Managed primary care of nursing home residents

The mechanisms responsible for immediate adjustments in cardiac output at onset of exercise, in the absence of neural drive, are not well defined in heart transplant (HT) recipients. Seven male HT recipients (mean +/- SD 57 +/- 6 years) and 7 age-matched sedentary normal control subjects (mean age 57 +/- 5 years) performed constant load cycle exercise at 40% of peak power output (Watts). Cardiac output and plasma norepinephrine were determined at rest and every 30 seconds during the first 5 minutes of exercise and at minutes 6, 8, and 10. All subjects were admitted to the General Clinical Research Center for determination of plasma volume. After 3 days of equilibration to a controlled and standardized diet, plasma volume was measured using a modified Evans Blue Dye (T-1824) dilution technique. Heart rate at rest was higher in the HT group (105 +/- 12 vs 74 +/- 6 beats/min), but during submaximum exercise, heart rates in the control group increased more rapidly (p < or = 0.05) and to a greater magnitude (54 +/- 7% vs 17 +/- 4% above rest). Stroke volume at rest was lower in HT recipients (45 +/- 4 vs 68 +/- 9 ml) but was significantly augmented immediately after onset of exercise (30 seconds) and the relative increase was greater than controls at peak exercise (61% vs 38% greater than baseline). Cardiac output at rest was within the normal range in both groups (4.58 +/- 0.27 vs 4.94 +/- 0.40 L/min). Relative increases in cardiac output were similar (p > or = 0.05) for the HT (106 +/- 12%) and control groups (97 +/- 10%). Plasma norepinephrine did not become significantly greater than resting values until approximately 4 minutes after onset of exercise in both groups. Blood volume, normalized for body weight, was 12% greater in the HT group. Thus, HT recipients with expanded blood volume (12%) augment stroke volume immediately after the onset of exercise. Plasma norepinephrine levels contribute negligibly to the rapid adjustment in cardiac output. Rather, we speculate that abrupt on-transit increases in stroke volume are due to augmented venous return, secondary to expanded blood volume.     

The single care home

This paper discusses the importance of nursing in the long-term care setting and the issues arising from the possible introduction of a single registration care home. The current situation is examined and the implications for patients are highlighted.     

Evacuatory paracentesis at home: why not in primary care?]

A case of multiple miliary osteomas of the face arising in a 45-year-old Caucasian female with no history of skin disease is reported. Spontaneous development of numerous asymptomatic, skin-coloured facial papules had occurred over a 3 year period. Originally described in association with long-standing acne vulgaris, multiple miliary osteomas of the face has recently been reported in patients without prior skin disease. The pathogenesis, classification and treatment of this rare condition are discussed.     

The relationship between primary care and psychiatry: an opportunity for change

The past two decades have seen the development of a symbiotic relationship between primary care and psychiatric services. The changes which have taken place, however, have been piecemeal and variable in their extent. With some exceptions, they have followed an empirical route, and have come about largely because individual practitioners intuitively felt that they yielded positive results or attractive patterns of working. For the most part, they have not followed the elaboration of a specific theory and although a great deal of subsequent research has been carried out in order to analyse their benefits and limitations, routine practice has been slow to change. The recent reorganization of the health service has yet to exert an appreciable effect on the relationship between the two disciplines. Owing to the newly developing structures and patterns of care, future change is inevitable and brings with it both opportunities and dangers. This paper sets out some of the arguments in favour of a new contract between psychiatry and primary care based on an equal partnership.     

The relationship of distress to mood disturbance in primary care and psychiatric populations.

Disagreement remains as how to interpret elevated scores on measures of self-reported distress. This study compared elevated scores on the Center for Epidemiologic Studies-Depression Scale (CES-D) in 2 samples to mood disturbance as assessed in an interview. In a primary medical care sample, most distressed patients did not have a mood disturbance, and distress without mood disturbance was associated with little impairment. Primary care patients with elevated scores on the CES-D were less distressed and less likely to have mood disturbance, major depression, or impairment than distressed psychiatric patients. Few patients with mood disturbance in either sample failed to meet criteria for major depression. Implications are discussed for research on depression using self-report measures, for generalizations across clinical and nonclinical populations, and for screening for preventive interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The geropsychiatric clinical nurse specialist in home care

Home care nurses often are asked to provide care to older adults with multiple problems, including psychiatric diagnoses. This article identifies areas of knowledge a general nurse needs to provide care for geropsychiatric patients and describes the role of the geropsychiatric clinical nurse specialist as part of a home care team.     

What primary care psychology has to offer the patient-centered medical home.

The Patient-Centered Medical Home (PCMH) proposes a new model to transform the practice of primary health care to one that is patient centered, high quality, continuous, comprehensive, and compassionate. In this paper, the authors provide an updated definition of, and skills needed for, primary care psychology, focused on integrating various psychological approaches with an overarching systemic theory. With this in mind, the authors suggest that primary care psychology can be important to achieving the goals of what some professionals now call the Patient-Centered Health Care Home. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The primary care physician and managed care

I have explored the major options open to PCPs. There are multiple variations on these themes. While the Connecticut market is fluid, one thing is clear, the solutions will vary from place to place. Health-care reorganization is a local phenomenon. Individual doctor groups can have a major influence on the direction of their local market. The future is uncertain, but whatever happens in Connecticut it will be evolutionary. PCPs must understand the realities of the current marketplace and plan a strategy to work with those realities to achieve their long-term goals. The choices we make today will have ramifications flowing far into future decades. PCPs and their patients will have to live with the consequences of these decisions. Please choose wisely.     

The cost of cancer home care to families

BACKGROUND: For the most part, previous research on costs of cancer care has focused on the formal medical care costs. Research on home care for patients with cancer has emphasized direct care costs (expenditures). Among indirect costs, only loss of income to family members has been studied. However, a major component of indirect costs, the family labor expended to care for the patient with cancer, needs to be included for a more realistic appreciation of home care costs. METHODS: The costs of family labor are estimated by imputing monetary values for the time spent caring for the patient with cancer. The assigned monetary cost either is equated with income losses of the helper in question or is based on a putative market value of the expended labor time. In addition, out-of-pocket expenditures examined in this study cover all cancer care-related expenses for which the patient was not reimbursed by third parties. Data were obtained from a convenience sample of 192 patients with cancer and their families in lower Michigan. RESULTS: When family labor is included in the cost calculations, average cancer home care costs for a 3-month period ($4563) are not much lower than the costs of nursing home care. The substantial variation in home care costs (standard deviation [SD] = $4313) appears to be unrelated to the type of cancer diagnosis, type of treatment, or time since diagnosis but seems to be driven by the functional status of the patient and the family living arrangements. CONCLUSIONS: Outpatient care for patients with cancer coupled with greater reliance on home care appear to be economically attractive because costs to families usually are underestimated.     

The home as a framework for health care

A 6-month-old infant presenting initially with clinical signs of bronchiolitis developed acute symptoms of large airway obstruction and respiratory failure despite treatment for bronchiolitis. Endotracheal intubation and oxygen therapy resulted in immediate and dramatic improvement of respiratory failure. Plain chest radiograph, computerized tomography and surgical biopsy with subsequent histological examination established that the respiratory failure was due to a mediastinal cystic hygroma.     

Hospital care at home

Red cell aggregation has been studied by photometry in 47 children with insulin-dependent diabetes mellitus. The disease was associated with boosting of reversible red cell aggregation, which was most of all expressed during metabolic decompensation with ketoacidosis. When metabolic subcompensation was attained, this parameter did not completely normalize and still had to be corrected.     

Emergency department-based home care

STUDY OBJECTIVE: To assess the feasibility of coordinating home care services from an inner-city emergency department. INTERVENTION: In a preintervention survey, the home care needs of 650 consecutive patients being discharged from the ED were evaluated. A nurse-coordinator who arranged and managed rapidly deployed home care services then was assigned to the ED for eight months. Patients were referred, and home care services were provided regardless of insurance status. SETTING: Teaching hospital serving a large indigent population. PARTICIPANTS: Adult patients about to be discharged home from the ED. MAIN RESULTS: Forty-five of 650 (7%) surveyed patients were not receiving home care services for which they were eligible. In the subsequent eight-month period, 670 patients were referred for home care on discharge from the ED (2% of all discharges). Seventy-six percent of these patients were women, and the average age was 73.5 years. Four hundred fifty patients (67%) received visits from home care providers managed by the ED coordinator. For 99 of these patients (22%), the availability of rapidly deployed home care services obviated the need for emergency admission to the hospital. Net billings to third-party payers exceeded the costs of the program. CONCLUSION: A significant proportion of elderly patients being discharged from the ED need home health services. Access to rapidly deployed home care services can obviate the need for hospital admission for a select group of debilitated patients. The provision of home care services from the ED is economically feasible.     

The course of back pain in primary care

STUDY DESIGN: Review paper of outcome studies among primary care back pain patients. OBJECTIVES: To determine the short-term and long-term pain and functional outcomes of patients with back pain who are seeking treatment in primary care settings. SUMMARY OF BACKGROUND DATA: Back pain has been viewed as running either an acute or a chronic course, but most patients experience recurrent back pain. This review summarizes outcome studies in light of the episodic course of back pain. METHODS: Studies reporting pain and functional outcome data for consecutive primary care patients with back pain were reviewed. RESULTS: Back pain among primary care patients typically is a recurrent condition for which definitions of acute and chronic pain based on a single episode are inadequate. Because a majority of patients experience recurrences, describing only the outcome of the initial back pain episode may convey a more favorable picture of long-term outcome than warranted. For the short-term follow-up evaluation, most patients improve considerably during the first 4 weeks after seeking treatment. Sixty-six percent to 75% continue to experience at least mild back pain 1 month after seeking care. At 1 month, approximately 33% report continuing pain of at least moderate intensity, whereas 20-25% report substantial activity limitations. For the long-term follow-up (1 year or more) period, approximately 33% report intermittent or persistent pain of at least moderate intensity, one in seven continue to report back pain of severe intensity, and one in five report substantial activity limitations. CONCLUSION: Results from existing studies suggest that back pain among primary care patients typically runs a recurrent course characterized by variation and change, rather than an acute, self-limiting course.