with those of Hewlett-Packard (HP-M-1350-A), maternal perception, and expert ultrasonography review.

RESULTS

A total of 86,592 seconds of videotape was scored for fetal movement. Russell 2 had a second-per-second sensitivity of 57.21% compared with Russell 1 at 40.95%, the HP-M-1350-A at 31.44%, and maternal perception at 30.80%. Russell 2 detected 67.57% of discrete movements compared with 57.52%, 41.98%, and 37.92%, respectively, in other systems.

CONCLUSION

Russell 2 represents a significant improvement over existing systems in detection of fetal movements on a second-per-second basis.

Protein-energy undernutrition and the risk of mortality within one year of hospital discharge: a follow-up study

OBJECTIVE

The primary objective of this study was to confirm the results of a previous study that demonstrated a strong independent correlation between the severity of protein-energy undernutrition and the risk of 1-year postdischarge mortality in a population of older rehabilitation patients.

DESIGN

Prospective survey (cohort study).

SETTING

The Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital.

PARTICIPANTS

Of 350 randomly selected admissions to the GRU, 322 were discharged alive from the hospital. These 322 patients represented the study population, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years.

MEASUREMENTS

At admission and again at discharge, each patient completed a comprehensive medical, functional, neuropsychological, socioeconomic, and nutritional assessment. After discharge, each subject was tracked for 1 year.

MAIN RESULTS

Within the 1-year posthospital discharge follow-up period, 64 study subjects (20%) died. This included 17% of the patients discharged home and 34% of the patients discharged to a nursing home (P < .01). Based on the Cox Proportional Hazards survival model, the variable most strongly associated with mortality was the discharge serum albumin, followed by discharge weight expressed as a percentage of ideal, self-dressing ability, and a discharge diagnosis of cardiac arrhythmia (usually atrial fibrillation). When all four of these variables were included in the analysis, the model was able to differentiate the survivors from those who died by years end with a sensitivity of 69%, a specificity of 69%, and an overall predictive accuracy of 69%. When tested using the data from the previous study, the model differentiated the patients who died from those who had not at a sensitivity of 62%, a specificity of 68%, and an overall predictive accuracy of 64%.

CONCLUSIONS

Protein-energy undernutrition appears to be a strong independent risk factor for 1-year postdischarge mortality.

Primary care physicians' response to dissemination of practice guidelines

BACKGROUND

Much effort has gone into producing clinical practice guidelines, but relatively few studies address dissemination issues. Unless guidelines are used, little is gained. This study evaluates the effect of three methods to disseminate asthma guidelines on physicians' behavior and attitudes toward education strategies.

METHODS

Asthma guidelines were mailed to 60 physicians in three Area Health Education Centers in Arkansas. Dissemination efforts at one site featured a short summary, telephone calls by "detailing" physicians, and a continuing medical education conference. Computer strategies were used at the second site, and a multimedia approach with facsimile messages, posters, videocassettes, audiocassettes, and a continuing medical education conference was used at the third site. A fourth site with 22 participants served as a comparison. Data were collected by mailed questionnaires, outpatient chart reviews, and physician interviews. Changes between baseline and posttest assessments following a 4-month intervention were calculated for medication use, and peak flow monitoring use was compared with the control group (general linear model). Regression analyses were used to identify physician and practice factors associated with particular education techniques.

RESULTS

Each site improved in the use of medications or peak flow monitoring, but none improved in all areas. The multimedia, continual reminder approach was well accepted but there was little support for the computer strategies.

CONCLUSIONS

Further efforts to disseminate clinical guidelines should include a variety of formats with an emphasis on short, concise summaries and frequent reminders. Social influence appears to play a role and will be a fruitful area for further research.

The risk of life-threatening complications in a select population of geriatric patients: the impact of nutritional status

OBJECTIVE

The primary objective of this study was to assess the interrelationship between protein-energy nutritional status, disease severity, and life-threatening complications in a population of elderly rehabilitation patients.

METHODS

Three-hundred and fifty randomly selected admissions to Geriatric Rehabilitation Unit of a Veterans Administration hospital were prospectively studied. The average age of the study subjects was 76 years, nearly all (99%) were male, and 75% were white. At admission, each patient completed a comprehensive medical, functional, neuropsychological, socioeconomic, and nutritional assessment. While remaining in the hospital, each subject was monitored on a daily basis for the development of complications.

RESULTS

Of the 96 variables evaluated, the best predictors of developing at least one life-threatening complication were serum albumin, body mass index, the presence of renal disease (i.e. blood urea nitrogen > 30 mg/L), the Katz Index of Activities of Daily Living score, and the amount of weight loss in the year prior to admission. When all of these variables were included in the logistic regression analysis, the final model was highly significant by the -2Log Likelihood Chi-square goodness-of-fit criterion (Chi-square of 64.1 with 5 d.f., p < 0.0001) with a sensitivity of 77%, a specificity of 77% and an overall predictive accuracy of 77%. When the predictive accuracy of the logistic model was tested using a second sample of 110 patients, the model differentiated those who developed a life-threatening complication from those who had not with a sensitivity of 88%, a specificity of 61%, and an overall predictive accuracy of 65%. As indicated by the Chi-square test, these results were significant (p < 0.0001).

CONCLUSIONS

Protein-energy undernutrition appears to be a strong independent risk factor for life-threatening morbidity during hospitalization.

Impact of nutritional status on morbidity in a population of geriatric rehabilitation patients

OBJECTIVE

The primary objective was to confirm the results of a prior study that demonstrated a strong independent correlation between the severity of protein-energy undernutrition and the risk of subsequent morbidity in a population of elderly rehabilitation patients. A second objective was to determine whether inadequate in-hospital nutrient intake is a co-contributor to the risk of subsequent morbidity.

DESIGN

Cohort study.

SETTING

Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital.

PATIENTS

Three hundred fifty randomly selected admissions to the GRU, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years.

MEASUREMENTS

At admission, each patient completed a comprehensive medical, functional, neuro-psychological, socio-economic, and nutritional assessment. While remaining in the hospital, each subject was monitored on a daily basis for the development of complications. Complete calorie counts were obtained at least every other day, and the average pre-complication daily nutrient intake was expressed as a percent of predicted requirements as determined using the Harris-Benedict equation.

RESULTS

Of the 96 variables evaluated, the strongest predictor of subsequent complications was the Katz Index of ADL score, followed by serum albumin, usual weight percent, number of prescription medications, presence of renal disease, individual income, the presence of decubiti, dysphagia, and mid-arm muscle circumference. When all nine of these variables were included in the logistic regression analysis, the final model had a sensitivity of 70%, a specificity of 71%, and an overall predictive accuracy of 71%. When tested using the data from the previous study, the model differentiated the patients who developed a complication from those who had not a sensitivity of 76.7, a specificity of 76.1, and an overall predictive accuracy of 76.3. There was no difference in the pre-complication average daily nutrient intake between the complication and the no-complication groups (79% vs 75% of predicted requirements, P > 0.2).

CONCLUSIONS

Protein-energy undernutrition appears to be a strong independent risk factor for in-hospital morbidity. However, in-hospital nutrient intake may not be a significant determinant of risk.

Assessment of hypoxemia in patients with sleep disorders using saturation impairment time

A method of recording cumulative nocturnal oxygen desaturation was utilized to develop a quantitative index of nocturnal hypoxemia (SIT index) to provide reference values and distributional properties for apneic and nonapneic sleep-disordered patients. The SIT indices were compared in patients with varying degrees of obstructive sleep apnea (OSA) as determined by traditional methods of counting apneas and hypopneas. We studied 298 patients who were divided into five groups based on the presence and frequency of apnea or sleep-related respiratory deterioration. SIT indices for patient groups and individual patients were compared with the respiratory disturbance index (apneas + hypopneas x 60/total sleep time = RDI) using scatter plots, Kruskal-Wallis analysis of variance, and Mann-Whitney U tests. The OSA and non-respiratory-impaired patient groups had mean SIT values that were significantly different (p < 0.05). Subjects with severe apnea differed (p < 0.05) from subjects with mild and moderate apnea at SIT index thresholds < baseline, < 90, < 80, and < 70% SaO2, but subjects with mild and moderate apnea did not differ statistically from each other at any threshold. In individual patients with similar RDI values, considerable variation in SIT index can be seen, and the reverse is also true. This suggests that using both RDI and SIT may provide complementary information in assessing the severity of OSA.

Effects of holmium:YAG laser on equine articular cartilage and subchondral bone adjacent to traumatic lesions: a histopathological assessment

This study was performed to investigate the effects of holmium:yttrium-aluminum-garnet (Ho:YAG) laser energy on articular cartilage and subchondral bone adjacent to traumatically created cartilage lesions in a continuous weight-bearing model. The 2.1-microns wavelength was delivered efficiently and precisely in hand-controlled contact and near-contact hard tissue arthroscopic surgery in a saline medium. Bilateral arthroscopy was performed on normal antebrachiocarpal and intercarpal joints of four adult horses. One hundred twenty traumatic lesions were created on three weight-bearing articular surfaces with a knife, curet, or motorized burr. Depths of the lesions were partial and full thickness. Configurations of the lesions were lacerations, scrapes, and craters. Left limbs were used as controls. Right limb lesions were treated with various intensities of laser energy: 0.1. 0.16, and 0.2 J. Animals were killed at intervals of 1, 3, and 8 weeks. Gross microscopic anatomy was documented, and tissue sections were subjected to blind review by a pathologist. Mankin grading for cellularity and proteoglycan content was used to qualitatively evaluate cartilage response. Cartilage adjacent to all lesions exposed to laser energy had better cellularity and proteoglycan content (p < 0.05) than did corresponding controls by Mankin grading. Mankin grades for levels of 0.16 and 0.2 J were lower (p < 0.05) than were those of controls or lesions exposed to 0.1 J. There was loss of cellularity and necrosis in subchondral bone at higher energy levels (0.16 and 0.2 J). This study examined the effects of Ho:YAG laser on articular cartilage and subchondral bone in terms of depth of damage and healing response over time in a weight-bearing model. Additional research to define dose-response curves for Ho:YAG laser treatment of cartilage and subchondral bone are indicated.

An arthroscopic biopsy procedure for obtaining osteochondral samples from the equine midcarpal joint

An in vivo biopsy technique was developed to harvest cylindrical osteochondral core samples (2 mm diameter x 2 mm depth) from the articular surfaces of radial carpal bones in adult horses for use in osteoarthritis drug kinetic studies. A 25 degree arthroscope was introduced into the midcarpal joint through the dorsolateral surface, and a custom-built motorized core drill was introduced through the dorsomedial surface to create the osteochondral core samples. A total of 24 core samples were sequentially harvested in vivo, and 16 at postmortem, from eight horses on four different occasions within a 96-h period. Cores ranged in weight, from 5.0 to 19.0 mg with a median of 13.25 mg, mostly due to the amount of subchondral bone present. No evidence of carpal bone fractures was observed associated with core sample sites at postmortem. No tissue distortion or thermal damage occurred to the osteochondral core samples. No detrimental effects on the tissue surrounding the biopsy sites was detected on microscopic examination. This technique offers a simple and effective procedure for obtaining multiple in vivo osteochondral core samples at various time intervals for cartilage or osteoarthritis research or analysis of clinical joint disease in the horse.

Pesticide concentrations in Arkansas breast milk

During an episode of pesticide dairy product contamination in Arkansas in 1986, breast milk samples from 942 women were analyzed for concentrations of chlorinated pesticides. The pesticides found most frequently in quantifiable concentrations were p,p'-DDE (100%), oxychlordane (84%), trans-nonachlor (77%), heptachlor epoxide (74%) and beta-HCH, an isomer of lindane (27%). The pesticides present in highest mean concentrations of all samples analyzed (reported as ppm in milk fat) were p,p'-DDE (0.952 ppm), trans-nonachlor (0.062 ppm), oxychlordane (0.051 ppm), heptachlor epoxide (0.045 ppm), p,p'-DDT (0.039 ppm), and beta-HCH (0.032 ppm). These concentrations are lower than previous reports from similar regions of the US. However, continued persistence in human breast milk is of concern due to potential adverse health effects from these chemicals.

Case-mix groups for VA hospital-based home care

The purpose of this study is to group hospital-based home care (HBHC) patients homogeneously by their characteristics with respect to cost of care to develop alternative case mix methods for management and reimbursement (allocation) purposes. Six Veterans Affairs (VA) HBHC programs in Fiscal Year (FY) 1986 that maximized patient, program, and regional variation were selected, all of which agreed to participate. All HBHC patients active in each program on October 1, 1987, in addition to all new admissions through September 30, 1988 (FY88), comprised the sample of 874 unique patients. Statistical methods include the use of classification and regression trees (CART software: Statistical Software; Lafayette, CA), analysis of variance, and multiple linear regression techniques. The resulting algorithm is a three-factor model that explains 20% of the cost variance (R2 = 20%, with a cross validation R2 of 12%). Similar classifications such as the RUG-II, which is utilized for VA nursing home and intermediate care, the VA outpatient resource allocation model, and the RUG-HHC, utilized in some states for reimbursing home health care in the private sector, explained less of the cost variance and, therefore, are less adequate for VA home care resource allocation.

Psychological correlates of loneliness in the older adult

Loneliness is the emotional response to the discrepancy between desired and available relationships. As people grow old, the likelihood of experiencing age-related losses increases. Such losses may impede the maintenance or acquisition of desired relationships, resulting in a higher incidence of loneliness. This pilot study examines how loneliness relates to age-related losses, hopelessness, self-transcendence, and spiritual well-being in a convenience sample of 107 adults aged 65 years or older. The collective utility of the independent variables in predicting loneliness was investigated by means of a regression decision tree with an automatic random subset crossvalidation procedure. This procedure explained 46% of the variance. Higher scores for age-related losses and hopelessness were associated with higher loneliness scores. Higher scores for self-transcendence and existential spiritual well-being were associated with lower loneliness scores.

Protein-energy undernutrition and the risk of mortality within 1 y of hospital discharge in a select population of geriatric rehabilitation patients

To determine whether undernourished elderly patients are at increased risk for mortality, independent of nonnutritional factors affecting outcomes, 109 patients were evaluated at admission to a geriatric rehabilitation unit (GRU) and then followed prospectively for 1 y after hospital discharge. During the interval of observation, 33 (30%) patients died, 11 before hospital discharge and 22 within the year subsequent to discharge. Of the 81 nutritional and nonnutritional variables analyzed, the best predictor of mortality, as determined by stepwise-discriminant-function analysis, within 1 y of hospital discharge was the percent of usual body weight lost in the year previous to admission, followed by the subscapular skinfold thickness and the discharge Katz Index of Activities of Daily Living (ADL) score. Percent of weight lost was also the strongest predictor of 1-y post-GRU-admission mortality. These results provide compelling evidence for the importance of nutritional status in predicting both in-hospital and postdischarge mortality in a population of frail, male GRU patients.

Impact of nutrition status on morbidity and mortality in a select population of geriatric rehabilitation patients

To determine whether the level of protein-calorie undernutrition at presentation correlated with the subsequent risk of developing in-hospital complications independently of nonnutrition factors influencing outcomes, a prospective study was conducted of 110 consecutive admissions to a Geriatric Rehabilitation Unit (GRU) of a Veteran's Administration hospital. In total, 54 variables were evaluated as possible predictors of outcomes. The risk of developing at least one complication while on the GRU was studied by using multivariate techniques (discriminant function analysis) and was found to correlate with, in order of significance, functional status as admission, serum albumin concentration at admission, amount of weight lost in the year before admission, and the presence or absence of a renal or pulmonary disease. Nutrition variables also independently correlated with the risk of developing an infectious complication or a major life-threatening complication and dying within the hospital. These data indicate the importance of nutrition status in geriatric rehabilitation patients.

Clinical comparison of immunoradiometric assays for intact versus beta-specific human chorionic gonadotropin

Monoclonal immunoradiometric assays (IRMA) for human chorionic gonadotropin (hCG) are available for either intact hCG (IhCG) or beta subunit hCG (beta hCG). The authors evaluated the clinical applications of both methods. Serum samples (N = 180) were divided into the following five clinical groups: Group 1: elevated luteinizing hormone (LH), follicular stimulating hormone (FSH), and thyroid-stimulating hormone (TSH), which share alpha subunits with hCG; Group 2: pregnancy; Group 3: trophoblastic tumors; Group 4: malignancy; and Group 5: positive rheumatoid factor or anti-nuclear antibody (ANA). The values of beta hCG versus IhCG for Group 1 showed statistical significance but no clinical significance, indicating negligible cross-reactivity in the alpha subunit group. beta hCG values, although exceeding the IhCG values, correlated well (r = 0.97) in intrauterine pregnancies; however, these values were not believed to be clinically significant. There is negligible interference by alpha subunits, elevated rheumatoid factor, ANA, or malignancy in the determination of IhCG versus beta hCG. The authors conclude that either the IhCG or beta hCG assays may be used in clinical conditions in which a potential exists for interference of alpha subunits, autoantibodies, or heterophile antibodies or in malignancy.

Serial incontinence assessment in elderly inpatient men

Urinary incontinence is a major problem for elderly chronic care patients. As a consequence, a high level of nursing care is required for patient management. Because incontinence rehabilitation programs are usually implemented during the day shift, the incidence of incontinence according to time of day has major implications regarding patient management. Although treatment is usually based on severity, assessment of incontinence severity in elderly chronic care inpatients is difficult. In this study, a telemetric incontinence detection system was developed to identify incontinence episodes. An absorbent pad exchange technique was used for incontinence volume measurement. The study group, 66 chronic care inpatient men over 65 years old, were subject to incontinence measurements over 10 days during all nursing shifts using the telemetric incontinence detection system. The results showed a significantly high incidence of incontinence episodes during the evening nursing shift. The volume of involuntary urine loss was significantly higher during the night nursing shift. Thus, the highest level of incontinence severity occurred during the time of day when nursing staff on chronic care units is usually the lowest.

Low dose ibuprofen reverses the hemodynamic alterations of canine endotoxin shock

The dose response of the nonsteroidal anti-inflammatory drug, ibuprofen, was evaluated in order to determine the most efficacious dose in the treatment of canine endotoxin shock. Fifteen minutes after an infusion of Escherichia coli endotoxin, four groups of dogs were given a single iv dose of 1, 5, 10, or 20 mg/kg of ibuprofen. These groups were compared to endotoxin only and saline control groups. All ibuprofen doses significantly improved the systolic, diastolic, and mean systemic arterial BP. The improvement in systemic BP was accompanied by an increase in the systemic vascular resistance. Pulmonary vascular pressures and resistance also increased after ibuprofen administration. The lack of a dose response and the demonstrated beneficial effect of low dose ibuprofen in the reversal of the hypotension associated with experimental canine endotoxin shock lead us to recommend the use of low dose ibuprofen for future endotoxin and sepsis studies. Use of low dose ibuprofen might have less of an effect on renal perfusion and would therefore be more likely to produce the beneficial hemodynamic response without compromising renal function.

Effects of ibuprofen on neutrophil function and acute lung injury in canine endotoxin shock

The role of the polymorphonuclear leukocyte in the development of acute lung injury has been the subject of much controversy. Experimental lung injury is associated with peripheral leukopenia and the intrapulmonary sequestration of leukocytes. We have previously shown that ibuprofen, a nonsteroidal anti-inflammatory drug, can improve the hemodynamic alterations of canine endotoxin shock. Ibuprofen has also been found to decrease leukocyte adherence. We investigated the dose response of ibuprofen on the increased neutrophil adherence and the extent of lung injury associated with canine endotoxin shock. Single doses of ibuprofen (1, 5, 10, and 20 mg/kg iv) were administered 15 min after Escherichia coli endotoxin. Endotoxemia resulted in leukopenia and an increased neutrophil adherence in both aortic and pulmonary artery blood. Endotoxin-treated animals exhibited increased neutrophils in the bronchoalveolar lavage fluid, a marker of lung injury. The 20-mg/kg ibuprofen dose decreased aortic granulocyte adherence at 30 min, while all ibuprofen doses decreased the aortic adherence at 120 min. The increased pulmonary artery neutrophil adherence was not affected by ibuprofen. Histologically, lung injury was manifested by intravascular leukostasis. Ibuprofen treatment did not affect the histologic or morphometric extent of the lung injury. The leukopenia and increased neutrophil adherence occur rapidly after endotoxemia and are associated with subsequent intravascular sequestration of leukocytes. Agents designed to prevent lung injury must either be given before the insult or be able to block the effects of the toxic products released by the activated granulocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Toxicity of methylenedioxymethamphetamine (MDMA) in the dog and the rat

Methylenedioxymethamphetamine (MDMA) was administered to dogs and rats orally once a day for a 28-day period to evaluate the morphological and neuropathological effects. Major clinical signs associated with the administration of MDMA in the dog included circling, depression, dilated pupils, hyperactivity, rapid breathing, and salivation. Major clinical signs in the rat included hyperactivity, excitability, piloerection, exophthalmos, and salivation. Gross observations at necropsy in the dog possibly related to administration of the test article included reduced testicular size (one high and one medium dose) and prostatic enlargement in two high-dose animals. No gross lesions were seen in the rats at necropsy. The medium- and the high-dose groups in both sexes in both the rats and the dogs gained significantly less weight than the control and low-dose groups. Food consumption decreased the first week for the high- and medium-dose groups, but a significant reversal toward more normal consumption was noted in the following weeks in both the rats and the dogs. Hematologic, clinical chemistry, and urinalysis values did not appear to be affected by the administration of the test article in the dog. In the rat clinical pathology variables showing a trend to decrease with dose included urinary pH, blood urea nitrogen, glucose, creatinine (females), lactate dehydrogenase (LDH) (females), and chloride. Clinical pathology variables showing a trend to increase with dose included total white blood cell count and phosphorus. Microscopically, testicular atrophy was present in one medium-dose and two high-dose male dogs. Prostatic hyperplasia was present in two high-dose male dogs. No test article-related lesions were seen in the brains of either species.

Statistical methods to predict morbidity and mortality: self assessment techniques for burn units

The medical records of 806 adult and paediatric burn patients were retrospectively reviewed. Patient data was summarized, coded and entered in a computer for subsequent analysis. This report describes the use of multiple regression analysis to produce equations useful for the prediction of the morbidity parameters: length of hospital stay, number of transfusions required and number of operative procedures. The multiple regression equations developed are useful as prediction tools, in patient medical audit and in assessing improvements in burn care. The classical technique of probit analysis for predicting the probability of mortality was used to develop the LA50's of burn injury. These LA50's were used as the basis for comparison of survival statistics between burned patients in this series and those registered in the National Burn Information Exchange (Feller, 1979). There is an apparent significantly improved survival in the children, young adults through 34 yrs and the older adults (60-74 yrs) in the current series of patients. This observation would support the adoption of the protocol of burn care used in treating these patients. The newer technique of discriminant analysis is also described. Discriminant analysis is a multifactorial method for discriminating between dichotomous outcomes (survivors and non-survivors). The technique of discriminant scoring proved to be 95.8 per cent accurate in predicting burn survival. Use of a burn severity scoring technique will also assist in recognition of the high risk patient.

Dynamics of adrenocorticotropin (ACTH) secretion in cyclic Cushing's syndrome: evidence for more than one abnormal ACTH biorhythm

We have studied a 57-yr-old woman with cyclic Cushing's syndrome of apparent pituitary origin who had a predominant cycle of 2-6 days. The patient also demonstrated an abnormal circadian rhythm, with afternoon peaks of plasma ACTH and plasma cortisol. In addition to these abnormal biorhythms, Fourier analysis showed what appeared to be a separate 35-day cycle. After 35 days of consecutive urinary free cortisol measurement, the patient was given cyproheptadine. During therapy with this agent, the urinary free cortisol levels fell dramatically, but cyclic secretion continued, albeit with a diminished amplitude. During general anesthesia for a bilateral adrenalectomy, there was a striking increase in the plasma ACTH level, and the ACTH concentration remained high in both the immediate and late postoperative periods. These observations indicated that stress could overcome cyclic ACTH secretion and that cortisol exerted feedback suppression on ACTH secretion. Although this is the predictable response for classic pituitary-dependent Cushing's syndrome, it is of interest in cyclic Cushing's syndrome, since previous studies of this entity have implied that cortisol secretion is independent of stimulation or feedback.

Arterial embolectomy in the leg. Results in a referral hospital

The clinical characteristics and course of 90 patients in whom 121 arterial emboli occurred from 1968 to 1978 were reviewed. The factor that correlated most significantly with a favorable outcome was the interval from onset of symptoms until arterial embolectomy was performed. The results of embolectomy were excellent in the patients operated on within 6 hours of symptoms (amputation rate 4 percent, mortality rate 15 percent), but less favorable in the patients operated on within 6 to 12 hours of onset of symptoms (amputation rate 27 percent, mortality 40 percent). Mortality (48 percent) and amputation (52 percent) rates in the patients operated on 12 to 48 hours after onset of symptoms were excessive. It is recommended that immediate embolectomy be performed in all potentially viable extremities in patients who present within 12 hours of symptoms, but that after 12 hours only those limbs with obvious viability (not paralyzed or anesthetic) should be operated on. Alternatives for the remainder are high dose intravenous heparinization or expedient amputation. In patients who present greater than 60 hours after the onset of symptoms, embolectomy can be performed with low morbidity and mortality.

A multivariate discriminate analysis of behavioral measures in genetically nervous dogs

For some years we have studied a strain of genetically nervous dogs in the Neuropsychiatric Research Laboratory, Veterans Administration Hospital, North Little Rock, Arkansas. In the manner of Pavlov and Gantt and later Scott and Fuller we have characterized these dogs in such descriptive terms as timid, human aversive, and catatonic-like. Behavioral tests have been administered on nearly all dogs in this longitudinal study, and we are using these data to try to develop statistical procedures to maximize the discriminatory power of the behavioral assay and to more accurately characterize the behavioral deficit. A multivariate discriminate analysis of 13 variables on 91 healthy and 63 nervous dogs assayed at 3 months of age shows: (1) that much of our present behavioral testing procedures is redundant, and (2) that simple "friendliness to humans" in the dog is as effective for discriminating between the two groups as any of the 13 measures, taken either singly or collectively.