Managed care and outcomes of hospitalization among elderly patients with congestive heart failure

123I-radiolabeled metaiodobenzylguanidine (123I-MIBG) cardiac imaging has been used to evaluate the distribution of sympathetic nervous system (SNS) in the heart. Different heart diseases have shown impaired cardiac SNS distribution as reflected by MIBG activity. The aim of this study was to assess the cardiac distribution of SNS in normal subjects, using MIBG imaging. Ten normal subjects (1 male and 9 females, mean age 46 +/- 9 years) with no cardiac abnormalities underwent myocardial 123I-MIBG scintigraphy, Tc-99m methoxyisobutylisonitrile (MIBI) cardiac perfusion imaging and equilibrium radionuclide angiography (RNA). Regional myocardial MIBG and MIBI activities were quantitatively evaluated using a region of interest analysis. For this purpose, the left ventricle was divided into 6 myocardial regions as anterior, apical, inferior, septum, lateral and posterolateral. In particular, myocardial MIBG and MIBI activities were measured as myocardium to mediastinum ratio. Regional left ventricular function was assessed by RNA. Myocardial MIBG uptake was homogeneous in anterior (2.2 +/- 0.5), inferior (2.5 +/- 0.7), septal (2.4 +/- 0.4), lateral (2.3 +/- 0.4), and posterolateral (2.3 +/- 0.4) regions. Conversely, MIBG uptake was significantly lower in the apical region (1.9 +/- 0.3) compared to all other left ventricular segments (p < 0.05). Regional myocardial perfusion, as measured by MIBI uptake, was homogeneous in all regions. No regional left ventricular wall motion abnormalities were observed by RNA. In conclusion, our data suggest that a decreased MIBG uptake may be observed in the left ventricular apical region of normal subjects reflecting reduced sympathetic innervation of the apex. This finding is not related to myocardial perfusion or wall motion abnormalities. The knowledge of cardiac sympathetic innervation in normal subjects may be helpful to assess SNS abnormalities in heart disease.     

Symptoms of depression among community-dwelling elderly African-American and white older adults

BACKGROUND: Few studies have explored the variance in individual symptoms by race in older adults. METHODS: Data were analysed from the Duke site of the Established Populations for Epidemiologic Studies of the Elderly (EPESE), a community sample of persons 65 years-of-age and older, 54% of whom were African-Americans. Of the 3401 subjects with adequate data on depressive symptomatology, confirmatory factor analysis and LISREL were first used to confirm the presence of the factor structure previously reported for the CES-D. Next, bivariate analysis was performed to determine the prevalence of individual symptoms by race. Finally, LISREL analysis was performed to control for potential confounding variables. RESULTS: When bivariate comparisons of specific symptoms by race were explored, African-Americans were more likely to report less hope about the future, poor appetite, difficulty concentrating, requiring more effort for usual activities, less talking, feeling people were unfriendly, feeling disliked by others and being more 'bothered' than usual. When LISREL analyses were applied to these data (controlling for education, income, cognitive impairment, chronic health problems and disability and other factors) racial differences in somatic complaints and life satisfaction disappeared, yet differences in interpersonal relations persisted. CONCLUSIONS: This study confirms earlier findings of minimal overall differences in symptom frequency between African-American and non-African-American community-dwelling older adults in controlled studies.     

Women, marital status, and symptoms of depression in a midlife national sample

Hospitals have to purchase new technology, update equipment, and replenish supplies continually to meet the needs of patients and the medical and nursing staff in a sound financial way. Thus, inventories must be maintained accurately and adequately with proper controls. Awareness of the cost of capital and operational supplies is essential to meeting budget allocations. With or without centralized buying, the MM department has the expertise to assist every department in purchasing to meet its needs and in setting and resetting inventory levels for its supplies. Explanations and formulas for handling capital equipment and regular supplies and some formats have been presented to facilitate the process. Because OR items are both expensive and numerous and OR storage space the most costly space in the hospital, physicians and nurse managers must understand the financial processes and inventory management and educate their staffs in these matters.     

Physical illness and symptoms of depression among elderly outpatients.

Elderly outpatients were assessed to clarify relations between symptoms of depression and physical illness, disability, pain, and selected psychosocial variables. Three types of assessments were made: (1) medical evaluations by physicians, (2) self-reported symptoms of depression and physical health, and (3) demographic and psychosocial data relating to participants' life circumstances. Both objective (physician-rated illness symptoms) and subjective (self-reported health, activity restriction, and use of pain medications) indicators of health accounted for independent variance in symptoms of depression. After controlling for these factors, additional variance was explained by health-related concerns (e.g., health care expenses, service needs), social support, and "other worries" (e.g., feeling useless, becoming a burden to others). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Religious activity and depression among community-dwelling elderly persons with cancer: the moderating effect of race

OBJECTIVES: Research has been oriented toward elucidating the links between religion and mental health. The purpose of this article is to further our knowledge in this area by examining the effect of religious activity on depressive symptomatology among community-dwelling elderly persons with cancer. We also test whether these effects differ between Blacks and Whites. METHODS: We use two waves of data collected from a community-dwelling sample of elderly persons living in North Carolina. Depressive symptomatology is measured using four subscales from the CES-D 20 scale: somatic-retarded activity, depressed affect, positive affect, and interpersonal relations. Measures of religious activity include service attendance, religious devotion, and watching or listening to religious programs. RESULTS: The findings indicate that among Blacks with cancer, religious activity is related to lower levels of depressive symptomatology; no such relationship is found for respondent with other illnesses or no illness. Further, the effects of religious activity are stronger among Blacks than Whites. DISCUSSION: The analyses lend support to the hypothesis that religious activity is a strong predictor of depression in elderly adults with cancer. This finding, however, is not as strong as we had anticipated.     

Gender differences in disability and lifestyle among community-dwelling elderly stroke patients in Kitakyushu, Japan

OBJECTIVE: To examine whether there were differences in lifestyle and performance of activities of daily living (ADL) between men and women in a population of elderly stroke patients. DESIGN: Case-comparison study. MATERIAL AND METHODS: Sixty-eight men and 34 women who were elderly stroke patients living in the community with a spouse or family members were evaluated with the self-rating Barthel Index (SRBI), Frenchay Activities Index (FAI), Stroke Impairment Assessment Set (SIAS), Functional Independence Measure (FIM), and a pedometer for physical activity. Control subjects, 30 men and 30 women, were assessed with the FAI. RESULTS: Among the stroke subjects, there were no significant differences in age, SRBI, motor score of the SIAS, or physical activity between men and women; however, men had significantly lower values than did women for three FIM items and the total FIM score and for 6 FAI items and the total FAI score. Among control subjects, men had significantly lower values than did women for 7 FAI items and the total FAI score (Tukey's test, p < .05). CONCLUSION: Among elderly stroke patients, men received more support from family members in ADL performance and had less active lifestyles than did women, possibly because of cultural gender roles.     

Religion and mortality among the community-dwelling elderly

OBJECTIVES: This study analyzed the prospective association between attending religious services and all-cause mortality to determine whether the association is explainable by 6 confounding factors: demographics, health status, physical functioning, health habits, social functioning and support, and psychological state. METHODS: The association between self-reported religious attendance and subsequent mortality over 5 years for 1931 older residents of Marin County, California, was examined by proportional hazards regression. Interaction terms of religion with social support were used to explore whether other forms of social support could substitute for religion and diminish its protective effect. RESULTS: Persons who attended religious services had lower mortality than those who did not (age- and sex-adjusted relative hazard [RH] = 0.64; 95% confidence interval [CI] = 0.52, 0.78). Multivariate adjustment reduced this relationship only slightly (RH = 0.76; 95% CI = 0.62, 0.94), primarily by including physical functioning and social support. Contrary to hypothesis, religious attendance tended to be slightly more protective for those with high social support. CONCLUSIONS: Lower mortality rates for those who attend religious services are only partly explained by the 6 possible confounders listed above. Psychodynamic and other explanations need further investigation.     

Interpretation of Mini-Mental State Examination scores in community-dwelling elderly and geriatric neuropsychiatry patients

Detection of Klebsiella pneumoniae strains with extended-spectrum beta-lactamase (ESBL)-related resistance phenotypes is becoming important in clinical microbiology laboratories. In this study, we investigated the usefulness of three screening methods, the Etest ESBL screen, the double-disk synergy test, and the ceftazidime disk test, for identifying ESBL-producing K. pneumoniae strains. The agar dilution method was used as the standard. We also determined the in vitro activity of several new antimicrobial agents against these organisms. Strains that exhibited an increase in the minimum inhibitory concentration (MIC) to the third-generation cephalosporins or aztreonam of 2 micrograms/mL or more, but were susceptible to the three cephamycins tested, were considered to have ESBL-related resistance phenotypes. The frequency of ESBL-producing K. pneumoniae isolates (according to the disk-diffusion method) has increased markedly in recent years, from 3.4% in 1993 to 10.3% in 1997. A total of 93 preserved isolates of K. pneumoniae collected from December 1995 through March 1997 were found to be resistant to at least one of the third-generation cephalosporins (cefotaxime and ceftazidime) or aztreonam using the routine disk diffusion method. Among these isolates, 35 were classified as having an ESBL phenotype using the agar dilution method. The remaining 58 isolates were classified as cephamycin resistant, which indicated resistance to both cephamycins and third-generation cephalosporins or aztreonam. The susceptibility rates of the ESBL-producing isolates were 11% for cefotaxime, 14% for ceftazidime, and 6% for aztreonam. The susceptibility rates of these 35 isolates to imipenem, ciprofloxacin, and ofloxacin were 100%, 80%, and 86%, respectively. Both the MIC50 and MIC90 of meropenem were 0.06 microgram/mL, while the MIC50 and MIC90 of BAY 12-8039 were 0.125 and 2 micrograms/mL, respectively. Thirty-two (91%) of the 35 isolates of K. pneumoniae with the ESBL-related resistance phenotype were detected by the Etest ESBL screen, while the ceftazidime disk screen test detected 77% of these isolates, and the double-disk synergy test detected 74%. The Etest ESBL screen appears to be an acceptable, convenient, and sensitive method for the detection of ESBL-producing isolates in the clinical microbiology laboratory.     

Physical activity, functional limitations, and the risk of fall-related fractures in community-dwelling elderly

The ability of positron emission tomography (PET) to serve as a useful myocardial perfusion indicator is well established. We describe a methodology for obtaining reliable quantitative kinetic parameters from dynamic cardiac PET data. Reconstructed images of the myocardium are subdivided into three-dimensional volumes of interest which are used to obtain quantitative measures of myocardial perfusion over physiologically meaningful anatomical regions. The quantitation technique rigorously models the uncertainty of estimated parameters while compensating for effects such as patient motion and partial volumes to arrive at model parameters with well-established confidence intervals.     

Characterization of major depression symptoms in multiple sclerosis patients

Retrospective review of affective disturbances in 238 patients with multiple sclerosis (MS) seen over a 6-month period revealed: 1) 51 patients (22%) received pharmacologic treatment for depressive symptoms during or within 4 years of the study period, and 17 (7%) received treatment for rapid mood swings; 2) among the 51 depressed patients, response rate to medication was extremely high; 3) relapse of depressive symptomatology after discontinuation of medication was also high (17/29); 4) first episodes of major depression frequently occurred during periods of MS progression or exacerbation, but first episodes also occurred during periods of relative clinical stability; 5) suicidal ideation was common (12 patients), but only 1 patient had a history of attempted suicide; and 6) side effects were tolerable in most patients.     

Patterns of hospitalization in elderly patients with asthma and chronic obstructive pulmonary disease

The purpose of this study was to describe the impact of asthma and chronic obstructive pulmonary disease (COPD) in the elderly on health care utilization. The Health Care Financing Administration (HCFA) file for the year 1984 through 1991 involving beneficiaries < or = 65 yr were searched for the diagnoses of asthma and COPD by ICD-9 codes. The study groups were created by determining the first admission for an exacerbation of either disease during each year from 1984 through 1991. Patients were identified by their social security number. The 1984 cohort consisted of 56,692 patients with asthma exacerbation and 162,899 with COPD exacerbation. The 1991 cohort consisted of 67,758 patients with asthma exacerbation and 131,974 patients with COPD exacerbation. In addition, the 1984 cohort was tracked by social security number for evidence of rehospitalization for either asthma or COPD through 1991. Length of hospitalization increased as patients grew older. The discharge rate to an independent living facility diminished as age increased. The use of convalescent and nursing homes or home health care after discharge more than doubled from 1984 through 1991. The utilization of health care resources by elderly patients with asthma and COPD is immense, both during hospitalization and after discharge.     

Functional status outcomes in rehabilitation. Implications for prospective payment

Previous studies have demonstrated that functional status is a significant predictor of resource utilization for rehabilitation patients. Before implementing a prospective payment system (PPS) for rehabilitation, it is important to first: 1) develop an underlying conceptual framework of rehabilitation resource use; and 2) understand how the role of functional status may vary by rehabilitation condition. In this study, a theoretical model of rehabilitation is presented that proposes relationships between patient and provider characteristics, rehabilitation treatment, costs, and clinical outcomes of rehabilitation. Also presented are regression analyses based on this model for a key outcome of rehabilitation, change in functional status, for nine rehabilitation conditions using variables that minimize adverse incentives by providers in selecting patients for admission to rehabilitation. The change-in-functional-status model explained the most variance for back injury, cardiopulmonary, and arthritis, and less variance for stroke, spinal cord injury, and neurologic impairment. The significant predictors of change in functional status varied by condition. Results support the use of functional status measurements in a PPS for rehabilitation services, the need to refine the measurement of functional status, and the use of condition-specific activities of daily living (ADL) items to include in summary indices.     

Depressive symptoms and physical decline in community-dwelling older persons

CONTEXT: Significant symptoms of depression are common in the older community-dwelling population. Although depressive symptoms and disability may commonly occur in the same person, whether depressive symptoms contribute to subsequent functional decline has not been elucidated. OBJECTIVE: To determine whether depressive symptoms in older persons increase the risk of subsequent decline in physical function as measured by objective performance-based tests. DESIGN: A 4-year prospective cohort study. SETTING: The communities of Iowa and Washington counties, Iowa. PARTICIPANTS: A total of 1286 persons aged 71 years and older who completed a short battery of physical performance tests in 1988 and again 4 years later. MAIN OUTCOME MEASURES: Baseline depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale. Physical performance tests included an assessment of standing balance, a timed 2.4-m (8-ft) walk, and a timed test of 5 repetitions of rising from a chair and sitting down. RESULTS: After adjustment for baseline performance score, health status, and sociodemographic factors, increasing levels of depressive symptoms were predictive of greater decline in physical performance over 4 years (odds ratio for decline in those with depressed mood vs those without, 1.55; 95% confidence interval [CI], 1.02-2.34). Even among those at the high end of the functional spectrum, who reported no disability, the severity of depressive symptoms predicted subsequent decline in physical performance (odds ratio for decline, 1.03; 95% CI, 1.00-1.08). CONCLUSIONS: This study provides evidence that older persons who report depressive symptoms are at higher risk of subsequent physical decline. These results suggest that prevention or reduction of depressed mood could play a role in reducing functional decline in older persons.     

Measures of functional status in community-dwelling elders

OBJECTIVE: To evaluate two performance-based measures of functional status and assess their correlation with self-report measures. DESIGN: Cross-sectional study. PARTICIPANTS: Of the 363 community-dwelling elders enrolled in a trial of comprehensive geriatric assessment who participated, all had at least one of four target conditions (urinary incontinence, depression, impaired functional status, or history of falling). MEASUREMENTS: Two performance-based measures, National Institute on Aging (NIA) Battery, and Physical Performance Test (PPT), and three self-report functional status measures, basic and intermediate activities of daily living and the Short-Form-36 (SF-36) physical functioning subscale, were used. Measures of restricted activity days, patient satisfaction and perceived efficacy were also used. MAIN RESULTS: All measures were internally consistent. There was a high correlation between the NIA and PPT (kappa = 0.71), while correlations between the performance-based and self-report measures ranged from 0.37 to 0.50. When patients with values above the median on the two performance-based measures were compared with those below, there were significant differences (p 相似文献   

Longitudinal assessment of symptoms of depression, agitation, and psychosis in 181 patients with Alzheimer's disease

OBJECTIVE: The goal of this study was to define the recurrence or continuation of neuropsychiatric symptoms in patients with Alzheimer's disease who were observed serially for a 1-year period. METHOD: One hundred eighty-one patients with probable Alzheimer's disease were assessed five times at 3-month intervals with a standardized neuropsychiatric rating instrument. RESULTS: Recurrence rates of neuropsychiatric symptoms during the 1-year period were 85% for depression, 93% for agitation, and 95% for psychosis. Symptom frequency at any point in time underestimated the cumulative 1-year frequency. Recurrence rates were significantly greater among patients who had multiple symptoms. Women exhibited more symptoms than men. Patients in the oldest age group (76-87 years) had more psychosis, less depression and agitation, and slower cognitive decline. Psychosis was associated with more rapid cognitive decline, and agitation was associated with more rapid functional deterioration. CONCLUSIONS: These results indicate that once psychiatric symptoms are present in patients with Alzheimer's disease, they frequently recur. These symptoms vary with age, sex, and rate of illness progression.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

Personality disorder, symptoms and dexamethasone suppression in depression

To identify serum-inducible genes in the insulin-producing cell line beta TC-1, a library subtraction screening procedure was performed on serum-deprived (G0) and serum-restimulated (G1) insulin-producing beta TC-1 cells. A cDNA containing a motif with strong homology to Src homology 2 (SH2) domains was found using this procedure and called Shb. The Shb cDNA contains two methionine codons in its N-terminus and thus may code for two proteins of 67 and 56 kDa, each with one SH2 domain in its C-terminus. No other structural similarity to proteins with catalytic activity could be detected, suggesting that Shb is a so called adaptor. Shb contains the proline-rich sequence PPPGPGR between the two proposed initiator methionines which resembles a sequence for binding to Src homology 3 (SH3) domains. A second proline-rich sequence was detected after the second methionine codon. The Shb cDNA hybridized to a similar or identical mRNA of 3.1 kb expressed in mouse brain, liver, kidney, heart, NIH3T3 fibroblasts and beta TC-1 cells. Western blot analysis of the same tissues using an antiserum directed against a synthetic peptide corresponding to a part of the SH2 domain of Shb, revealed reactivity with two proteins of 56 and 67 kDa. In addition, a third reactive component of 40 kDa was detected in most tissues. Transfection and transient expression of the Shb cDNA in COS-1 cells yielded increased expression of the 67, 56 and 40 kDa proteins. Transfection and stable expression of the Shb cDNA in pig aortic endothelial cells showed increased expression primarily of the 67 kDa protein. A fusion protein consisting of the SH2 domain of Shb linked to glutathione S-transferase showed increased binding to glycoproteins of cells stimulated with platelet-derived growth factor (PDGF-BB). Furthermore, the autophosphorylated PDGF beta-receptor but not the autophosphorylated epidermal growth factor (EGF) receptor bound specifically to immobilized fusion protein. It is concluded that Shb is a novel SH2-containing protein with proline-rich domains and therefore probably involved in the signal-transduction of some ligand-activated tyrosine kinase receptors.     

Depression screening scale validation in an elderly, community-dwelling population.

This study contrasted the relative effectiveness of an interviewer-rated instrument, the Hamilton Depression Rating Scale, and 2 self-report scales, the short form of the Beck Depression Inventory and the depression scale from the Brief Symptom Inventory, in identifying cases of depression. Cases of major depression, dysthymia, and depressive disorder not otherwise specified (NOS) were identified by means of the Structured Clinical Interview for DSM-III—R (SCID) in a sample of 177 elderly community-dwellers. Receiver operating curves were used to evaluate the relative abilities of the 3 screening instruments to identify cases of depression. All 3 instruments identified major depression and depressive disorder NOS. None was consistently sensitive to cases of dysthymia. The incremental utility of the interview-based instrument for screening was nonsignificant, suggesting that the increased expense in a community setting may not be justified. (PsycINFO Database Record (c) 2010 APA, all rights reserved)