bluuebunny/crossref_metadata_2025 huggingface dataset:
Pathogenicity and other genomic islands in plant pathogenic bacteria
Authors: Arnold Dawn L. , Pitman Andrew , Jackson Robert W.
Published: September 2003

Pathogenicity islands (PAIs) were first described in uropathogenic E. coli. They are now defined as regions of DNA that contain virulence genes and are present in the genome of pathogenic strains, but absent from or only rarely present in non‐pathogenic variants of the same or related strains. Other features include a variable G+C content, distinct boundaries from the rest of the genome and the presence of genes related to mobile elements such as insertion sequences, integrases and transposases. Although PAIs have now been described in a wide range of both plant and animal pathogens it has become evident that the general features of PAIs are displayed by a number of regions of DNA with functions other than pathogenicity, such as symbiosis and antibiotic resistance, and the general term genomic islands has been adopted. This review will describe a range of genomic islands in plant pathogenic bacteria including those that carry effector genes, phytotoxins and the type III protein secretion cluster. The review will also consider some medically important bacteria in order to discuss the range, acquisition and stabilization of genomic islands.
Emergency Department Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the Elderly: The Multicenter Airway Research Collaboration
Authors: Cydulka Rita K. , Rowe Brian H. , Clark Sunday , Emerman Charles L. , Camargo Carlos A. , On Behalf Of The MARC Investigators
Published: September 2003

OBJECTIVES: To determine adherence of emergency department (ED) management of acute exacerbation of chronic obstructive pulmonary disease (COPD) to current treatment guidelines.

DESIGN: A prospective cohort study, as part of the Multicenter Airway Research Collaboration.

SETTING: The study was performed at 29 EDs in 15 U.S. states and three Canadian provinces.

PARTICIPANTS: ED patients, aged 55 and older, who presented with COPD exacerbation and underwent a structured interview in the ED and another by telephone 2 weeks later.

MEASUREMENTS: Adherence of ED management of COPD exacerbation to that recommended in current treatment guidelines.

RESULTS: The cohort consisted of 397 subjects, of whom 224 (56%) reported only COPD and 173 (44%) reported asthma and COPD. The average age was 70. Most (80%) patients had used rescue medications in the 6 hours before seeking emergency care. Only 31% were evaluated using spirometry and 48% using arterial blood gas measurement. ED treatment included inhaled short‐acting beta‐agonists for 91% of patients, inhaled anticholinergics for 77%, methylxanthines for 0.3%, systemic corticosteroids for 62%, and antibiotics for 28%. More than half the patients required hospitalization. At 2‐week follow‐up, 43% of patients reported a relapse event or ongoing exacerbation. Overall, adherence to national and international guidelines was low.

CONCLUSION: Important differences exist between guideline recommendations and actual ED management of COPD exacerbations in older adults. Outcomes after ED treatment are poor and may be related to these shortcomings in quality of care. Better adherence to guideline recommendations when caring for elderly patients with COPD exacerbations may lead to improved clinical outcomes and better resource usage.
The Relationship Between Age and Process of Care and Patient Tolerance of Bronchoscopy
Authors: Hehn Boyd T. , Haponik Edward , Rubin Haya R. , Lechtzin Noah , Diette Gregory B.
Published: September 2003

OBJECTIVES: To determine whether patient age is associated with differences in flexible bronchoscopy technique and tolerance.

DESIGN: Prospective cohort study.

SETTING: University hospital system.

PARTICIPANTS: One thousand three hundred fifty‐eight adults, including 219 (16.1%) aged 70 and older, undergoing bronchoscopy.

MEASUREMENTS: Indications, sampling procedures, medication doses, patient reports of pain, willingness to return, and adverse events associated with bronchoscopy.

RESULTS: Indications for bronchoscopy varied with age, with solitary pulmonary nodule (P < .001), mass (P < .001), or lymphadenopathy (P < .001) being more common in older patients. Invasive sampling methods were used more often with increasing age, but variation in disease processes between age groups accounted for the difference in sampling method performed. Mean doses of midazolam and fentanyl given for sedation decreased with increasing age (P < .001). There was no significant difference between older and younger patients in reported very good to excellent pain control (50% of patients ≥70 vs 64% of patients <40; P = .56) or in willingness to return for repeat bronchoscopy (98% vs 92%, respectively; P = .324). Overall risk for an adverse event increased with increasing patient age (P < .01), but adverse events were uncommon and generally not severe. Hypotension and pneumothorax were rare but occurred more often in older persons (1.9% and 3.4% in patients ≥70 vs 0.5% and 0.7% in patients <40, respectively).

CONCLUSION: Despite more‐invasive sampling methods and less sedation during bronchoscopy, elderly patients tolerate bronchoscopy as well as younger patients. There is increased risk for adverse events with increasing age, but the absolute frequency is low, suggesting that chronological age should not be a contraindication for bronchoscopy in older persons.
Self‐Reported Heart Attack in Mexican‐American Elders: Examination of Incidence, Prevalence, and 7‐Year Mortality
Authors: Otiniano Max E. , Ottenbacher Kenneth J. , Markides Kyriakos S. , Ray Laura A. , Du Xianglin L.
Published: September 2003

OBJECTIVES: To examine the prevalence, incidence, and mortality of self‐reported heart attack in older Mexican Americans and to identify significant factors associated with heart attack.

DESIGN: Cross‐sectional and longitudinal study.

SETTING: Baseline and three follow‐up interviews in five southwestern states (Arizona, California, Colorado, New Mexico, and Texas) of the Hispanic Established Population for the Epidemiological Study of the Elderly.

PARTICIPANTS: Three thousand fifty Mexican Americans aged 65 to 107 (mean age = 73).

MEASUREMENTS: Sociodemographic factors (age, sex, marital status, language of interview, health insurance coverage, living arrangements, and financial strain) and health factors (smoking, alcohol consumption, obesity, diabetes mellitus, hypertension, stroke, cancer, hip fracture, arthritis, depression, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and mortality) were determined at baseline (1993–94). New heart attacks were assessed at follow‐ups in 1995–96, 1998–99, and 2000–01. Vital status was determined over the 7‐year follow‐up.

RESULTS: Prevalence of self‐reported heart attack was 9.1% at baseline. Incidence of self‐reported heart attack was 6.1%, 9.1%, and 7.9%, respectively, for the three subsequent follow‐ups. Older age, male sex, diabetes mellitus, hypertension, and stroke were significantly associated with heart attack at baseline. Age was a significant predictor for new heart attack at each follow‐up. Having ADL (odds ratio (OR) = 2.91, 95% confidence interval (CI) = 2.19–3.86) and IADL (OR = 2.25, CI = 1.72–2.94) disabilities was significantly associated with self‐reported heart attack. Subjects with heart attack were significantly more likely to die at 7 years (hazard ratio = 1.57, 95% CI = 1.29–1.91). Of those with self‐reported heart attack, 42.4% had died of heart attack as the underlying cause of death by 7‐year follow‐up.

CONCLUSION: In Mexican Americans, self‐reported heart attack was associated with being older and male and having diabetes mellitus, hypertension, stroke, and ADL and IADL disabilities. Nearly half of subjects with heart attack had died of heart attack as underlying cause of death by 7‐year follow‐up. Prevention and control for this disease would be especially important in this population to avoid early mortality.
Long‐Term Prognostic Importance of Total Cholesterol in Elderly Survivors of an Acute Myocardial Infarction: The Cooperative Cardiovascular Pilot Project
Authors: Foody JoAnne Micale , Wang Yun , Kiefe Catarina I. , Ellerbeck Edward F. , Gold Jay , Radford Martha J. , Krumholz Harlan M.
Published: September 2003

OBJECTIVES: To determine the long‐term prognostic importance of in‐hospital total serum cholesterol in elderly survivors of acute myocardial infarction (AMI).

DESIGN: Retrospective medical record review.

SETTING: Acute care, nongovernmental hospitals in Alabama, Connecticut, Iowa, and Wisconsin.

PARTICIPANTS: Four thousand nine hundred twenty‐three Medicare beneficiaries from four states aged 65 and older discharged alive with a principal diagnosis of AMI between June 1, 1992, and February 28, 1993, who had a measurement of total serum cholesterol during hospitalization.

MEASUREMENTS: Primary endpoint of all‐cause mortality within 6 years of discharge.

RESULTS: Of the 7,166 hospitalizations meeting study inclusion criteria, 4,923 (68.7%) had total cholesterol assessed, and 22% had a cholesterol level of 240 mg/dL or greater. Of AMI hospitalization survivors with cholesterol of 240 md/dL or greater, 17.2% died within 1 year and 47.9% died within 6 years, compared with 17.4% (P = .73) and 48.7% (P = .98) of those with a cholesterol level less than 240 mg/dL. The adjusted hazard ratio for elevated total serum cholesterol measured during hospitalization for all‐cause mortality in the 6 years after discharge was 0.97 (95% confidence interval (CI) = 0.87–1.09). The unadjusted 1‐ and 6‐year mortality rates for those with total cholesterol less than 160 mg/dL were 22.2% and 55.5%, respectively, not significantly different from mortality for patients with cholesterol of 160 mg/dL or greater, even after adjustment.

CONCLUSION: Among elderly survivors of AMI, elevated total serum cholesterol measured postinfarction is not associated with an increased risk of all‐cause mortality in the 6 years after discharge. Furthermore, this study found no evidence of an increased risk of all‐cause mortality in patients with low total cholesterol. Further studies are needed to determine the relationship of postinfarction lipid subfractions and mortality in older patients with coronary artery disease (CAD).
Donepezil Is Associated with Delayed Nursing Home Placement in Patients with Alzheimer's Disease
Authors: Geldmacher David S. , Provenzano George , McRae Thomas , Mastey Vera , Ieni John R.
Published: September 2003

OBJECTIVES: To assess the relationship between donepezil treatment and time to nursing home placement (NHP) for patients with Alzheimer's disease (AD).

DESIGN: Observational follow‐up of patient NHP and vital status.

SETTING: Community.

PARTICIPANTS: Patients previously enrolled in one of three randomized, double‐blind, placebo‐controlled clinical trials of donepezil and two subsequent open‐label studies (total N = 1,115); 671 patients provided complete data for analysis.

MEASUREMENTS: Data were obtained through follow‐up interviews with caregivers and chart reviews of patients with AD. Comparison groups were defined by whether patients received an effective dose of donepezil (≥5 mg/d; ≥80% compliance) for specific numbers of weeks during the double‐blind or open‐label trial phase, in both phases, or in neither. Cox proportional hazards models were used to estimate risk ratios for NHP and survival curves from which median times to NHP were estimated for first dementia‐related placement of longer than 2 weeks and permanent placement. The models were adjusted for age, sex, baseline Mini‐Mental State Examination score, whether the caregiver was a spouse, caregiver continuity, and use of other cholinesterase inhibitors after the clinical trials.

RESULTS: Use of donepezil of 5 mg/d or more was associated with significant delays in NHP. A cumulative dose‐response relationship was observed between longer‐term sustained donepezil use and delay of NHP. When donepezil was taken at an effective dose for at least 9 to 12 months, conservative estimates of the time gained before NHP were 21.4 months for first dementia‐related NHP and 17.5 months for permanent NHP.

CONCLUSION: Use of donepezil by AD patients resulted in significant delays in NHP. Long‐term use of donepezil may help AD patients live longer in community settings, with consequent personal, social, and economic benefits.
Prevention of Weight Loss in Dementia with Comprehensive Nutritional Treatment
Authors: Keller Heather H. , Gibbs Amie J. , Boudreau Lynn D. , Goy Richard E. , Pattillo Marg S. , Brown Heather M.
Published: September 2003

OBJECTIVES: To determine whether body weight can be maintained or improved in dementia residents of special care units (SCUs) using a comprehensive intervention strategy.

DESIGN: Quasi‐experimental with an interventional site and a noninterventional site.

SETTING: Four SCUs in two long‐term care facilities in Ontario.

PARTICIPANTS: The intervention site included 33 residents; the comparison site included 49 residents.

MEASUREMENTS: Weight change over time was the primary outcome. Three time periods were compared: 9‐month baseline period, 9‐month intervention period (enhanced dietitian monitoring and menu changes at intervention site), and 12‐month postintervention period (only menu changes at intervention site). Comparisons were made within and between sites. Full nutritional assessments were completed for the intervention group. Medical charts and basic anthropometric, behavioral, and cognitive measures were completed in both groups to determine baseline site differences. Weight change over time was analyzed with a repeated measures analysis, controlling for various covariates. Bivariate analyses were completed for other outcomes of death, number of infections, falls, and hospital days.

RESULTS: The intervention period that included the dietitian time and menu changes significantly promoted weight gain, compared with the standard treatment at the comparison facility. Other covariates of pacing, type of dementia, sex, age, number of comorbid conditions, and medications were also significant predictors of weight change. Weight gain or maintenance regardless of site was associated with survival.

CONCLUSION: Body weight can be maintained in residents of SCUs regardless of pacing and other clinical characteristics. The comprehensive intervention of clinical dietitian time and an enhanced menu designed to be individualized for ambulatory people with dementia promoted significant gains in body weight. A minimum 5% weight gain is associated with survival in these residents of SCUs.
Psychopathological Features in Alzheimer's Disease: Course and Relationship with Cognitive Status
Authors: Holtzer Roee , Tang Ming‐Xin , Devanand D. P. , Albert Steven M. , Wegesin Domonick J. , Marder Karen , Bell Karen , Albert Marilyn , Brandt Jason , Stern Yaakov
Published: September 2003

OBJECTIVES: To examine the course, clinical correlates, and relationship between cognitive status and psychopathological features in patients with probable Alzheimer's disease (AD) followed over a 5‐year period.

DESIGN: Cohort study with follow‐up of 5 years.

SETTING: Patients were recruited at three sites: 91 patients at Columbia Medical Center, 84 at Johns Hopkins School of Medicine, and 61 at Massachusetts General Hospital.

PARTICIPANTS: Patients diagnosed with probable AD (n = 236) enrolled in a longitudinal study (Predictors study).

MEASUREMENTS: Wandering/agitation, physical aggression, hallucinations, and delusions were evaluated at 6‐month intervals using the Columbia Scale for Psychopathology in Alzheimer's Disease. Descriptive analyses were used to provide estimates of prevalence and course of psychopathological features. General estimating equations determined the odds of having any of the four psychopathological behaviors as a function of cognitive status. Markov analyses provided 6‐month transition probabilities for psychopathological behaviors given patients' cognitive status and the presence or absence of such behaviors in the previous evaluation.

RESULTS: For wandering/agitation, prevalence (39–57%) and persistence increased as a function of time and decrement in cognitive status. Physical aggression was less prevalent (6–22%) and increased as a function of cognitive decline but tended to persist only in the more severely impaired patients. Delusions (34–49%) reached a peak at the second year and then declined. The odds of delusions were maximal with intermediate decline but remained persistent regardless of cognitive status. Hallucinations, despite some fluctuations, were relatively stable during the follow‐up period (8–17%) and moderately persistent.

CONCLUSION: Psychopathological features, particularly wandering/agitation and delusions, in AD were common throughout the disease course. The natural history and persistence of the four psychopathological features varied. These findings provide important information to clinicians and caregivers regarding the course, predictability, and possible treatment of psychopathological behaviors in patients with probable AD.
Life‐Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?
Authors: Gallo Joseph J. , Straton Joseph B. , Klag Michael J. , Meoni Lucy A. , Sulmasy Daniel P. , Wang Nae‐yuh , Ford Daniel E.
Published: September 2003

OBJECTIVES: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life‐sustaining treatment they wish in the event of incapacity to make these decisions for themselves.

DESIGN: Mailed survey to a cohort of physicians.

SETTING: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964.

PARTICIPANTS: Physicians who completed the advance directive questionnaire (mean age 68).

MEASUREMENTS: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on‐going study that began in 1946, asking physicians about their preferences for life‐sustaining treatments.

RESULTS: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty‐six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty‐four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49–4.69) or family members (OR = 9.58, 95% CI = 5.33–17.23) were aware of their preferences for end‐of‐life care and were more likely to refuse treatments than those without advance directives.

CONCLUSION: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.
Hospice Usage by Minorities in the Last Year of Life: Results from the National Mortality Followback Survey
Authors: Greiner K. Allen , Perera Subashan , Ahluwalia Jasjit S.
Published: September 2003

OBJECTIVES: To examine racial/ethnic variations in rates of hospice use in a national cohort and to identify individual characteristics associated with hospice use.

DESIGN: Secondary analysis of the 1993 National Mortality Followback Survey (NMFS), a nationally obtained sample using death certificates and interviews with relatives (proxy respondents) to provide mortality, social, and economic data and information about healthcare utilization in the last year of life for 23,000 deceased individuals.

SETTING: Hospice care.

PARTICIPANTS: Individuals aged 15 and older who died in 1993. Subjects were included in this analysis if they died of nontraumatic causes (N = 11,291).

MEASUREMENTS: Hospice use was dichotomized by proxy responses indicating use or nonuse of home or inpatient hospice services. The percentage of individuals using hospice services in the last year of life was calculated.

RESULTS: Unadjusted bivariate results found that African Americans were less likely to use hospice than whites (odds ratio (OR) = 0.59; P < .001) and that those without a living will (LW) (OR = 0.23; P < .001) and without a cancer diagnosis (OR = 0.28; P < .001) were less likely to use hospice. The negative relationship between African Americans and hospice use was unaffected when controlled for sex, education, marital status, existence of a LW, income, and access to health care. Logistic models revealed that presence of a LW diminished the negative relationship between African Americans and hospice use, but the latter remained significant (OR = 0.83; P = .033). A subanalysis of subjects aged 55 and older showed a significant interaction between access to care and race/ethnicity with respect to hospice use (P = .044). Inclusion of income in this multivariable logistic model attenuated the relationship between African‐American race/ethnicity and hospice use (OR = 0.77), and the difference between whites and African Americans became only marginally statistically significant (P = .060).

CONCLUSION: In the 1993 NMFS, hospice use was negatively associated with African‐American race/ethnicity independent of income and access to healthcare. The relationship is not independent of age, insurance type, or history of stroke. For subjects aged 55 and older, access to healthcare may be an important confounder of the negative relationship between African‐American race/ethnicity and hospice use. Consistent with previous studies, this analysis found that African Americans were less likely to use LWs than whites. The reduced importance of African‐American race/ethnicity on hospice use with the inclusion of presence of a LW in logistic models suggests that similar cultural processes may shape differences between African Americans and whites in advance care planning and hospice use.
The Effects of Implementation of the Agency for Health Care Policy and Research Urinary Incontinence Guidelines in Primary Care Practices
Authors: Bland Deirdre R. , Dugan Elizabeth , Cohen Stuart J. , Preisser John , Davis Cralen C. , McGann Paul E. , Suggs Patricia K. , Pearce Katherine F.
Published: September 2003

OBJECTIVES: To determine whether a multifaceted intervention based on the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines for Urinary Incontinence would increase primary care physician screening for and management of urinary incontinence (UI).

DESIGN: Group randomized trial, conducted from 1996 to 1997.

SETTING: Internal medicine and family medicine community practices.

PARTICIPANTS: Forty‐one primary care practices, including 57 physicians and their staff and 1,145 patients aged 60 and older.

INTERVENTION: Twenty of the 41 primary care practices in North Carolina were randomized to a composite intervention that included a 3‐hour continuing medical education accredited course, training in management of UI, patient educational materials, and on‐site physician and office support. The remaining 21 practices served as “usual care” controls. Telephone surveys of UI status and quality of life were obtained from 1,145 patients before the intervention. At 1 year, patients and physicians were contacted by telephone and mail to determine the effect of the educational intervention.

MEASUREMENTS: Patients completed telephone surveys to assess screening for UI, UI status, treatment interventions, and quality of life. Physicians completed surveys related to UI treatment and practice patterns.

RESULTS: Baseline and endpoint telephone surveys were completed by 668 of 1,145 (58%) of patients, who were cared for by 45 physicians (10 internists, 35 family medicine). Physician screening rates for UI were 22% for those patients who did not report UI. UI was reported by 39.5% of patients at baseline, of whom 30% reported being asked about UI by their primary care physician during the study. Rates of assessment and management of existing UI were low in both the control and intervention groups. Additional historical questioning indicated that 54.2% reported that they had ever undergone assessment, including history, urinalysis, or testing, or had had management of their UI by any physician.

CONCLUSION: Attempts at increasing screening and management of UI by primary care physicians using the AHCPR standardized guidelines using a multifaceted system of educational and logistical support were not successful. These guidelines may not be the best approach to treating UI in the primary care setting.
Effects of Exercise Training Added to Ongoing Hormone Replacement Therapy on Bone Mineral Density in Frail Elderly Women
Authors: Villareal Dennis T. , Binder Ellen F. , Yarasheski Kevin E. , Williams Daniel B. , Brown Marybeth , Sinacore David R. , Kohrt Wendy M.
Published: September 2003

OBJECTIVES: To determine whether exercise training added to ongoing hormone replacement therapy (HRT) increases bone mineral density (BMD) in physically frail elderly women.

DESIGN: Prospective controlled trial.

SETTING: University‐based research center.

PARTICIPANTS: Twenty‐eight women on HRT, aged 75 and older with physical frailty.

INTERVENTIONS: Participants were assigned to 9 months of supervised (EXER) or home (HOME) exercise. The EXER program started with physical therapy and gradually incorporated resistance and endurance training. The HOME program consisted of flexibility exercises.

MEASUREMENTS: Changes in BMD and body composition.

RESULTS: There were larger increases in lumbar spine BMD in response to EXER than with HOME (3.5% vs 1.5%, P = .048), with a trend for larger increases in total body BMD (1.5% vs 0.2%, P = .058). There were no significant between‐group differences in hip BMD. The EXER group had decreases in weight (−2.2 ± 0.3 kg, P = .010) and fat mass (−2.7 ± 0.4 kg, P = .018) and increases in muscle strength (9–30%, P < .05).

CONCLUSION: In physically frail elderly women on HRT, relatively vigorous exercise training significantly increased lumbar spine BMD. The improved BMD and strength in response to exercise could reduce fracture risk in frail women already on HRT.
Low Total Cholesterol and Increased Risk of Dying: Are Low Levels Clinical Warning Signs in the Elderly? Results from the Italian Longitudinal Study on Aging
Authors: Brescianini Sonia , Maggi Stefania , Farchi Gino , Mariotti Sergio , Di Carlo Antonio , Baldereschi Marzia , Inzitari Domenico , For The ILSA Group
Published: September 2003

OBJECTIVES: To analyze the relationship between serum total cholesterol (TC) and all‐cause mortality, taking into account various potential confounders.

DESIGN: Population‐based prospective cohort study.

SETTING: Older Italians residing in the general community.

PARTICIPANTS: Four thousand five hundred twenty‐one men and women aged 65–84.

MEASUREMENTS: Vital status data were available for 1992–95. The hazard ratios of dying for subjects in the second, third, and fourth quartiles compared with the first quartile of TC were computed using Cox proportional hazards, adjusting for lifestyle factors, anthropomorphic and biochemical measures, preexisting medical conditions, and frailty indicators.

RESULTS: Blood samples were obtained from 3,295 (73%) of the participants, of whom 399 died during almost 3 years of follow‐up. Low TC was associated with a higher risk of death. Those with TC in the second, third, and fourth quartiles (TC>189 mg/dL or 4.90 mmol/L) had lower hazard ratios (HRs) of death than subjects in the first quartile (0.57, 95% confidence interval (CI) = 0.38–0.87; 0.56, 95% CI = 0.36–0.88; and 0.53, 95% CI = 0.33–0.84, respectively). Few subjects taking lipid‐lowering drugs (LLDs) were in the lowest quartile of cholesterol, suggesting that these individuals have low TC values for reasons other than LLD use.

CONCLUSION: Subjects with low TC levels (<189 mg/dL) are at higher risk of dying even when many related factors have been taken into account. Although more data are needed to clarify the association between TC and all‐cause mortality in older individuals, physicians may want to regard very low levels of cholesterol as potential warning signs of occult disease or as signals of rapidly declining health.
Risk Factors for Nosocomial Pneumonia in a Geriatric Hospital: A Control‐Case One‐Center Study
Authors: Rothan‐Tondeur Monique , Meaume Sylvie , Girard Laurence , Weill‐Engerer Sébastien , Lancien Evelyne , Abdelmalak Soha , Rufat Pierre , Le Blanche Alain‐Ferdinand
Published: September 2003

OBJECTIVES: To determine the risk factors (RFs) and the incidence of nosocomial pneumonia (NP).

DESIGN: Control/case study conducted from January 1 to April 15, 1999. Prospective enrollment.

SETTING: Geriatric university hospital with long‐, intermediate‐, and short‐term care facilities.

PARTICIPANTS: Inpatients aged 65 and older with NP.

MEASUREMENTS: NP diagnosis relied on at least two clinical signs of respiratory infection and on chest radiography. Each NP case was randomly paired with two controls and followed up for 30 days to determine complication and mortality rates. RFs between cases and controls were compared (chi‐square test, odds ratio (OR), 95% confidence interval, significance level P = .05). RFs that were significant in univariate analysis were tested using multivariate analysis and logistic regression.

RESULTS: Seventy‐five cases of NP were diagnosed in 2,142 patients. The average incidence rate was 3.5% (short‐term facilities = 0.5%; intermediate‐term facilities = 8.3%; long‐term care facilities = 5.3%). The complication rate was 58.1%. The most frequent complications were recurrent NP, heart and respiratory failure, phlebitis, and pressure ulcers. The NP mortality rate was 12.2%. The independent RFs of NP were a history of NP during the previous 6 months (OR = 4.50) and oxygen therapy (OR = 16.15), P < .001. Additional RFs were severe malnutrition, heart failure, prescription of antibiotics during the month preceding the emerging NP, eating dependency, and feeding by nasogastric tube.

CONCLUSION: The main RF for NP is a history of pneumonia. NP prevention in geriatrics should rely on early management of respiratory infections and malnutrition, surveillance of oxygen therapy and enteral feeding, rational use of antibiotics, and adaptation to the patient's dependency.
Dementia after Delirium in Patients with Femoral Neck Fractures
Authors: Lundström Maria , Edlund Agneta , Bucht Gösta , Karlsson Stig , Gustafson Yngve
Published: September 2003

Objectives: To investigate whether delirium in older patients with femoral neck fractures is associated with an increased risk of developing dementia and a higher mortality rate.

Design: A 5‐year prospective follow‐up study.

Setting: Department of Orthopedic Surgery at the University Hospital in Umeå, Sweden.

Participants: Seventy‐eight nondemented patients aged 65 and older operated on for femoral neck fractures were followed for 5 years.

Measurements: The patients were assessed using the Organic Brain Syndrome (OBS) Scale pre‐ and postoperatively. Medical and social data were collected from the patients, their caregivers, and medical records, and the survivors were visited and assessed with the OBS Scale and the Mini‐Mental State Examination in their homes 5 years after the fracture.

Results: Thirty of 78 (38.5%) nondemented patients with a femoral neck fracture developed dementia within a 5‐year period. Twenty of 29 (69%) who were delirious postoperatively developed dementia, compared with 10 of 49 (20%) who were not delirious during their hospital stay (P < .001). Twenty‐one (72.4%) of those with postoperative delirium died within 5 years, compared with 17 of 49 (34.7%) of those who remained lucid postoperatively (P = .001).

Conclusion: Delirium in nondemented femoral neck fracture patients is associated with the development of dementia and a higher mortality rate. Patients with preoperative or postoperative delirium should therefore be assessed not only for the etiology of the delirium but also for any underlying organic brain disorder. Questions that remain unanswered are whether postoperative delirium is a marker of undetected dementia and whether postoperative delirium contributes to the development of dementia.
The Nutritional Status of 250 Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months
Authors: Visvanathan Renuka , Macintosh Caroline , Callary Mandy , Penhall Robert , Horowitz Michael , Chapman Ian
Published: September 2003

OBJECTIVES: To identify predictors and consequences of nutritional risk, as determined by the Mini Nutritional Assessment (MNA), in older recipients of domiciliary care services living at home.

DESIGN: Baseline analysis of subject characteristics with low MNA scores (<24) and follow‐up of the consequences of these low scores.

SETTING: South Australia.

PARTICIPANTS: Two hundred fifty domiciliary care clients (aged 67–99, 173 women).

MEASUREMENTS: Baseline history and nutritional status were determined. Information about hospitalization was obtained at follow‐up 12 months later.

INTERVENTION: Letters suggesting nutritional intervention were sent to general practitioners of subjects not well nourished.

RESULTS: At baseline, 56.8% were well nourished, 38.4% were at risk of malnutrition, and 4.8% were malnourished (43.2% not well nourished). Independent predictors of low MNA scores (<24) were living alone, and the physical and mental component scales of the 36‐item Short Form Health Survey. Follow‐up information was obtained for 240 subjects (96%). In the ensuing year not well‐nourished subjects were more likely than well‐nourished subjects to have been admitted to the hospital (risk ratio (RR) = 1.51, 95% confidence interval (CI) = 1.07–2.14), have two or more emergency hospital admissions (RR = 2.96, 95% CI = 1.15–7.59), spend more than 4 weeks in the hospital (RR = 3.22, 95% CI = 1.29–8.07), fall (RR = 1.65, 95% CI = 1.13–2.41), and report weight loss (RR = 2.63, 95% CI = 1.67–4.15).

CONCLUSION: The MNA identified a large number of subjects with impaired nutrition who did significantly worse than well‐nourished subjects during the following year. Studies are needed to determine whether nutritional or other interventions in people with low MNA scores can improve clinical outcomes.
Interventions to Prevent Aspiration Pneumonia in Older Adults: A Systematic Review
Authors: Loeb Mark B. , Becker Marissa , Eady Angela , Walker‐Dilks Cindy
Published: September 2003

A systematic review was conducted to assess the effectiveness of the following interventions for prevention of aspiration pneumonia (AP) in older adults: compensatory strategy/positioning changes, dietary interventions, pharmacologic therapies, oral hygiene, and tube feeding. Data sources included a key word search of the MEDLINE, EMBASE, Cochrane Library, CINAHL, and HealthSTAR databases and hand searches of six journals. Reference lists of relevant primary and review articles were searched. Studies included were randomized, controlled trials (RCTs) enrolling adults aged 65 and older at risk of and assessed for AP. Two investigators extracted data on population, intervention, outcomes, and methodological quality. Of the 17 identified RCTs, eight met the selection criteria, two addressed dietary management or compensatory swallowing, two assessed pharmacological therapies, one assessed oral hygiene, and three assessed tube feeding. None of the eight trials reported use of blinding, and allocation concealment was unclear in five. Use of amantadine prevented pneumonia in one trial of nursing home residents. The antithrombotic agent cilostazol prevented AP in another trial but resulted in excessive bleeding. Insufficient data exist to determine the effectiveness of positioning strategies, modified diets, oral hygiene, feeding tube placement, or delivery of food in preventing AP. Considering how common the problem of AP is in older adults, larger, high‐quality RCTs on the effectiveness of preventive interventions are warranted.
A Model for Managing Delirious Older Inpatients
Authors: Flaherty Joseph H. , Tariq Syed H. , Raghavan Srinivasan , Bakshi Sanjeev , Moinuddin Asif , Morley John E.
Published: September 2003

Although multiple models of care exist to prevent the development of delirium in hospitalized patients, models for the management of patients for whom delirium is unpreventable or who already have delirium on admission to the hospital are needed.

This article describes the development, management, and economics of a new model of care for patients with delirium, called the Delirium Room (DR). The DR is a specialized 4‐bed unit that provides 24‐hour intensive nursing care and is completely free of physical restraints. Another important feature of the 4‐bed DR is that it is an integral part of a 22‐bed acute care for the elderly (ACE) unit. As such, patients in the DR benefit from features of the ACE unit: a change in the physical environment of the medical floor to promote mobility and function and discourage bedrest, comprehensive geriatric care that identifies and addresses problems that can lead to a decline in function, and use of a daily multidisciplinary team meeting.

This article also presents descriptive data on a group of delirious patients managed in the DR with the intention of giving baseline data for other ACE units that are considering opening a DR or for future prospective studies in this area.
Medical Care of the Terminally Ill is More Than Symptom Management
Authors: Rainone Francine
Published: September 2003

PURPOSE: To provide clinicians with a concise review of the literature applicable to clinical management of the dying patient.

BACKGROUND: Various clinical trials,1 epidemiologic studies, and personal accounts have documented that a large part of the suffering of the terminally ill is preventable and ameliorable. Broadcast media2 and creative artists3 have also highlighted the fact that physicians are poorly prepared to recognize and address symptom management at the end of life.
Estimation of Glomerular Filtration Rate in Older Patients with Chronic Renal Insufficiency: Is the Modification of Diet in Renal Disease Formula an Improvement?
Authors: Lamb Edmund J. , Webb Michelle C. , Simpson David E. , Coakley Anthony J. , Newman David J. , O'Riordan Shelagh E.
Published: September 2003

OBJECTIVES: To evaluate a new formula for glomerular filtration rate (GFR), derived from the Modification of Diet in Renal Disease (MDRD) study in older people.

DESIGN: An observational study of the performance of the MDRD formula compared with other formulae and creatinine clearance (ClCr) as measures of the GFR.

SETTING: Volunteers were recruited via outpatient clinics.

PARTICIPANTS: Fifty‐two patients (27 men, 25 women: mean age 80, range 69–92) with a variety of medical diagnoses. Mean GFR was 53.3 mL/min/1.73 m2 (range 15.9–100.2). Exclusion criteria included renal replacement therapy/renal transplantation and cognitive impairment.

MEASUREMENTS: 51Chromium ethylenediaminetetraacetic acid (51Cr EDTA) was used as the reference method against which the formulaic estimates of GFR were compared using bias plot and regression analyses.

RESULTS: The MDRD and Cockcroft and Gault formulae (both coefficient of determination (R2) = 0.84) gave the best fit with GFR, followed by the Jelliffe formula (R2 = 0.81), ClCr (R2 = 0.73) and the Baracskay formula (R2 = 0.56). ClCr (−1.2%) demonstrated minimal bias compared with the MDRD (8.0%) and Cockcroft and Gault (−10.4%) formulae. However, imprecision compared with 51Cr EDTA was lowest for the Cockcroft and Gault formula, with 50% of estimates lying between −9.5 and −0.5 mL/min/1.73 m2 of measured 51Cr EDTA clearance. This compares with −6.7 and 10.1 mL/min/1.73 m2 for ClCr and 0.0 and 12.7 mL/min/1.73 m2 for the MDRD formula.

CONCLUSION: Calculated estimates of GFR are an improvement over ClCr estimation. On balance, the MDRD formula does not improve the estimate of GFR compared with the Cockcroft and Gault formula in older Caucasian patients with chronic renal insufficiency.
The relationship between risk and insight in a high‐security forensic setting
Authors: WOODS P. , REED V. , COLLINS M.
Published: September 2003

It is often intimated amongst practitioners in mental healthcare that clients who display poor insight either into their mental health or behaviour present a greater risk either to themselves or others. This paper reports relationships found between the risk and insight subscales of the Behavioural Status Index. This is an instrument designed specifically for healthcare practitioners to measure health functioning amongst mental health clients, in particular those in forensic mental healthcare. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 patients in two high‐security mental health hospitals. Seven factors emerged through factor analysis. The first of these contained all the insight items. Significant differences were found on a number of factors between independent groups. Generally, results indicate that patients on lower dependency wards scored more normatively on the factors, adding to instrument validity. Men were found to score more normatively than women. Clinical practice implications and ongoing European studies examining the use of the instrument in clinical practice and its association with treatment planning are discussed.
Predictors of psychological distress in family caregivers of persons with psychiatric disabilities
Authors: PROVENCHER H. L. , PERREAULT M. , ST‐ONGE M. , ROUSSEAU M.
Published: September 2003

The purpose of the study was to determine the relationships of primary and secondary stressors, and informal and formal supports, to psychological distress in 154 family caregivers of persons with psychiatric disabilities. All caregivers were members of self‐help groups located in the Province of Quebec in Canada. Psychological distress was significantly lower among older caregivers, those working full time, and those experiencing lower objective and subjective burdens. Contrary to the hypotheses, caregivers who perceived more support from friends and had more contacts with their relatives’ primary mental health providers experienced a higher level of psychological distress.
Experiences of parents with a son or daughter suffering from schizophrenia
Authors: FERRITER M. , HUBAND N.
Published: September 2003

Parents of 22 patients diagnosed with schizophrenia, and receiving care in a secure forensic setting, were interviewed to elicit their views on the causes of the disorder, the emotional burden and the helpfulness of others when seeking support. Pathological parenting theories of causation were rated the least important, and biological and life‐event models the most. Stress, loss and fear were the most commonly reported reactions. Violence, withdrawal and verbal aggression were most often identified as behaviours causing difficulty. Many participants felt guilt, usually in the absence of being blamed. Family members and self‐help groups were recalled as being of most help, and professional staff were considered to be of least help. Parenting a son or daughter with schizophrenia frequently causes considerable emotional distress, often with perception of unhelpful responses from professional staff. Parents often blame themselves for the disorder, even when not blamed by others. Guilt does not appear to arise from belief in a pathological parenting model of schizophrenia. Factors contributing to self‐blame in this group are discussed, together with suggestions for appropriate therapeutic intervention.
Nurses’ conceptions of how health processes are promoted in mental health nursing
Authors: JORMFELDT H. , SVEDBERG P. , ARVIDSSON B.
Published: September 2003

The health and well‐being of the individual is a central goal in nursing, and health promotion seeks to enable people to increase control over and improve their health. In mental health care, health is often described in negative terms such as the absence of mental illness, which may create hopelessness and constitute a barrier to a policy of health promotion. The aim of this study was to describe nurses’ conceptions of how health processes are promoted in mental health nursing. Twelve nurses working in mental health care were interviewed and the data were analysed using a phenomeographic approach. The nurses expressed 11 different conceptions of the phenomenon, which were summarized into three descriptive categories: presence, balance of power, and focus on health. The findings show that the nurses expressed ambiguous attitudes towards meeting the patient in mental health care. It is suggested that the goal of nursing care should be clarified for nurses in practice, otherwise they may adopt the perspectives of other mental health professionals.
Exploring core relationships between insight and communication and social skills in mentally disordered offenders
Authors: WOODS P. , REED V. , COLLINS M.
Published: September 2003

This paper reports collective data analysis for the Behavioural Status Index insight and communication and social skills subscales. This is an instrument designed specifically for health care practitioners to measure behavioural and social functioning among mental health clients, in particular those in forensic care. Data were collected, using a repeated measures method by primary nurses, from a sample of 503 patients in two high security mental health hospitals in the UK. Results are reported for interscalar item correlations and factor analysis. Data trends are indicative of clinically interesting relationships. A six‐factor structure emerged suggesting groupings of intra‐ and interscalar behaviours. The first of these contained all the Behavioural Status Index insight items. Significant differences were found on a number of factors between independent groups. Generally, results indicate that patients on lower dependency wards scored more normatively on the factors, adding to instrument validity. Men were found to score more normatively than women. According to Mental Health Act 1983 classifications, psychopathically disordered patients scored more normatively than mentally ill patients, who in turn scored more normatively than patients with learning disability. Clinical practice implications and ongoing European studies examining the use of the instrument in clinical practice and its association to treatment planning are discussed.
Differences in the progress of discharged and undischarged patients in a medium secure unit: a pilot study
Authors: HEAP M.
Published: September 2003

This study compared 15 patients (‘undischarged’ group) who were showing little sign of progress in a medium secure unit (MSU) after 2 years with 15 who had been discharged from the same unit 1–2 years following admission. The two groups were compared across a number of broadly defined behavioural indices during their first 6 months and first 12 months following admission. The measures used were indices of progress to wards of lower security (highest ward status and transfers to wards of higher security) and progress in terms of leave (highest leave status and reductions in leave status). In addition, the two groups were compared on number of recorded incidents attributable to them. Discharged patients were significantly older at the time of their admission than the undischarged patients (median ages 33 and 26 years, respectively). They made more progress in their first year in terms of ward security and leave status and were responsible for fewer recorded incidents. These results were also obtained at 6 months following admission with the exception that the difference for highest ward status was not statistically significant. The findings of this small‐scale study suggest that within the first 6 months of admission, it may be possible to distinguish patients who will probably make good progress in a MSU from those whose progress is likely to be very slow. Implications of the study are discussed.