bluuebunny/crossref_metadata_2025 huggingface dataset:
Unusual uveal tract tumor: Mesectodermal leiomyoma of the ciliary body
Authors: Lai Chuan‐Tsai , Tai Ming‐Cheng , Liang Chang‐Min , Lee Herng‐Sheng
Published: April 2004

Benign smooth muscle tumor, leiomyoma, can occur throughout the whole body, including the most common sites of the genitourinary and gastrointestinal tracts, less frequently in the skin, and rarely in the deep soft tissue or uveal tract. A 23‐year‐old Chinese woman presented with a 4 month history of a pigmented ciliary body mass in her left eye. The tumor's clinical appearance and ancillary data were initially consistent with malignant melanoma. However, instead of enucleation, sclerotomy with a tumor biopsy was performed because of the patient's young age and the possibility of benign tumors. Under light microscopy, tumor cells were short spindle‐ or ovoid‐shaped with fine nuclear chromatin and fibrillary cytoplasmic processes resembling neural tissue. Although the tumor displayed neurogenic morphology, it showed strong reactivity for α‐smooth muscle‐specific actin and h‐caldesmon, and was negative for neurogenic markers, except CD56, by immunohistochemistry. Primary mesectodermal leiomyoma of the ciliary body was diagnosed because of both the myogenic and neurogenic characteristics. The tumor biopsy or intraoperative frozen section is suggested for accurate pathological diagnosis before enucleation. In a review of the literature, only 14 cases have been reported. Seven cases (50%) were subjected to enucleation and eventually showed a benign mesectodermal leiomyoma. This case report provides novel expression of h‐caldesmon and CD56 by the tumor cells of mesectodermal leiomyoma.
Uterine leiomyoma with massive lymphoid infiltration: Case report and review of the literature
Authors: Paik Seung Sam , Oh Young‐Ha , Jang Ki Seok , Han Hong Xiu , Cho Sam Hyun
Published: April 2004

Uterine leiomyoma with massive lymphoid infiltration is a rare and unusual pathological finding. Only 13 cases have been reported in English literature. A case of uterine leiomyoma showing massive lymphoid infiltration in a 45‐year‐old woman is described. The tumor was relatively soft compared with usual leiomyomas. Microscopically, the tumor showed the typical features of leiomyoma with moderate to severe lymphocytic infiltrate consisting of mature lymphocytes, a few plasma cells and occasional histiocytes. This cellular infiltration was confined to the leiomyoma. Immunohistochemically, the diffusely infiltrated lymphoid cells were stained by antibodies to CD45RO, CD3 and CD8. Germinal centers were stained by antibodies to CD20 and CD79a. Some CD68+ histiocytes were seen. Lymphoid infiltration within the leiomyoma is a peculiar histological morphology, although the cause is not clear. The recognition of its distinct histological features is important to avoid possible confusion with differential diagnoses including malignant lymphoma, inflammatory pseudotumor and pyomyoma.
Multiple epithelial cysts of the spleen and on the splenic capsule, and high serum levels of CA19‐9, CA125 and soluble IL‐2 receptor
Authors: Hashimoto Takeaki , Sugino Takashi , Fukuda Takeaki , Hoshi Nobuo , Ogura Go , Watanabe Kazuo , Satoh Yukio , Hasegawa Takeo , Ohishi Akio , Haga Jinichi , Miyata Masayuki , Suzuki Toshimitsu
Published: April 2004

An 18‐year‐old woman with abdominal pain was diagnosed as having splenic cysts by computed tomography scan. She had high serum levels of CA19‐9 (2886.8 U/mL; normal value, <35 U/mL), CA125 (131.1 U/mL; normal value, <35 U/mL) and soluble IL‐2 receptor (1490 U/mL; normal range, 220–530 U/mL). The resected spleen weighed 1050 g, was 14 × 28 cm, and had more than 10 macroscopic cysts up to 10.3 × 9.5 cm. There were numerous microscopic cysts in the spleen and several on the splenic capsule. The levels of CA19‐9 and CA125 in the cyst fluid were 2 165 550 U/mL and 160 400 U/mL, respectively. After the surgery, the serum levels of the tumor markers decreased gradually. The inside of the largest cyst was mainly covered by granulation tissue with a focal lining of epithelial cells, and the other macroscopic cysts had stratified squamous epithelium. The microscopic splenic cysts and cysts on the splenic capsule were lined by either attenuated single‐layered or multilayered epithelial cells. The lining epithelial cells of these cysts were positive for epithelial membrane antigen and cytokeratins. CA19‐9 and CA125 were detected in the lining cells of the splenic cysts. In the present case, it is suspected that the splenic cysts were derived from the capsular lining cells that showed migration from the capsule or formed microcysts on the splenic capsule, as in the case of ovarian inclusion cysts.
Immunohistochemical examination of mucinous cystadenoma of the testis
Authors: Naito Shinji , Yamazumi Kazuyuki , Yakata Yuichi , Shono Takefumi , Hakariya Hironobu , Nakayama Toshiyuki , Nakashima Masahiro , Sekine Ichiro
Published: April 2004

A case of mucinous cystadenoma of the testis in a 55‐year‐old man is reported. The tumor was confined to the testis and was clearly separated from the epididymis. There was no connection between the tumor cyst and the rete testis. The lumen of the cyst was lined with a single‐layer of columnar cells interspersed with goblet cells. There was neither stromal invasion nor metastasis to other organs and there were no ovarian or germ cell neoplastic elements in the tumor. Immunohistochemical analysis revealed that MUC2, MUC5AC, carcinoembryonic antigen, CA19‐9, CK7 and CK20 proteins were expressed on the tumor epithelial cells, whereas expression of MUC6, α‐fetoprotein, CA125, human chorionic gonadotrophin, estrogen receptor, progesterone receptor, calretinin, chromogranin A, p53, cyclin D1 and bcl‐2 proteins was absent. Ki‐67 protein was weakly and sparsely expressed in the nuclei of epithelial cells. The mucinous cystadenoma in the present case, which was devoid of a connection to testicular appendices and had the immunohistochemical characteristics of gastrointestinal mucosa, might have originated from one‐sided differentiation of teratoma cells.
Palisading subcutaneous fibrous histiocytoma
Authors: Fukunaga Masaharu
Published: April 2004

A case of palisading subcutaneous fibrous histiocytoma, a very rare variant of fibrous histiocytoma (dermatofibroma), arising in the wrist of a 41‐year‐old man is presented. An unencapsulated subcutaneous tumor measuring 0.8 × 0.8 × 0.7 cm was histologically characterized by predominant nuclear palisading and a peripheral area with a pattern quite characteristic of conventional fibrous histiocytoma. Immunohistochemically, the tumor cells were strongly positive for vimentin, alpha‐smooth muscle, and muscle actin, but negative for S‐100 protein, indicating a fibroblastic or myofibroblastic nature. The patient has been well without recurrence for 6 years and 8 months after the excision. This neoplasm should be differentiated from benign and malignant skin or soft tissue tumors with a palisading pattern. Pathologists and clinicians should know of the existence of this type of fibrous histiocytoma and should avoid overdiagnosis and overtreatment.
Parachordoma is not distinguishable from axial chordoma using immunohistochemistry
Authors: Scolyer Richard A. , Bonar S. Fiona , Palmer A. Allan , Barr Elizabeth M. , Wills Edward J. , Stalley Paul , Schatz Julie , Soper Judith , Li Ling‐Xi L. , McCarthy Stanley W.
Published: April 2004

Parachordoma is a rare soft tissue tumor that morphologically resembles chordoma of the axial skeleton but occurs in a peripheral site. A recent study reported immunohistochemical differences between chordoma and parachordoma. While both tumors were positive for cytokeratin (CK) 8/18 (as recognized by the antibody Cam5.2), S100 and epithelial membrane antigen (EMA), only the chordoma was positive for CK7, CK20, CK 1/5/10/14 (as recognized by the antibody 34βE12) and carcinoembryonic antigen (CEA). It has since been suggested that tumors indistinguishable from chordoma that involve the periphery should be termed chordoma periphericum and that these tumors are distinct from parachordoma. In the current study, the clinical, radiological, pathological, immunohistochemical and ultrastructural features of a chordoma‐like tumor involving the deep soft tissues of the lower leg of a 69‐year‐old woman are presented. Microscopically, the tumor had a pseudolobulated growth pattern and consisted of sheets, nests and cords of epithelioid cells, some with a physaliferous appearance, separated by abundant myxoid stroma. The tumor cells were positive for CK 8/18, EMA and S100, showed focal staining for CK7, and were negative for CK20, CK 1/5/10/14 and CEA. On the basis of these results a diagnosis of parachordoma was favored. For comparison, an immunohistochemical analysis of five axial chordomas was also performed. The chordomas showed positivity for CK 8/18 (5 of 5 cases), EMA (5 of 5 cases), S100 (5 of 5 cases), CK 1/5/10/14 (1 of 5 cases) and CK7 (1 of 5 cases). Stains for CK20 and CEA were negative in all five chordomas. The results of the present study suggest that the expression of antigens for CK 1/5/10/14, CK7, CK20 and CEA in chordoma might not be as common as what has been previously reported. The results also suggest that parachordoma might not be easily distinguished immunohistochemically from axial chordoma (and therefore also from so‐called chordoma periphericum).
Intraneural perineurioma involving the ulnar nerve
Authors: Hamazaki Shuji , Fujiwara Kazuo , Okada Shigeru
Published: April 2004

Intraneural perineurioma is a rare peripheral nerve sheath tumor consisting of intraneural proliferation of neoplastic perineurial cells. Clinical and pathological findings of a perineurioma involving the ulnar nerve is presented. A 7‐year‐old girl presented with a 2 year history of weakness and atrophy of the right hand muscles. Physical examination and imaging study revealed a pea‐sized tumor in the ulnar side of the right forearm. At surgery, a fusiform swelling of the ulnar nerve was found and an excisional biopsy of the lesion was performed. Light microscopy revealed numerous whorls consisting of concentric layers of spindle cells encircling the nerve fibers. The proliferating cells were immunoreactive for vimentin, epithelial membrane antigen and glucose transporter protein 1 (Glut1), but negative for S‐100 protein and CD34. Ultrastructural examination revealed features of perineurial cell differentiation. The current study suggests that Glut1 is a useful marker of intraneural perineurioma.
Resistance and Agility Training Reduce Fall Risk in Women Aged 75 to 85 with Low Bone Mass: A 6‐Month Randomized, Controlled Trial*
Authors: Liu‐Ambrose Teresa , Khan Karim M. , Eng Janice J. , Janssen Patti A. , Lord Stephen R. , Mckay Heather A.
Published: April 2004

Objectives: To compare the effectiveness of group resistance and agility‐training programs in reducing fall risk in community‐dwelling older women with low bone mass.

Design: A randomized, controlled, single‐blind 25‐week prospective study with assessments at baseline, midpoint, and trial completion.

Setting: Community center.

Participants: Community‐dwelling women aged 75 to 85 with low bone mass.

Intervention: Participants were randomly assigned to one of three groups: resistance training (n=32), agility training (n=34), and stretching (sham) exercises (n=32). The exercise classes for each study arm were held twice weekly.

Measurements: The primary outcome measure was fall risk (derived from weighted scores from tests of postural sway, reaction time, strength, proprioception, and vision), as measured using a Physiological Profile Assessment (PPA). Secondary outcome measures were ankle dorsiflexion strength, foot reaction time, and Community Balance and Mobility Scale score.

Results: Attendance at the exercise sessions for all three groups was excellent: resistance training (85.4%), agility training (87.3%), and stretching program (78.8%). At the end of the trial, PPA fall‐risk scores were reduced by 57.3% and 47.5% in the resistance and agility‐training groups, respectively, but by only 20.2% in the stretching group. In the resistance and agility groups, the reduction in fall risk was mediated primarily by improved postural stability, where sway was reduced by 30.6% and 29.2%, respectively. There were no significant differences between the groups for the secondary outcomes measures. Within the resistance‐training group, reductions in sway were significantly associated with improved strength, as assessed using increased squat load used in the exercise sessions.

Conclusion: These findings support the implementation of community‐based resistance and agility‐training programs to reduce fall risk in older women with low bone mass. Such programs may have particular public health benefits because it has been shown that this group is at increased risk of falling and sustaining fall‐related fractures.
Efficacy and Safety of Rofecoxib 12.5 mg Versus Nabumetone 1,000 mg in Patients with Osteoarthritis of the Knee: A Randomized Controlled Trial
Authors: Kivitz Alan J. , Greenwald Maria W. , Cohen Stanley B. , Polis Adam B. , Najarian Daryl K. , Dixon Mary E. , Moidel Robert A. , Green Jerry A. , Baraf Herbert S. B. , Petruschke Richard A. , Matsumoto Alan K. , Geba Gregory P. ,   for the Protocol 085,   study investigators
Published: April 2004

Objectives: To evaluate the use of starting doses of rofecoxib and nabumetone in patients with osteoarthritis (OA) of the knee.

Design: A 6‐week, randomized, parallel‐group, double‐blind, placebo‐controlled study.

Setting: One hundred thirteen outpatient sites in the United States.

Participants: A total of 1,042 male and female patients aged 40 and older with OA of the knee (>6 months).

Interventions: Rofecoxib 12.5 mg once a day (n=424), nabumetone 1,000 mg once a day (n=410), or placebo (n=208) for 6 weeks.

Measurements: The primary efficacy endpoint was patient global assessment of response to therapy (PGART) over 6 weeks, which was also specifically evaluated over the first 6 days. The main safety measure was adverse events during the 6 weeks of treatment.

Results: The percentage of patients with a good or excellent response to therapy as assessed using PGART at Week 6 was significantly higher with rofecoxib (55.4%) than nabumetone (47.5%; P=.018) or placebo (26.7%; P<.001 vs rofecoxib or nabumetone). Median time to first report of a good or excellent PGART response was significantly shorter in patients treated with rofecoxib (2 days) than with nabumetone (4 days, P=.002) and placebo (>5 days, P<.001) (nabumetone vs placebo; P=.007). The safety profiles of rofecoxib and nabumetone were generally similar, including gastrointestinal, hypertensive, and renal adverse events.

Conclusion: Rofecoxib 12.5 mg daily demonstrated better efficacy over 6 weeks of treatment and quicker onset of OA efficacy over the first 6 days than nabumetone 1,000 mg daily. Both therapies were generally well tolerated.
Treatment of Nursing Home Residents with Dementia and Lower Respiratory Tract Infection in the United States and the Netherlands: An Ocean Apart
Authors: Van Der Steen Jenny T. , Kruse Robin L. , Ooms Marcel E. , Ribbe Miel W. , Van Der Wal Gerrit , Heintz Lawrence L. , Mehr David R.
Published: April 2004

Objectives: To compare treatment of nursing home residents with dementia and lower respiratory tract infection (LRI) in Missouri and the Netherlands.

Design: Two separate but simultaneous prospective cohort studies.

Setting: Nursing homes in Missouri (n=36) and the Netherlands (n=61).

Participants: Selected residents (701 from Missouri and 551 from the Netherlands) diagnosed with LRI and dementia.

Measurements: Treatment, dementia severity, symptoms and signs of LRI, and general health condition were recorded at the time of diagnosis of LRI. Death was monitored at follow‐up. Treatment and mortality, stratified for dementia severity, are reported.

Results: Treatment of nursing home‐acquired LRI in Missouri residents involved a larger number of antibiotics, more frequent hospitalization, and greater use of intravenous antibiotics and rehydration therapy than in Dutch residents of equal dementia severity. Furthermore, for Missouri residents, intensive interventions were more often provided irrespective of severe dementia. By contrast, in both countries, treatments to relieve symptoms of LRI were provided for only a minority of residents. Dutch mortality rates were higher overall.

Conclusion: Care for U.S. nursing home residents with LRI and dementia is more aggressive than care for Dutch residents, particularly in residents with severe dementia. These results are relevant to the debate on optimal care in relation to curative or palliative treatment goals.
Validity of the Minimum Data Set in Identifying Urinary Tract Infections in Residents of Long‐Term Care Facilities
Authors: Stevenson Kurt B. , Moore James W. , Sleeper Barbara
Published: April 2004

Objectives: To determine the validity of the Minimum Data Set (MDS) to detect cases of urinary tract infection (UTI) that meet specific evidence‐based criteria.

Design: Prospective surveillance.

Setting: Sixteen long‐term care facilities (LTCFs) in Idaho.

Participants: Residents of participating LTCFs for whom an MDS form was completed.

Measurements: Prospective surveillance of all types of infection, including UTI, and data collection on clinical manifestation, microbiology, and treatment; MDS data on identification of UTI.

Results: A stratified analysis demonstrated that the validity of MDS was 14% when using the evidence‐based criteria for UTIs as the criterion standard. The estimated sensitivity and specificity of MDS entries were 57.9% and 86.5%, respectively. The estimated positive and negative predictive values for the study population were 13.9% and 98.2%, respectively.

Conclusion: MDS has the potential to be an important measure of quality in the long‐term care setting. When used to detect residents with UTIs, it appears to greatly overestimate the number of cases while adequately screening out residents without UTIs. These problems may be overcome by providing more‐explicit definitions for UTIs to be used by providers when completing MDS information on individual residents.
Urinary Incontinence and Its Association with Death, Nursing Home Admission, and Functional Decline
Authors: Holroyd‐Leduc Jayna M. , Mehta Kala M. , Covinsky Kenneth E.
Published: April 2004

Objectives: To determine whether urinary incontinence (UI) is an independent predictor of death, nursing home admission, decline in activities of daily living (ADLs), or decline in instrumental activities of daily living (IADLs).

Design: A population‐based prospective cohort study from 1993 to 1995.

Setting: Community‐dwelling within the United States.

Participants: Six thousand five hundred six of the 7,447 subjects aged 70 and older in the Asset and Health Dynamics Among the Oldest Old study who had complete information on continence status and did not require a proxy interview at baseline.

Measurements: The predictor was UI, and the outcomes were death, nursing home admission, ADL decline, and IADL decline. Potential confounders considered were comorbid conditions, baseline function, sensory impairment, cognition, depressive symptoms, body mass index, smoking and alcohol, demographics, and socioeconomic status.

Results: The prevalence of UI was 14.8% (18.5% in women; 8.5% in men). At 2‐year follow‐up, subjects incontinent at baseline were more likely to have died (10.9% vs 8.7%; unadjusted odds ratio (OR)=1.29, 95% confidence interval (CI)=1.02–1.64), be admitted to a nursing home (4.4% vs 2.6%, OR=1.77; 95% CI=1.18–2.63), and to have declined in ADL function (13.6% vs 8.1%; OR=1.78, 95% CI=1.36–2.33) and IADL function (21.2% vs 13.8%; OR 1.69, 95% CI 1.39–2.05). However, after adjusting for confounders, UI was not an independent predictor of death (adjusted OR (AOR)= 0.90, 95% CI=0.67–1.21), nursing home admission (AOR=1.33, 95% CI=0.86–2.04), or ADL decline (AOR=1.24, 95% CI=0.92–1.68). Incontinence remained a predictor of IADL decline (AOR=1.31; 95% CI=1.05–1.63), although adjustment markedly reduced the strength of this association.

Conclusion: Higher levels of baseline illness severity and functional impairment appear to mediate the relationship between UI and adverse outcomes. The results suggest that, although UI appears to be a marker of frailty in community‐dwelling elderly, it is not a strong independent risk factor for death, nursing home admission, or functional decline.
Anemia Is Associated with Disability and Decreased Physical Performance and Muscle Strength in the Elderly
Authors: Penninx Brenda W. J. H. , Pahor Marco , Cesari Matteo , Corsi Anna Maria , Woodman Richard C. , Bandinelli Stephania , Guralnik Jack M. , Ferrucci Luigi
Published: April 2004

Objectives: To examine the association between anemia and disability, physical performance, and muscle strength in older persons.

Design: Cross‐sectional.

Setting: Community‐dwelling older persons in the Chianti area in Italy.

Participants: A total of 1,156 persons aged 65 and older participating in the InChianti Study (“Invecchiare in Chianti,” i.e., Aging in the Chianti Area).

Measurements:
Anemia was defined according to World Health Organization criteria as a hemoglobin concentration below 12 g/dL in women and below 13 g/dL in men. Disability in six basic and eight instrumental activities of daily living was assessed. Physical performance was assessed using the short physical performance battery (4‐m walk, balance, and chair stands), which yields a summary performance score ranging from 0 to 12 (high). Muscle strength was determined using knee extensor and handgrip strength assessments.

Results: Overall, 11.1% of the men and 11.5% of the women had anemia. After adjustment for age, sex, body mass index, Mini‐Mental State Examination score, creatinine level, and presence of various comorbid conditions, anemic persons had more disabilities (1.71 vs 1.04, P=.002) and poorer performance (8.8 vs 9.6, P=.003) than persons without anemia. Anemic persons also had significantly lower knee extensor strength (14.1 vs 15.2 kg, P=.02) and lower handgrip strength (25.3 vs 27.1 kg, P=.04) than persons without anemia. Further adjustment for inflammatory markers (interleukin‐6, C‐reactive protein, tumor necrosis factor‐α) did not change these associations.

Conclusion: Anemia is associated with disability, poorer physical performance, and lower muscle strength. Further research should explore whether treating anemia has a beneficial effect on the functional status of older persons.
Differences in End‐of‐Life Preferences Between Congestive Heart Failure and Dementia in a Medical House Calls Program
Authors: Haydar Ziad R. , Lowe Alice J. , Kahveci Kellie L. , Weatherford Wilson , Finucane Thomas
Published: April 2004

Objectives: To compare end‐of‐life preferences in elderly individuals with dementia and congestive heart failure (CHF).

Design: Retrospective case‐control study.

Setting: Geriatrician‐led interdisciplinary house‐call program using an electronic medical record.

Participants: Homebound individuals who died while under the care of the house‐call program from October 1996 to April 2001.

Measurements: Medical records review for demographics, functional status, advance medical planning, hospice use, and place of death.

Results: Of 172 patients who died in the program, 29 had CHF, 79 had dementia, 34 had both, and 30 had neither. Patients with CHF were younger (82.6 vs 87.0, P=.011) and less functionally dependent (activities of daily living score 9.1 vs 11.5, P=.001). Time from enrollment to death was not significantly different (mean±standard deviation=444±375 days for CHF vs 325±330 days for dementia, P=.113). A do‐not‐resuscitate (DNR) directive was given in 62% of patients with CHF and 91% with dementia (P<.001). Advance medical planning discussions were not significantly different (2.10 in CHF vs 1.65 in dementia, P=.100). More patients with CHF participated in their advance medical planning than those with dementia (86% vs 17%, P<.001). Hospice was used in 24% of CHF and 61% of dementia cases (P<.001). Finally, 45% of patients with CHF and 18% of patients with dementia died in the acute hospital (P=.006). Multivariate analysis showed that the fact that more patients with CHF were involved in their medical planning was not significant in predicting end‐of‐life preferences. Alternatively, Caucasian ethnicity was an independent predictor of having a documented DNR and death outside of the acute hospital.

Conclusion: In the months before death, patients with CHF were more likely to have care plans directed at disease modification and treatment, whereas dementia patients were more likely to have care plans that focused on symptom relief and anticipation of dying. Several factors may contribute to this difference.
Do Rural Elders Have Limited Access to Medicare Hospice Services?
Authors: Virnig Beth A. , Moscovice Ira S. , Durham Sara B. , Casey Michelle M.
Published: April 2004

Objectives: To examine whether there are urban‐rural differences in use of the Medicare hospice benefit before death and whether those differences suggest that there is a problem with access to hospice care for rural Medicare beneficiaries.

Design: Observational study using 100% of Medicare enrollment, hospice, and hospital claims data.

Setting: Inpatient hospitals and hospices.

Participants: Persons aged 65 and older in the Medicare program who died in 1999.

Measurements: Rates of hospice use before death and in‐hospital death rates were calculated.

Results: In 1999, there were 1.76 million deaths of Medicare beneficiaries aged 65 and older. Hospice services were used by 365,700 of these beneficiaries. Rates of hospice care before death were negatively associated with degree of rurality. The lowest rate of hospice use, 15.2% of deaths, was seen in rural areas not adjacent to an urban area. The highest rate of use, 22.2% of deaths, was seen in urban areas. Rural areas adjacent to urban areas had an intermediate level of hospice use (17.0% of deaths). Hospices based in rural areas had a smaller number of elderly patients each year than hospices based in urban areas (P<.001) and were more likely to have very low volumes (average daily census of three patients or less).

Conclusion: The consistently lower use of Medicare hospice services before death and smaller sizes of rural hospices suggest that the combination of Medicare hospice payment policies and hospice volumes are problematic for rural hospices. Adjusting Medicare payment policies might be a critical step to assure availability of hospice services forterminally ill beneficiaries regardless of where they live.
The Quality of Medical Care Provided to Vulnerable Older Patients with Chronic Pain
Authors: Chodosh Joshua , Solomon David H. , Roth Carol P. , Chang John T. , MacLean Catherine H. , Ferrell Bruce A. , Shekelle Paul G. , Wenger Neil S.
Published: April 2004

Objectives: To assess the quality of chronic pain care provided to vulnerable older persons.

Design: Observational study evaluating 11 process‐of‐care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999.

Setting: Two senior managed care plans.

Participants: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed‐care plans.

Measurements: Percentage of quality indicators satisfied for patients with chronic pain.

Results: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2‐year period. One hundred twenty‐three patients (33%) had medical record documentation of a new episode of chronic pain during a 13‐month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow‐up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase‐selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity.

Conclusion: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow‐up, and attention to potential toxicities of therapy.
Daily Pain That Was Excruciating at Some Time in the Previous Week: Prevalence, Characteristics, and Outcomes in Nursing Home Residents
Authors: Teno Joan M. , Kabumoto Glen , Wetle Terrie , Roy Jason , Mor Vincent
Published: April 2004

Objectives:To examine the prevalence, correlates, and consequences of nursing home (NH) staff reports of “excruciating” level of pain at some time in the previous week in persons with daily pain reported on the Minimum Data Set (MDS).

Design:Cross‐sectional study.

Setting:NHs in the United States.

Participants:A total 2,138,442 persons who resided in 15,745 nursing homes in the United States.

Measurements:Pain reported as daily and at its most excruciating in the previous week on the MDS at initial and follow‐up assessment. Associations were examined with demographic characteristics, functioning, and measures of disease burden reported on the MDS.

Results:NH staff noted that 80,512 (3.7%) of residents had daily pain that was at one or more times excruciating in the previous week. This level of pain was more prevalent in younger residents. Nearly two‐thirds (62.1%) of persons with this level of pain were no longer independent in activities of daily living, but 48.8% were rated to have normal cognitive status. In contrast, those without daily pain that was sometimes excruciating were less likely to be cognitively intact (25.7%P<.001) and less likely to have declined in their functioning (30.1%,P=.001). More than one in five with daily pain that was excruciating at times had a cancer diagnosis, and 21.5% experienced weight loss. Of the 24,300 persons with a second assessment, 10,284 (42.3%) still had excruciating pain at some time in the previous week.

Conclusion:NH residents with daily pain that was sometimes excruciating were younger and seriously ill with functional decline and weight loss. Too often, persons remain in this level of pain.
Predictors of Varying Levels of Nonadherence to Mammography Screening in Older Women*
Authors: Levy‐Storms Lené , Bastani Roshan , Reuben David B.
Published: April 2004

Objectives: To identify predictors of varying levels of nonadherence to mammography screening in older women.

Design: Cross‐sectional survey.

Setting: Sixty community‐based sites where seniors gather.

Participants: Consecutive volunteer sample of 499 women aged 60 to 84 who had not received a mammogram within the previous year.

Measurements: Three levels of nonadherence (never had a mammogram (never), mammogram more than 2 years before (lapsed), and mammogram in the past 1 to 2 years (due/reference group)). These were based on a Transtheoretical Model and incorporated into the Adherence Model. Bivariate and multivariate multinomial logistic regression analysis was used for variables obtained.

Results: Two risk factors, having difficulty getting to a facility and not intending to ask a health provider for a mammogram, were predictive of the never and lapsed levels. Distinct risk factors for being in the never compared with the due level of nonadherence included being concerned about pain, not being enrolled in a health maintenance organization, not getting preventive checkups, and being only somewhat (versus very) likely to ask a physician for mammogram. In contrast, distinct risk factors for the lapsed compared with the due level of nonadherence included perceiving that no friends have routine mammograms and not having a provider referral.

Conclusion: Some risk factors for not being up to date with mammography vary by the level of nonadherence. Interventions should be individualized to women's level of nonadherence and include common core strategies that encourage women to ask for a mammogram and to lessen the difficulty of getting to a screening facility.
Depression After Stroke: A Prospective Epidemiological Study
Authors: Whyte Ellen M. , Mulsant Benoit H. , Vanderbilt Joni , Dodge Hiroko H. , Ganguli Mary
Published: April 2004

Objectives: To elucidate the relationship between stroke and depressive symptoms and to determine whether disability or cerebrovascular risk factors mediate that relationship.

Design: A prospective longitudinal epidemiological survey.

Setting: The mid‐Monongahela Valley, a rural, nonfarm, low‐socioeconomic‐status community.

Participants: Random sample of 1,134 subjects aged 65 and older.

Measurements: The dependent variable was clinically significant depressive symptoms, as defined by five or more symptoms on the modified Center for Epidemiological Studies Depression scale. The independent variables were demographics (age, sex, education), stroke, number of impaired instrumental activities of daily living (IADLs), diabetes mellitus, hypertension, atherosclerotic heart disease, and smoking. Logistic regression analyses were conducted for cross‐sectional and longitudinal models examining whether stroke was associated with or predicted depressive symptoms, with other associated factors included as covariates.

Results: Clinically significant depressive symptoms were cross‐sectionally associated with stroke (odds ratio (OR)=3.5, 95% confidence interval (CI)=1.4–8.3), diabetes mellitus (OR=2.8, 95% CI=1.7–4.6; P≤.05), and IADL impairment (OR=1.6, 95% CI=1.4–1.8; P<.05). Longitudinal analysis demonstrated that stroke (OR=6.3, 95% CI=1.7–23.2) and depressive symptoms at baseline (OR=15, 95% CI=7.7–29.5) predicted subsequent clinically significant depressive symptoms measured 2 years later, whereas education was protective (OR=0.4, 95% CI=0.2–0.8).

Conclusion: Stroke survivors have a greatly elevated risk for clinically significant depressive symptoms even 2 or more years after index stroke, independent of functional disability, cerebrovascular risk factors, and previous depressive symptoms.
The Effect of Raloxifene on Markers of Bone Turnover in Older Women Living in Long‐Term Care Facilities
Authors: Hansdóttir Helga , Franzson Leifur , Prestwood Karen , Sigur∂´sson Gunnar
Published: April 2004

Objectives: To examine the effect of raloxifene on bone turnover in elderly women.

Design: Clinical intervention.

Setting: Long‐term care facilities.

Participants: Nineteen women completed the study, mean age 85 (range 76–99).

Intervention: Raloxifene 60 mg was given daily for 12 weeks.

Measurements: Markers of bone turnover were plasma C‐telopeptides of type I collagen (CTx), urine cross‐linked N‐telopeptides of type I collagen (NTx) and serum tartrate–resistant acid phosphatase (TRAP 5b), plasma osteocalcin, and serum bone alkaline phosphatase. Other markers were serum 25‐OH vitamin D, parathyroid hormone, ionized calcium, and phosphate. Markers were measured at baseline, after calcium and vitamin D had been taken for 6 weeks, after raloxifene had been taken for 12 weeks, and 6 weeks after raloxifene had been stopped. Paired sample t test was used to examine changes in markers at each time point.

Results: Plasma CTx decreased on average by 31%, urinary NTx by 35%, plasma osteocalcin by 25%, serum bone alkaline phosphatase by 15% (P<.01), and serum TRAP 5b by 10% (P<.05) on treatment.

Conclusion: Raloxifene reduces bone turnover in elderly women living in long‐term care facilities. The effect of raloxifene on bone turnover is comparable with that seen in younger postmenopausal women.
Effect of Psychiatric and Other Nonmotor Symptoms on Disability in Parkinson's Disease
Authors: Weintraub Daniel , Moberg Paul J. , Duda John E. , Katz Ira R. , Stern Matthew B.
Published: April 2004

Objectives: To examine the effect of depression and other nonmotor symptoms on functional ability in Parkinson's disease (PD).

Design: A cross‐sectional study of a convenience sample of PD patients receiving specialty care.

Setting: The Parkinson's Disease Research, Education and Clinical Center at the Philadelphia Veterans Affairs Medical Center.

Participants: One hundred fourteen community‐dwelling patients with idiopathic PD.

Measurements: The Unified Parkinson's Disease Rating Scale (UPDRS); Hoehn and Yahr Stage; Mini‐Mental State Examination; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, depression module; probes for psychotic symptoms; Hamilton Depression Rating Scale; Geriatric Depression Scale—Short Form; Apathy Scale; and Epworth Sleepiness Scale. Disability was rated using the UPDRS activity of daily living (ADL) score and the Schwab and England ADL score. Multivariate analysis determined effect of depression and other nonmotor symptoms on disability.

Results: The presence of psychosis, depressive disorder, increasing depression severity, age, duration of PD, cognitive impairment, apathy, sleepiness, motor impairment, and percentage of time with dyskinesias were related to greater disability in bivariate analyses. Entering these factors into two multiple regression analyses, only the increasing severity of depression and worsening cognition were associated with greater disability using the UPDRS ADL score, accounting for 37% of the variance in disability (P<.001). These two factors plus increasing severity of PD accounted for 54% of the variance in disability using the Schwab and England ADL score (P<.001).

Conclusion: Results support and extend previous findings that psychiatric and other nonmotor symptoms contribute significantly to disability in PD. Screening for nonmotor symptoms in PD is necessary to more fully explain functional limitations. Further study is required to determine whether identifying and treating these symptoms will improve function and quality of life.
Interactive Video Specialty Consultations in Long‐Term Care
Authors: Wakefield Bonnie J. , Buresh Kelli A. , Flanagan James R. , Kienzle Michael G.
Published: April 2004

Objectives: To assess provider and resident satisfaction with and outcomes of specialist physician consultations provided via interactive video to residents of a long‐term care (LTC) center.

Design: Cross‐sectional survey.

Setting: Two Veterans Affairs Medical Centers (VAMC) and a state LTC center.

Participants: Physicians (n=12) at the VAMC and nurses (n=30) and residents (n=62) at the LTC center.

Intervention: Interactive video conferencing to provide physician specialty visits to residents at the LTC center.

Measurements: Satisfaction ratings and record review to determine changes in treatment plan and follow‐up care.

Results: Data were collected on 76 individual consultations in six clinics. The most frequent outcome was a change in treatment plan with the resident remaining at the LTC setting (n=29, 38%) or no change in treatment (n=26, 34%). Physicians' ratings were 78% good to excellent for usefulness in developing a diagnosis, 87% good to excellent for usefulness in developing a treatment plan, 79% good to excellent for quality of transmission, and 86% good to excellent satisfaction with the consult format. Overall, 72% of residents were satisfied with the consult format, and 92% felt that it was easier to obtain medical care via telemedicine. Nurses felt that the telemedicine clinics were a good use of their time and skills (100%).

Conclusion: There was a high rate of physician, patient, and nurse satisfaction with interactive video conferencing. Care delivered to residents of LTC settings via video conferencing offers a number of potential advantages, including avoidance of travel for patient and provider and potentially greater continuity of care.
Drug‐Induced Lithium Toxicity in the Elderly: A Population‐Based Study
Authors: Juurlink David N. , Mamdani Muhammad M. , Kopp Alexander , Rochon Paula A. , Shulman Kenneth I. , Redelmeier Donald A.
Published: April 2004

Objectives: To study the association between hospital admission for lithium toxicity and the use of diuretics, angiotensin‐converting enzyme (ACE) inhibitors, and nonsteroidal antiinflammatory drugs (NSAIDs) in the elderly.

Design: Population‐based nested case‐control study.

Setting: Ontario, Canada.

Participants: Ontario residents aged 66 and older treated with lithium.

Measurements: Estimated relative risk of hospital admission for lithium toxicity.

Results: From January 1992 to December 2001, 10,615 elderly patients continuously receiving lithium were identified, of whom 413 (3.9%) were admitted to the hospital at least once for lithium toxicity. After adjustment for potential confounders, a dramatically increased risk of lithium toxicity was seen within a month of initiating treatment with a loop diuretic (relative risk (RR)=5.5, 95% confidence interval (CI)=1.9–16.1) or an ACE inhibitor (RR=7.6, 95% CI=2.6–22.0). Conversely, neither thiazide diuretics nor NSAIDs were independently associated with a significantly increased risk of hospitalization for lithium toxicity.

Conclusion: The use of loop diuretics or ACE inhibitors significantly increases the risk of hospitalization for lithium toxicity, particularly in naïve recipients.
Increased Velocity Exercise Specific to Task (InVEST) Training: A Pilot Study Exploring Effects on Leg Power, Balance, and Mobility in Community‐Dwelling Older Women
Authors: Bean Jonathan F. , Herman Seth , Kiely Dan K. , Frey Ingrid C. , Leveille Suzanne G. , Fielding Roger A. , Frontera Walter R.
Published: April 2004

Objectives: To evaluate a dynamic form of weighted vest exercise suitable for home use and designed to enhance muscle power, balance, and mobility.

Design: A single‐blind, randomized, controlled trial.

Setting: Outpatient exercise research facility situated within an academic long‐term care center.

Participants: Twenty‐one community‐dwelling women aged 70 and older with a Short Physical Performance Battery (SPPB) score between 4 and 10 (out of 12).

Interventions: Subjects were randomized into a progressive resistance‐training program using weighted vests for resistance with exercises designed to be specific to mobility tasks and have a component performed at the fastest possible velocity (Increased Velocity Exercise Specific to Task (InVEST), n=11) or a control exercise group (control, n=10), which performed slow‐velocity, low‐resistance exercise. Both groups exercised three times a week for 12 weeks.

Measurements: Changes in muscle power, balance, and physical performance were compared.

Results: In comparison to control group, InVEST group manifested significant improvements (P<.05) in leg power across measurements obtained at 75% to 90% of the one‐repetition maximum. Both groups demonstrated significant improvements in chair stand and SPPB score from baseline, and the InVEST group showed significant improvements in gait speed and chair stand from baseline (P<.05). InVEST produced significantly greater changes in chair stand time than control (P<.05).

Conclusion: InVEST training appears be an effective means of enhancing leg power and chair rise in this population and is worthy of further investigation as a means of enhancing balance and mobility.
Rib Fractures in the Elderly: A Marker of Injury Severity
Authors: Stawicki Stanislaw P. , Grossman Michael D. , Hoey Brian A. , Miller Donna L. , Reed James F.
Published: April 2004

Objectives: To examine the relationship between the number of rib fractures (RIBFs) and mortality, injury severity, and resource consumption in elderly patients admitted to trauma centers.

Design: Thirteen‐year retrospective statewide database analysis.

Setting: Participating trauma centers in Pennsylvania.

Participants: A total of 27,855 trauma patients, including 8,648 elderly patients, admitted to a trauma center with more than one RIBF.

Measurements: Patient demographics, number of RIBFs, Injury Severity Score, complications, patient mortality, preexisting conditions (PECs), and hospital and intensive care unit length of stay.

Results: Mortality for elderly patients (aged≥65) with RIBFs was greater than for patients younger than 65 (20.1% vs 11.4%, P<.001). Mortality rates increased with increasing numbers of RIBFs for both age groups and were always significantly higher in elderly trauma patients. The effect of PECs on patient mortality was inversely related to number of RIBFs and was most pronounced for patients with four or more RIBFs. Seven of 10 complications were more common in elderly patients despite lower mean±standard deviation Injury Severity Score (19.4±13.4 vs 23.2±14.2, P<.001).

Conclusion: Overall trauma‐related mortality is higher in elderly patients with RIBFs than younger patients with RIBFs. Mortality rates rise with increasing number of RIBFs. The number of RIBFs is easy to quantify and may be a useful predictor of overall injury severity and outcome for elderly trauma patients.
Out‐of‐Pocket Healthcare Expenditures of Older Americans with Depression
Authors: Harman Jeffrey S. , Kelleher Kelly J. , Reynolds Charles F. , Pincus Harold Alan
Published: April 2004

The objective of this study was to estimate mean annual out‐of‐pocket (OOP) healthcare expenditures of Americans aged 65 and older with self‐reported depression and compare these expenditures with the OOP expenditures of older Americans with hypertension, heart disease, diabetes mellitus, and arthritis. Data from the 1999 Medical Expenditure Panel Survey, which employs a nationally representative stratified random sample of households in the United States, were used to estimate mean OOP expenditures for health care during 1999. The data were limited to observations on individuals aged 65 and older living in households in the United States included in the 1999 Medical Expenditure Panel Survey sample (N=2,730). Mean OOP expenditures for older Americans with depression were $1,835 in 1999. Most of the spending ($1,090) was for prescription drugs in this population. For patients with depression, only 8% of total OOP spending was for depression‐specific services and treatments. Mean OOP spending was greater for persons with depression than it was for older Americans with hypertension ($1,181) and arthritis ($1,190), whereas OOP spending for depression was similar to spending of older Americans with heart disease ($1,412) and diabetes mellitus ($1,527). Older Americans with depression have high OOP expenditures, with most of this spending for health services and drugs to treat general medical conditions.
A User's Guide to Enhancing Geriatrics in an Undergraduate Medical School Curriculum: The Ten‐Step Model to Winning the “Geriatric Game”
Authors: Medina‐Walpole Annette , Clark Nancy S. , Heppard Brian , Dannefer Elaine , Hall William , McCann Robert
Published: April 2004

In 1999, the University of Rochester School of Medicine and Dentistry committed to major restructuring of its undergraduate medical school curriculum. A distinguishing feature of this reform was the planned emphasis on and integration of several core topics or themes throughout the 4 years of the curriculum. One of these curricular themes was aging. The faculty in geriatrics was presented with an unparalleled opportunity to develop a geriatrics curriculum of major proportions through the development of an aging theme. Through a user's guide approach based on the authors' experience to date, this article identifies the 10 steps necessary to “win the geriatric game” successfully integrating an aging theme into an undergraduate medical school curriculum. Since the initiation of the aging theme, several new courses, cases, and conferences have been added or enhanced, affecting all 4 years of the curriculum. Key operational challenges included successful engagement of course directors, tracking the actual experience of the aging theme, and evaluation of students' attainment of learning objectives and eventual career choices. The authors' experience suggests that an aging theme can successfully enhance the geriatrics curricular content of undergraduate education and strongly affect students across all 4 years. This 10‐step approach may serve as a model for other universities committed to integrating geriatrics across the full undergraduate medical curriculum.