bluuebunny/crossref_metadata_2025 huggingface dataset:
Relationship between quality of care, staffing levels, skill mix and nurse autonomy: literature review
Authors: Currie Veronica , Harvey Gill , West Elizabeth , McKenna Hugh , Keeney Sinead
Published: June 2005

Aims.  This paper reports a literature review exploring the relationship between quality of care and selected organizational variables through a consideration of what is meant by perceptions of quality, whose perceptions are accorded prominence, and whether changes in staffing, skill mix and autonomy affect perceptions of quality.

Background.  Three basic ideas underpin this literature review: the growing focus on quality improvement in health care, concerns about the quality of care, and the move towards patient involvement and consultation. Of particular interest is the way in which changes in nurse staffing, skill mix and autonomy may affect the delivery of quality patient care.

Methods.  A search was conducted using the CINAHL, Medline and Embase databases. Key words used were quality of health care; quality of nursing care; nurse; patient; skill mix; nurse–patient ratio; outcomes; adverse health care events and autonomy. The objective was to draw together a diverse collection of literature related to the field of health care quality. Papers were included for their relevance to the field of enquiry. The original search was conducted in 2003 and updated in 2004.

Findings.  Quality of care is a complex, multi‐dimensional concept which presents researchers with a challenge when attempting to evaluate it. Traditional nursing assessment tools have fallen out of use, partly because they have failed to provide opportunities to engage with and access the views of patients or nurses. There is also evidence that patient satisfaction as an indicator of quality is compromised on a number of fronts. There is conflicting information on how nurses and patients think about quality. Research looking at the relationship between the selected organizational variables and perceptions of quality also suffers from a number of limitations. We argue that there is a requirement for more patient‐centred research exploring perceptions of quality and differences in nurse staffing, skill mix and autonomy.
Knowing you: the interpersonal perceptions of staff towards aggressive individuals with mild to moderate intellectual disabilities in situations of conflict
Authors: Jahoda A. , Wanless L. K.
Published: June 2005

Objectives Staff attributions concerning challenging behaviour have been found to play a role in determining their responses. The emphasis in the literature has been on staff beliefs about the challenging behaviour itself. However, staff are also likely to be responding to the person engaging in the behaviour. The aim of this study was to explore workers’ perceptions of individuals who are frequently aggressive.

Design and methods Thirty‐six staff members working with individuals presenting problems of frequent aggression participated in this study. They were interviewed about an incident of aggression involving the person they worked with. The semi‐structured interview, based on a Rational Emotive Therapy format, aimed to tap into the emotions aroused in the staff members and interpersonal appraisals that they made at the time of the incident. The responses were content analyzed.

Results The strength of the staff member's emotional reactions were noteworthy. Furthermore, approximately half of the staff members believed that the clients’ aggression was directed at them personally. In turn, the majority of staff members described their clients in negative terms, and said that their first impulse had been to confront the clients.

Conclusions The findings suggest that interpersonal perceptions may have a role in determining staff responses to individuals who behave aggressively. The clinical and theoretical implications of the findings were discussed, alongside directions for future research.
Correlates of restraint use in an institutional population: a replication
Authors: Sturmey P. , Lott J. D. , Laud R. , Matson J. L.
Published: June 2005

Background  Reducing inappropriate restraint is an important mission of services for people with intellectual disabilities (IDs).

Methods  In this study, 52 clients who had been restrained were compared with 52 other clients, individually matched on age, gender and level of IDs. Participants were mostly adults with severe and profound IDs in an institutional setting.

Results  The two groups differed on six Diagnostic Assessment for the Severely Handicapped‐II (DASH‐II) and three Aberrant Behaviour Checklist (ABC) scales. However, discriminant functional analysis demonstrated that only DASH‐II Impulse control disorder and ABC Irritability and Elimination disorder scores predicted group membership but only moderately.

Conclusions  Individual differences in maladaptive behaviours were only moderately predictive of restraint use.
Careers of offenders with an intellectual disability: the probabilities of rearrest
Authors: Cockram J.
Published: June 2005

Background  This paper reports results from a total population of persons with intellectual disabilities (ID) in Western Australia arrested for the first time since 1 April 1984. It is part of a longitudinal study that ‘tracked’ offenders with ID through the criminal justice system over an 11‐year period to compare their experiences at each stage of the justice process with a sample of the general offending population. The research draws on an analysis of the Western Australian Police Services Apprehension records and the Disability Services Commission database.

Method  The data collected provided the opportunity to calculate base rates of the probability of rearrest of offenders with ID in comparison to mainstream offenders.

Results  The study found that people with ID had a significantly higher rate of rearrest than general population offenders and the study canvasses some possible reasons for this finding.
Clozapine treatment of psychosis associated with velo‐cardio‐facial syndrome: benefits and risks
Authors: Gladston S. , Clarke D. J.
Published: June 2005

Background  Clozapine is licensed for the treatment of psychotic illnesses resistant to other antipsychotic medications. Velo‐cardio‐facial syndrome (VCFS) is associated with a vulnerability to psychotic illness that may be resistant to treatment with conventional typical and atypical antipsychotics.

Patients and methods  A 32‐year‐old man with intellectual disability (ID) and a long history of treatment‐resistant psychosis was found to have VCFS. Treatment with typical antipsychotic drugs and with one atypical olanzapine produced no improvement.

Results  Treatment with clozapine produced an improvement in psychotic symptoms and associated behavioural abnormalities, but caused hypersalivation, constipation and a seizure disorder. The latter led to two fractures, one requiring surgery. The addition of sodium valproate stopped seizures.

Conclusions  Clozapine may improve psychotic symptoms for people with ID associated with VCFS, but clinicians should be alert for potential adverse effects.
Social variation in size at birth and preterm delivery in the Czech Republic and Sweden, 1989–91
Authors: Koupilová  , Vågerö  , Leon  , Pikhart  , Príkazský  , Holčík  , Bobák
Published: June 2005

Summary.
 All livebirths resulting from singleton pregnancies reported to the Czech (n = 380 633) and Swedish (n = 351 775) birth registries in 1989–91 were studied with respect to social variation in birthweight, ponderal index (weight/length at birth3) and preterm delivery. The mean birthweight was significantly lower in the Czech population (3310 g vs. 3522 g, P < 0.001). The mean difference in birthweight between children of mothers with primary and university education was 197 g [95% CI 190, 205] in the Czech and 136 g [95% CI 128, 144] in the Swedish population, adjusted for maternal age, parity and sex of the infant. Mean birthweight was significantly higher in mothers who were married or lived with partners in both countries; the difference was 167 g [95% CI 161, 173] in the Czech Republic (CR) and 86 g [95% CI 78, 94] in Sweden, adjusted for age, parity and sex. The extent of social variation in ponderal index and frequency of preterm birth was also greater in the CR. Between 1989 and 1991, mean birthweight in the CR fell from 3323 g to 3292 g (P < 0.001) and the social differences increased, largely as a result of more rapid worsening in the lower socio‐economic groups. There did not appear to be such a decline in birthweight in Sweden. We suggest that the fall in mean birthweight and the increasing social variation in birth outcome in the CR is related to decline and divergence in living standards in 1989–91.
Early obstetric discharge: does it make a difference to health outcomes?
Authors: Brown  , Lumley  , Small
Published: June 2005

Summary.
 Clinicians in several countries have expressed concerns about possible adverse effects of shortening obstetric length of stay. A population‐based survey of 1366 mothers who gave birth in Victoria, Australia, in 1993 was used to investigate social and obstetric characteristics of mothers discharged home ‘early’, and to assess whether shorter stays were associated with adverse health outcomes, or a lesser degree of satisfaction, or both. Women's views and experiences of length of hospital stay were gathered via a statewide postal survey of women who gave birth in a 2‐week period; 62.5% (n = 1336) responded. Assessment of the relationship between length of stay (1–2 days vs. 5 days, and 3–4 days vs. 5 days) and four main outcome measures (infant feeding at 6 weeks, period prevalence of feeding problems, maternal confidence and depression) showed no association between these variables and length of stay after adjusting for other obstetric and social factors in separate regression analyses. For stays of 3–4 days, the adjusted odds ratio (OR) for formula feeding at 6 weeks was 1.35 [95% confidence interval (CI) 0.9–1.9]; for feeding problems OR = 0.87 [0.7–1.2]; for lacking confidence OR = 0.81 [0.6–1.2]; and for depression OR = 0.96 [0.7–1.4]. Large randomised trials of early obstetric discharge are required to resolve continuing uncertainties about the safety, and possible benefits of shorter hospital stays.
Risk factors for perinatal death in Cape Verde
Authors: Wessel  , Cnattingius  , Dupret  , Reitmaier  , Bergström
Published: June 2005

Summary.  Risk factors for perinatal death in the Cape Verde islands were assessed among 104 bereaved mothers and 292 mothers of surviving infants in an area‐based case–control study in 1992–93. Prospectively gathered information on risk factors was obtained from medical records supplemented with post‐partum interviews and anthropometric measurements of mothers and infants. No autopsies were performed. Multiple logistic regression analysis was applied. Out of 23 alleged maternal and two alleged infant risk factors, the following seven proved significantly and independently correlated with perinatal death: first pregnancy (odds ratio [OR] = 2.9); previous hypertensive disease (OR = 4.2); previous perinatal death (OR = 4.6); pre‐eclampsia (OR = 7.0); non‐cephalic fetal presentation (OR = 17.1); male infant (OR = 2.1) and maternal post‐partum fever (OR = 3.1). The perinatal mortality rate was calculated as 37–46/1000 total births. A reduction in the mortality rate warrants antenatal and obstetric care with emphasis on primiparous women; improved detection and treatment of hypertensive disorders and genital infections; and improved intrapartum fetal observation and resuscitation routines.
Suicide‐related perforating injury of globe with nail gun
Authors: Rofail Marc , Lee Lawrence R , Lee Graham A , Todd Brian
Published: June 2005

A case is reported of nail gun injury due to suicide attempt involvingboth orbits, frontal lobe and abdomen, which resulted in an unusualposterior perforation of the left globe. Injury was inflicted witha total of eight nails. Three nails entered the left orbit, oneof which perforated the posterior aspect of the left globe. Onenail entered the right orbit involving the optic nerve and crossedthe midline to finish in the left sphenoid sinus. Three nails enteredthe frontal lobe near the midline and the final nail pierced theleft lobe of the liver. The left eye underwent primary repair, lensectomyand vitrectomy with silicone oil and achieved a visual acuity of 6/60,3 months post removal of oil with sutured posterior chamberintraocular lens. The right eye suffered traumatic optic neuropathyand currently has a visual acuity of 6/36 due to senilecataract formation. No other serious sequelae resulted from theother injuries and the patient has recovered from his episode ofdepression.
Inherited corneal disease: the evolving molecular, genetic and imaging revolution
Authors: Vincent Andrea L , Patel Dipika V , McGhee Charles NJ
Published: June 2005

Abstract

Advances in molecular genetics and in vivo ocular imaging modalities have enhanced our understanding of the corneal dystrophies. To date at least 11 genes have been identified, in which mutations manifest in corneal disease. In addition there are at least eight other loci identified to which corneal dystrophies have been linked. The information gained from the knowledge of gene function, aberrant protein production, or altered enzyme activity in the cornea, has resulted in greater knowledge of the pathophysiological mechanisms in these disorders. In vivo confocal microscopy has recently enabled microstructural study of dystrophic corneas throughout the disease course, rather than being limited to histopathological analysis of tissue removed at corneal transplantation. This perspective article summarizes the current knowledge, with emphasis on the genes, mutant proteins and resultant mechanisms that lead to manifestations of disease, along with characteristic findings with in vivo confocal microscopy.
Subfoveal nodule in Coats’ disease
Authors: Khurana Rahul N , Samuel Michael A , Murphree A Linn , Loo Roy H , Tawansy Khaled A
Published: June 2005

Abstract

An atypical presentation of Coats’ disease is reported with a prominent subfoveal nodule with peripheral retinal exudates. A 6‐year old boy presented with 6/120 vision in the left eye associated with an elevated 1 mm subfoveal, circular lesion with peripheral exudates. The fluorescein angiogram showed peripheral retinal telangiectasias with leakage consistent with Coats’ disease. The prominent subfoveal nodule is an uncommon initial presentation of Coats’ disease and physicians should be aware of this atypical finding.
Genotypic and phenotypic spectrum of X‐linked retinoschisis in Australia
Authors: Hewitt Alex W , FitzGerald Liesel M , Scotter Lindsey W , Mulhall Lindsay E , McKay James D , Mackey David A
Published: June 2005

Abstract

Background:  X‐linked retinoschisis (XLRS), an X‐linked recessive inherited degenerative retinopathy, is characterized by splitting in the nerve fibre layer and is caused by alterations in the RS1 gene. The aim of the present study was to review both the phenotypic features of XLRS and the mutation spectrum of the RS1 gene in an Australian cohort.

Methods:  Patients were recruited from ophthalmic and paediatric hospitals as well as private ophthalmic clinics across Australia. A cohort of 18 presumably unrelated families was identified. Twenty‐two affected patients underwent clinical examination. Following DNA extraction all six exons of the RS1 gene were sequenced.

Results:  The median age at diagnosis was 8 years (range 1–43 years); the median age at review was 14 years (range 5–63 years). The median best‐corrected visual acuity upon review was 6/24 (range 6/6–1/36). Typical foveal schisis was found in 90.1% eyes examined (39/43) while peripheral schisis was present in 30% of eyes (13/43). The scotopic blue b‐wave amplitude ranged between 2% and 82% of the mean normal amplitude. Five novel mutations (61G→T, Gly21X; 103C→T, Gln35X; 327–329del, Cys110del; 527T→C, Phe176Ser; 573Gdel, Pro192fs) and six previously identified missense mutations (304C→T, Arg102Trp; 305G→A, Arg102Gln; 336G→C, Trp112Cys; 418G→A, Gln140Arg; 598C→T, Arg200Cys; 625C→T, Arg209Cys) were found. The mutations present in codons 21 and 102 were each identified in two presumably unrelated pedigrees. One previously described point deletion (416Adel) was identified. Two pedigrees contained affected individuals where exons 2 or 3, respectively, were unable to be amplified, indicating the likely presence of a significant deletion. No mutation was found in the RS1 gene in two affected individuals from different pedigrees.

Conclusion:  Population genetic studies of XLRS have not previously been conducted in Australia. The phenotype associated with these mutations varied. The identification of each pedigree's specific mutation allows future determination of female carrier status for genetic counselling purposes. Further study into the refinement of the XLRS phenotype as well as the degree of intrafamilial phenotypic variation is required.
Comparison of mean macular thickness using optical coherence tomography and visual acuity in diabetic retinopathy
Authors: Hussain Anjli , Hussain Nazimul , Nutheti Rishita
Published: June 2005

Abstract

Background:  The purpose of the present study was to quantitatively assess the mean macular thickness in diabetic patients using optical coherence tomography and its correlation with visual acuity.

Methods:  A prospective case series study was undertaken of consecutive diabetic patients referred to a tertiary eye care centre for an eye check up from January 2003 to June 2003. One hundred and five eyes from 55 patients with varying degree of diabetes underwent optical coherence tomography examination. The study patients were divided into four groups: group I, non‐proliferative diabetic retinopathy (NPDR); group II, NPDR with clinically significant macular oedema (CSME); group III, proliferative diabetic retinopathy (PDR); and group IV, PDR with CSME.

Results:  The mean macular thickness of the entire group was 256.0 ± 129.7 µm. A positive correlation (r = 0.424, P < 0.0001) was evident between mean macular thickness and visual acuity.

Conclusion:  Optical coherence tomography is a useful tool for objectively monitoring macular thickness in patients with diabetic retinopathy. Mean macular thickness correlates with visual acuity.
Ocular hypertensive and anti‐inflammatory responses to different dosages of topical dexamethasone in children: a randomized trial
Authors: Lam Dennis SC , Fan Dorothy SP , Ng Joan SK , Yu Christopher BO , Wong Chun Y , Cheung Albert YK
Published: June 2005

Abstract

Background:  The purpose of the present study was to investigate the ocular hypertensive and anti‐inflammatory responses to two different dosage schedules of 0.1% topical dexamethasone in a population of Chinese children undergoing strabismus surgery.

Methods:  Children undergoing bilateral strabismus surgeries were randomly assigned to receive topical 0.1% dexamethasone eye drops four times daily (group A) or twice daily (group B) for 4 weeks. Intraocular pressure (IOP) and anti‐inflammatory responses were monitored for 8 weeks.

Results:  A total of 137 children with mean age 6.5 years (SD, 1.9 years; range, 3–10 years) participated in the study. The IOP increased significantly after 4 weeks in both groups compared to the preoperative values (P < 0.001). Peak IOP ranged from 14.0 to 50.3 mmHg in group A and 11.0–41.3 mmHg in group B. Cases in group A (mean, 13.8 mmHg; SD, 8.4 mmHg) had a greater net increase in IOP than cases in group B (mean, 10.2 mmHg; SD, 6.2 mmHg; P = 0.004). Younger‐aged children had higher peak IOP (r = −0.244, P = 0.048), and attained the peak IOP earlier (r = 0.252, P = 0.041) in group A. There was no significant difference in ocular inflammatory response between the two groups.

Conclusion:  Ocular hypertensive effect to topical 0.1% dexamethasone is dose and age dependent in children. Twice‐daily 0.1% topical dexamethasone eye drops control inflammation after strabismus surgery as effectively as four‐times‐daily dosage, but induces less increase in IOP, and may be a better treatment schedule.
Govern(mentality) and Accounting: the Influence of Different Enlightenment Discourses in Two Spanish Cases (1761–1777)
Authors: Sánchez‐Matamoros Juan Baños , Hidalgo Fernando Gutiérrez , Espejo Concha Álvarez‐Dardet , Fenech Francisco Carrasco
Published: June 2005

New perspectives in accounting history have uncovered previously unattended relations between accounting and government. Earlier Foucauldian analyses of governments have not explained sufficiently the relations of accounting practices to governmental discourses in order to manage populations.

This work uses the governmentality frame to analyse the role of accounting in two organizations located in the south of Spain in the second half of the eighteenth century: the New Settlements of Sierra Morena and Andalucia (NSs) and the Royal Tobacco Factory of Seville (RTFS). The period studied is remarkable because it was the apogee of the Enlightenment in Spain. From the standpoint of government, this period facilitated a new way to manage populations. The present work has drawn on Foucault's concept of governmentality in order to discover how accounting worked in two government‐supported organizations independently of the discourses that pervaded each one. Drawing on the reticulation of the space, the use of rules and accounting from the governmental perspective, we analyse those institutions.

The article concludes that the reticulation of space is an essential apparatus to exert action at a distance; the rules are a type of government technology; and, overall, accounting is a practice for the mastery of the population independently from the discourse of the institution.
Accounting for the U.K.'s Private Finance Initiative: An Interview‐Based Investigation
Authors: Hodges Ron , Mellett Howard
Published: June 2005

This article investigates the development of the public sector accounting policy for the United Kingdom's Private Finance Initiative. A novel approach to investigating the development of accounting regulation is applied, based on interviews with persons involved in the process. A fuller explanation of events is obtained by going beyond published material that is already in the public domain in order to reflect the informal procedures which cause regulatory outcomes to be determined by negotiation and persuasion. The article concludes that the limited participation of public sector bodies at the formal stage of lobbying through written representations may not be critical in view of the existence of other means to influence the outcome of the regulatory process.
Testing the Fit of a Vector Autoregressive Moving Average Model
Authors: Paparoditis Efstathios
Published: June 2005

Abstract. A new procedure for testing the fit of multivariate time series model is proposed. The method evaluates in a certain way the closeness of the sample spectral density matrix of the observed process to the spectral density matrix of the parametric model postulated under the null and uses for this purpose nonparametric estimation techniques. The asymptotic distribution of the test statistic is established and an alternative, bootstrap‐based method is developed in order to estimate more accurately this distribution under the null hypothesis. Goodness‐of‐fit diagnostics useful in understanding the test results and identifying sources of model inadequacy are introduced. The applicability of the testing procedure and its capability to detect lacks of fit is demonstrated by means of some real data examples.
Book Review: The Estimation and Tracking of Frequency
Authors: Whittle P.
Published: June 2005

Erratum. Journal of Time Series Analysis Volume 26 Issue 5.
Apolipoprotein E Genotype and Mortality: Findings from the Cache County Study
Authors: Hayden Kathleen M. , Zandi Peter P. , Lyketsos Constantine G. , Tschanz JoAnn T. , Norton Maria C. , Khachaturian Ara S. , Pieper Carl F. , Welsh‐Bohmer Kathleen A. , Breitner John C. S. ,   for the Cache County Investigators
Published: June 2005

Objectives: To evaluate the association between apolipoprotein E (apo E) ɛ4 and mortality, the population attributable risk for mortality with ɛ4, and relative contributions of cardiovascular disease (CVD) and Alzheimer's disease (AD).

Design: Population‐based cohort study.

Setting: Community‐based.

Participants: Permanent residents of Cache County, Utah, aged 65 and older as of January 1, 1995.

Measurements: Participants were genotyped at the apo E locus using buccal‐swab deoxyribonucleic acid. Cardiovascular health was ascertained using self‐ or proxy‐report interviews at participants' residences. AD was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, and National Institute of Neurological and Communicative Disorders and Stroke—Alzheimer's Disease and Related Disorders criteria. Utah Department of Vital Statistics quarterly reports were reviewed to identify participants who died.

Results: Crude evaluations showed nonsignificantly greater risk of death for ɛ2/2 (hazard ratio (HR)=1.66, 95% confidence interval (CI)=0.92–2.76) and ɛ3/4 (HR=1.11, 95% CI=0.97–1.26) genotypes and significantly greater risk for ɛ4/4 (HR=1.48, 95% CI=1.09–1.96). After adjustment for age, age2, sex, and education, risks increased to 1.98 (95% CI=1.08–3.35), 1.28 (95% CI=1.12–1.46), and 2.02 (95% CI=1.47–2.71), respectively, compared with ɛ3/3 genotypes. Adjustment for presence of any CVD did not change the risk of death for ɛ3/4 and ɛ4/4. Adjustment for AD reduced the risk of death for ɛ3/4 (HR=1.13, 95% CI=0.99–1.30) and ɛ4/4 (HR=1.59, 95% CI=1.15–2.14). The population attributable risk of death for ɛ3/4 and ɛ4/4 genotypes combined is estimated at 9.6%.

Conclusion: These findings suggested that the ɛ2/2, ɛ3/4, and ɛ4/4 genotypes have greater early mortality risks. Further analyses showed that AD partially mediates the association between ɛ3/4, ɛ4/4, and death.
Insomnia and Hypnotic Use, Recorded in the Minimum Data Set, as Predictors of Falls and Hip Fractures in Michigan Nursing Homes
Authors: Avidan Alon Y. , Fries Brant E. , James Mary L. , Szafara Kristina L. , Wright Glenn T. , Chervin Ronald D.
Published: June 2005

Objectives: To examine the relationship between insomnia, hypnotic use, falls, and hip fractures in older people.

Design: Secondary analysis of a large, longitudinal, assessment database.

Setting: Four hundred thirty‐seven nursing homes in Michigan.

Participants: Residents aged 65 and older in 2001 with a baseline Minimum Data Set assessment and a follow‐up 150 to 210 days later.

Measurements: Logistic regression modeled any follow‐up report of fall or hip fracture. Predictors were baseline reports of insomnia (previous month) and use of hypnotics (previous week). Potential confounds taken into account included standard measures of functional status, cognitive status, intensity of resource utilization, proximity to death, illness burden, number of medications, emergency room visits, nursing home new admission, age, and sex.

Results: In 34,163 nursing home residents (76% women, mean age±standard deviation 84±8), hypnotic use did not predict falls (adjusted odds ratio (AOR)=1.13, 95% confidence interval (CI)=0.98, 1.30). In contrast, insomnia did predict future falls (AOR=1.52, 95% CI=1.38, 1.66). Untreated insomnia (AOR=1.55, 95% CI=1.41, 1.71) and hypnotic‐treated (unresponsive) insomnia (AOR=1.32, 95% CI=1.02, 1.70) predicted more falls than did the absence of insomnia. After adjustment for confounding variables, insomnia and hypnotic use were not associated with subsequent hip fracture.

Conclusion: In elderly nursing home residents, insomnia, but not hypnotic use, is associated with a greater risk of subsequent falls. Future studies will need to confirm these findings and determine whether appropriate hypnotic use can protect against future falls.
Outcomes of Older People Admitted to Postacute Facilities with Delirium
Authors: Marcantonio Edward R. , Kiely Dan K. , Simon Samuel E. , John Orav E. , Jones Richard N. , Murphy Katharine M. , Bergmann Margaret A.
Published: June 2005

Objectives: To compare outcomes of patients admitted to postacute skilled nursing facilities with delirium, subsyndromal delirium, and no delirium.

Design: Observational cohort study.

Setting: Seven skilled nursing facilities that specialize in postacute care within a single metropolitan region.

Participants: Five hundred four subjects chosen from 1,248 consenting subjects aged 65 and older who underwent mental status testing within 5 days of admission to the participating facilities. Subjects who met full Confusion Assessment Method (CAM) criteria were classified as delirious, those with one or more CAM criteria were classified as having subsyndromal delirium, and those with no CAM features were classified as having no delirium. All subjects with delirium and with available medical records were included. A random subset of subjects with no delirium and subsyndromal delirium with available medical records was included.

Measurements: The medical records of all subjects underwent a structured review by trained research nurses who were masked to the subjects' initial delirium status. Records were reviewed for the development of new complications within the postacute setting and to determine whether the subjects were discharged within 30 days and, if so, the discharge destination. The National Death Index was used to assess 6‐month mortality.

Results: Subjects with delirium were more likely to experience one or more complications than subjects with no delirium (73% vs 41%, P < .01). Within 30 days of postacute admission, subjects with delirium were more than twice as likely to be rehospitalized (30% vs 13%), and less than half as likely to be discharged to the community (30% vs 73%) than subjects without delirium (differences P < .01). Subjects with subsyndromal delirium had outcomes intermediate between those with and without delirium. Finally, subjects admitted to the postacute setting with delirium experienced a 6‐month mortality rate of 25.0%, compared with 5.7% in subjects admitted without delirium. Subjects with subsyndromal delirium had a 6‐month mortality rate of 18.3%.

Conclusion: Patients admitted to postacute skilled nursing facilities with delirium are more likely to experience complications, rehospitalization, and death than patients without delirium. These findings support the need for improved case finding and management of delirium in postacute care.
The Effects of Megestrol Acetate Suspension for Elderly Patients with Reduced Appetite After Hospitalization: A Phase II Randomized Clinical Trial
Authors: Reuben David B. , Hirsch Susan H. , Zhou Kefei , Greendale Gail A.
Published: June 2005

Objectives: To provide preliminary evidence on the effectiveness and optimal dosage of megestrol acetate for older persons with impaired appetite after hospitalization.

Design: Randomized clinical trial.

Setting: Acute care hospital.

Participants: Forty‐seven older persons (mean age 83) who were recently discharged from an acute care hospital and had fair or poor appetite.

Intervention: Participants were randomized to placebo or megestrol acetate suspension 200 mg, 400 mg, or 800 mg daily for 9 weeks.

Measurements: Appetite, health‐related quality of life, and adverse effects were measured at baseline and 20, 42, and 63 days. Serum nutritional markers were measured at baseline and 20 and 63 days.

Results: During the course of the study, there were no significant differences between treatment groups on any of the appetite questions, although participants in the 400‐mg and 800‐mg groups demonstrated significant improvement from baseline on some questions. At 20 days, prealbumin increased in a dose‐response relationship across the four groups (by 0.4, 5.1, 7.5, and 9.0 mg/dL, respectively). Participants in the 400‐mg and 800‐mg groups demonstrated greater improvement in prealbumin levels at 20 days than those receiving placebo (P=.009 and P=.004, respectively) and those in the 400‐mg group also demonstrated improvement at 63 days (P=.02). At 20 days, no participant taking placebo had a morning serum cortisol level less than 8 ng/mL (the lower limit of normal). In contrast, 33%, 70%, and 78% of those taking 200 mg, 400 mg and 800 mg, respectively, had values below this level; by 63 days, these percentages were 11%, 30%, 56%, and 37%, respectively. No patient reported clinical symptoms of adrenal insufficiency. Diarrhea developed in three subjects, and thromboembolism occurred in two receiving active treatment.

Conclusion: Megestrol acetate at doses of 400 mg and 800 mg increases prealbumin in recently hospitalized older persons. Cortisol suppression is common at higher doses and may be persistent. In this small study, the drug did not confer benefit on other nutritional or clinical outcomes.
Where Does Research Occur in Geriatrics and Gerontology?
Authors: Navarro Albert , Lynd Frances E.
Published: June 2005

The International Plan of Action on Aging 2002 emphasized the need to promote and develop research on aging, especially in underdeveloped countries. This article aims at describing the current situation with regard to the international scientific production in the field of geriatrics and gerontology. All articles published in journals included in the categories “Geriatrics and Gerontology” of the Science Citation Index or “Gerontology” of the Social Science Citation Index in 2002 were analyzed. There is unquestionable predomination by the United States, which participates in 53.8% of the articles analyzed, followed by the United Kingdom (9.66%) and Canada (6.66%). The production of the 15 European Union countries together is 31.2%. When adjustments are made for economic or population factors, other countries show their importance: Israel and Sweden, for example. Authors from richer countries participate in more than 95% of the articles, whereas those in less‐developed countries tend to publish less, and when they do so, it is through collaboration with more‐developed countries. In general, only 10.5% of the articles are written in collaboration with institutions from different countries. One of the keys to stimulating research in less wealthy countries would seem to be precisely through collaboration. This would aid the transfer of knowledge and experience, allowing researchers in these countries to obtain autonomy to perform their own studies independently and to provide them with the ability to gain access for their publications at the international level.
Evaluation of Nationally Mandated Drug Use Reviews to Improve Patient Safety in Nursing Homes: A Natural Experiment
Authors: Briesacher Becky , Limcangco Rhona , Simoni‐Wastila Linda , Doshi Jalpa , Gurwitz Jerry
Published: June 2005

Objectives: To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes.

Design: Quasi‐experimental, longitudinal study.

Setting: Data source is the 1997–2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries.

Participants: Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664).

Measurements: Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications.

Results: In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3–30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8–25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4–26.4) and 18.0% in ALFs (95% CI=15.6–20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1–27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7–21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0–22.0) and 15.6% of ALF residents (95% CI=15.2–15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long‐term care facilities with mandatory drug use reviews and those without.

Conclusion: Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy.
Beyond Autonomy: Diversifying End‐of‐Life Decision‐Making Approaches to Serve Patients and Families
Authors: Winzelberg Gary S. , Hanson Laura C. , Tulsky James A.
Published: June 2005

Efforts to improve end‐of‐life decision‐making quality have emphasized the principle of individual autonomy to better ensure that patients receive care consistent with their preferences. This principle has primarily been defined through court decisions during the past 3 decades as a patient's right to refuse medical technologies and avoid life‐prolonging treatments. However, autonomy as traditionally defined only serves a small segment of dying patients. Patients might not value autonomy or consider autonomy important but define it differently than decision‐making self‐determination. Some patients also think in terms of their care goals rather than individual treatment preferences. Patients' functional and cognitive abilities, age, racial and ethnic backgrounds, and desire to avoid burdening loved ones may influence attitudes and definitions regarding autonomy. To improve end‐of‐life decision‐making for an increasingly multicultural and aging population, the following priorities should be set: (1) Increase the flexibility of advance care planning and decision‐making strategies used with capable patients to encompass diverse perceptions of autonomy; and (2) Improve communication between physicians and patients' families when patients lack decision‐making capacity to facilitate decision‐making and address families' emotional burdens. The goal of these priorities is to promote understanding of patients' and families' decision‐making preferences and goals and to minimize decision‐making burdens on families.
Evaluating Potentially Modifiable Risk Factors for Prevalent and Incident Nocturia in Older Adults
Authors: Johnson Theodore M. , Sattin Richard W. , Parmelee Patricia , Fultz Nancy H. , Ouslander Joseph G.
Published: June 2005

Objectives: To examine associations between nocturia and potentially modifiable risk factors in older adults.

Design: Secondary analysis of cross‐sectional and longitudinal data.

Setting: Respondents were selected using population‐based sampling, drawing from a single Michigan county in 1983. They were followed through 1990.

Participants: Community‐living adults aged 60 and older.

Measurements: Episodes of nocturia, development of nocturia at 2 years after baseline survey, age, sex, hypertension, diabetes mellitus, drinking fluids before bedtime, amount of fluid intake before bedtime, diuretic use, and 24‐hour coffee intake. All measures were self‐reported.

Results: Bivariate cross‐sectional analysis revealed significant associations with two or more episodes of nocturia for hypertension (odds ratio (OR)=1.7, 95% confidence interval (CI)=1.37–2.1), diabetes mellitus (OR=1.51, 95% CI=1.1–2.0), diuretic use (OR=1.7, 95% CI=1.3–2.1), age (OR=1.05 per additional year over 60, 95% 1.03–1.06), and number of cups of coffee (OR=0.93 for each cup of coffee, 95% CI=0.89–0.97). In multivariate analysis, hypertension (OR=1.52, 95% CI=1.2–1.9), diuretic use (OR=1.3, 95% 95% CI=1.0–1.7), and age (OR=1.04 per additional year over 60, 95% 1.03–1.06) were independently associated with two or more nocturia episodes per night. No baseline factors predicted future development of nocturia (save for age, in one model).

Conclusion: Hypertension, older age, and diuretic use were independently associated with two or more episodes of nocturia in cross‐sectional analysis. No baseline factor was related to the development of nocturia over a 2‐year interval in this sample. Nighttime fluid intake and coffee intake, practices providers commonly target in patients with nocturia, were not associated with nocturia in this population‐based sample of community‐living older adults.
Depression in Older Patients Admitted for Postacute Nursing Home Rehabilitation
Authors: Webber Adam P. , Martin Jennifer L. , Harker Judith O. , Josephson Karen R. , Rubenstein Laurence Z. , Alessi Cathy A.
Published: June 2005

Objectives: To describe the prevalence, recognition, and persistence of depression in older adults undergoing postacute rehabilitation in a nursing home (NH) setting and to explore the effect of depression on rehabilitation outcomes.

Design: Prospective cohort study.

Setting: One rehabilitative NH in the Los Angeles area.

Participants: One hundred fifty‐eight patients (aged ≥65) admitted for postacute rehabilitation over a 9‐month recruitment period.

Measurements: Depression was assessed using the 15‐item Geriatric Depression Scale (GDS‐15) or the Cornell Scale for Depression (in participants with dementia). Medical records were reviewed for documentation of depression and antidepressant use before and during the rehabilitative NH stay. Rehabilitation process was assessed using total amount of successfully completed therapy (minutes). Rehabilitation outcome was assessed using the motor component of the Functional Independence Measure (mFIM). Measures were performed at admission and 2 months later.

Results: Of the 646 potentially eligible patients admitted during the study, 158 consented, and 151 were screened for depression. Forty‐two (27.8%) had depressive symptoms (GDS=6 or Cornell=5). Of these, only 15 had a documented diagnosis of depression, and 12 were receiving antidepressants. Depression was associated with longer NH stay but not with discharge mFIM score. Two months later, depression persisted in 24 participants and was associated with worse mFIM (55.5±22.7 vs 67.0±23.7, depressed vs nondepressed; P=.03).

Conclusion: Depression was common, underrecognized, and undertreated in these postacute rehabilitation patients. Depression generally persisted and was associated with worse functional status at 2‐month follow‐up.
Prevalence of Appropriate and Problematic Antiepileptic Combination Therapy in Older People in the Nursing Home
Authors: Harms Susan L. , Eberly Lynn E. , Garrard Judith M. , Hardie Nancy A. , Bland Pat C. , Leppik Ilo E.
Published: June 2005

Objectives: To determine the prevalence of mono‐ and poly‐antiepileptic drug (AED) therapy in a cohort of nursing home (NH) residents and to describe specific AED combinations used, as well as demographic, clinical, and functional factors associated with poly‐AED therapy and the most common AED combination.

Design: Retrospective, point prevalence study.

Setting: All NHs owned/managed by Beverly Enterprises.

Participants: All residents aged 65 and older residing in one of the study NHs on July 1, 1999, and receiving an AED (N=3,881).

Measurements: Data were gathered using two secondary source data sets: physicians' orders (AED use) and the Minimum Data Set (health status indicators).

Results: Of residents taking AEDs, 370 (9.5%) were taking two or more; 268 of those (72%) were taking problematic AED combinations (those with the potential of undesirable pharmacokinetic or pharmacodynamic interactions). Phenytoin (PHT) with phenobarbital (PB) was the most common combination (27.0%). Logistic regression indicated that poly‐AED subjects were more likely to have a diagnosis of epilepsy/seizure (epi/sz) and less likely to have a diagnosis of cerebrovascular accident (CVA). Residents taking the PHT/PB combination were more likely to have an epi/sz diagnosis and longer NH stay. The association between CVA and PHT/PB polytherapy differed by presence or absence of aphasia.

Conclusion: The overall prevalence of poly‐AED therapy is less than 10% in NH residents, but 72% of those residents were receiving problematic polytherapy combinations, thereby exposing them to potential risk of adverse reactions and toxicity.
Microbial contamination of hematopoietic progenitor cell grafts—incidence, clinical outcome, and cost‐effectiveness: an analysis of 735 grafts
Authors: Kamble Rammurti , Pant Shubham , Selby George B. , Kharfan‐Dabaja Mohamed A. , Sethi Sanjay , Kratochvil Kristen , Kohrt Nancy , Ozer Howard
Published: June 2005

BACKGROUND: Screening of progenitor cell grafts (marrow, peripheral blood, and cord blood) for microbial contamination is required by the standards of AABB. Clinical sequelae from infusion of these contaminated grafts, however, is uncommon.

STUDY DESIGN AND METHODS: A retrospective analysis of 735 consecutive marrow and peripheral blood progenitor cell harvests between 1998 and 2003 was performed. Analysis included incidence, clinical outcome, and cost outcomes of positive blood cultures and antibiotic therapy.

RESULTS: Thirty‐three of 735 (4.5%) harvests were contaminated. The incidence of microbial contamination varied with the source of the graft (4 of 26 [15%] were cord blood, 8 of 177 [4.5%] were marrow, and 21 of 532 [3.9%] were peripheral blood). Coagulase‐negative Staphylococcus (n = 22) and Propionibacterium acnes (n = 8) were most frequently isolated. Potentially pathogenic organisms were isolated in 6 of 735 (0.81%) grafts (methicillin‐sensitive Staphylococcus aureus, 4; methicillin‐resistant S. aureus, 1; and Enterobacter cloacae, 1). The estimated total cost of surveillance was approximately $81,585. The cost of vancomycin therapy in 4 patients who received prophylactic antibiotic therapy was approximately $10,000. No adverse sequelae followed infusion of contaminated grafts.

CONCLUSION: Clinical sequelae following infusion of microbially contaminated progenitor cells is extremely rare. Prophylactic empiric antibiotics may be unnecessary. Routine microbial surveillance of progenitor cell grafts is a low‐yield procedure.
Issues in the quality of umbilical cord blood stem cells for transplantation
Authors: McCullough Jeffrey , McKenna David , Kadidlo Diane , Schierman Therese , Wagner John
Published: June 2005

BACKGROUND: Because the frequency of umbilical cord blood (UCB) stem cell transplantation has increased, the quality of UCB available in banks is an important part of the success of UCB stem cell transplants.

STUDY DESIGN AND METHODS: A quality assurance monitoring system was used to evaluate 268 UCB units provided to us for transplant by UCB banks in the United States and Europe.

RESULTS: Quality issues were found in 151 (56%) of 268 units, and there were a total of 246 specific issues in 151 units. The issues involved quality control (54%), medical history (40%), and labels and documentation (6%). Risks to patients from these issues were likely in 10 percent, potential in 35 percent, and unlikely in 55 percent.

CONCLUSION: Because standards have evolved over time, cord blood banks contain units that have different levels of quality. Some units have been placed in the usable inventory with incomplete test results and/or documentation or that may not meet the bank's own current criteria. Information about any quality or operating procedure deviation should be provided in sufficient detail and at the initiation of the search process so that transplant physicians can consider these quality issues against the unique value of a particular UCB unit.