Appropriateness of acute medical care for the elderly: an analysis of the literature

Over the past 30 years, an explosion in health care expenditures has occurred. Prior to 1960, health care accounted for 4.4% of the U.S. Gross National Product; today it is 11%. Before rational solutions to controlling this rise can be proposed, we must determine whether the care that we are currently paying for is appropriate to the needs of the elderly. This paper analyzes the literature regarding appropriateness of acute care provided to the elderly. We identified 17 articles that explicitly cited appropriate or inappropriate care (including under-, over- and misuse) provided in hospital and ambulatory settings and for procedures, and 19 articles that presented data on the appropriateness of medication use in the elderly. Virtually every study included in this review found at least double-digit levels of inappropriate care. Perhaps as much as one-fifth to one-quarter of acute hospital services or procedures were felt to be used for equivocal or inappropriate reasons, and two-fifths to one-half of the medications studied were overused in outpatients. The few studies that examined underuse or misuse of services also documented the existence of these phenomena. This was especially true for the ambulatory care of chronic physical and mental conditions and concerned the use of low-cost technologies (visits, preventive services, some medications). Thus, we conclude that there appears to be a substantial problem in the matching of acute services to the needs of elderly patients. This mismatch occurs both in terms of overuse and underuse, at least for areas where research has been conducted.     

Rhabdomyolysis complicating acute Epstein-Barr virus infection

Summary Infection with Epstein-Barr virus (EBV) is common and induces a broad spectrum of illness. In the majority of cases the disease manifests with typical signs of heterophile-positive infectious mononucleosis in which myalgia may be seen in up to 20% of cases. In this study, a case of rhabdomyolysis is reported occurring during the clinical course of an 18-year-old patient with infectious mononucleosis. This severe form of muscle involvement has been rarely associated with EBV infections. Five similar cases previously published in the English literature are also reviewed. The clinical implications of rhabdomyolysis and infectious mononucleosis are discussed.

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Rhabdomyolyse als Komplikation einer akuten Epstein-Barr-Virus-Infektion

Zusammenfassung Die Infektion mit dem Epstein-Barr-Virus (EBV) ist häufig, sie verursacht ein breites Spektrum von Krankheitsbildern. Die meisten Infektionen verlaufen mit dem typischen Bild einer infektiösen Mononukleose mit heterophilen Antikörpern, in bis zu 20% der Fälle treten Myalgien auf. Wir berichten über einen 18jährigen Mann, bei dem im Verlauf einer infektiösen Mononukleose eine Rhabdomyolyse auftrat. Diese schwere Form der Muskelbeteiligung wird bei EBV-Infektionen selten gesehen. Über fünf ähnliche, in der englischsprachigen Literatur mitgeteilte Fälle wird ebenfalls berichtet. Die klinischen Folgen einer Rhabdomyolyse bei infektiöser Mononukleose werden diskutiert.

     

Efficacy of topical gentamicin treatment after 193-nm photorefractive keratectomy in an experimental Pseudomonas keratitis model

Background: The treatment of Pseudomonas keratitis has many limitations, and further investigation to identify more effective approaches is required. We therefore studied the possible contribution of the debridement effect of 193-nm excimer laser on Pseudomonas keratitis in rabbit eyes. Methods: Pseudomonas keratitis was induced in 30 rabbit eyes by inflicting controlled central corneal scratches and applying a drop of Pseudomonas aeruginosa suspension. After 24 h, one cornea of each animal was photo-ablated (excimer laser: fluency 90 mJ/cm², 10 Hz, 213 pulses), yielding 50 m of tissue ablation, while the follow cornea served as control. Five groups of six animals each were formed and received: a subconjunctival injection of gentamicin 20, mg (group 1), topical 14 mg/ml gentamicin hourly (group 2) or every 2.5 h (group 3), or NaCl 0.9% hourly (group 4) for 8 h. In group 5, animals were sacrificed without additional treatment. After 9 h corneas were excised, homogenized, serially diluted, and plated on agar blood plates. The numbers of colony-forming units (CFU) per cornea were statistically evaluated (Mann-Whitney test). Results: In control eyes, a greater decrease of CFU was observed in group 2 than in group 3 (P = 0.03). In laser-ablated eyes, there was no difference in CFU between groups 2 and 3. Comparison of the excimer-treated and control eyes revealed a greater number of bacteria (CFU) in controls only in group 3 (P=0.02). Conclusion: Our study suggests that controlled debridement of cornea with excimer laser may improve the effect of topical antibiotics.Presented at ECORA First Annual Meeting, 5 October 1993, Bonn, Germany     

Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood

BACKGROUND: A community-based longitudinal study was conducted to investigate whether personality disorders (PDs) during adolescence increase the risk for Axis I psychiatric disorders and suicidality during early adulthood. METHOD: Psychosocial and psychiatric interviews were administered to a representative community sample of 717 youths and their mothers from 2 counties in the state of New York in 1975, 1983, 1985-1986, and 1991-1993. Anxiety, disruptive, eating, mood, personality, and substance use disorders and suicidal ideation and behavior were assessed in 1983 and 1985-1986, when the participants were adolescents, and in 1991-1993, when they were young adults. RESULTS: Adolescents with PDs were more than twice as likely as those without PDs to have anxiety, disruptive, mood, and substance use disorders during early adulthood. These associations remained statistically significant after co-occurring Axis I disorders during adolescence were controlled statistically. Cluster A, B, and C PDs and DSM-IV Appendix B PDs during adolescence were all associated with elevated risk for Axis I disorders during early adulthood after co-occurring Axis I and Axis II disorders during adolescence were controlled statistically. Cluster C PDs during adolescence were associated with elevated risk for suicidal ideation or behavior during early adulthood after co-occurring psychiatric disorders and suicidality during adolescence were controlled statistically. CONCLUSIONS: Adolescents in the community with personality disorders are at elevated risk for major mental disorders and suicidal ideation or behavior during early adulthood. This increase in risk is not accounted for by co-occurring Axis I disorders or suicidality during adolescence.     

Olanzapine compared to lithium in mania: a double-blind randomized controlled trial

Neuroleptics are of established efficacy in mania. Controlled data on the use of olanzapine in mania is however, absent. In this study, 30 patients meeting DSM-IV criteria for mania were randomly allocated to receive either olanzapine or lithium in a 4 week double-blind randomized controlled design. There were no significant outcome differences between the two groups on any of the primary outcome measures, the Brief Psychiatric Rating Scale (lithium 28.2; olanzapine 28.0; P = 0.44); Clinical Global Impression (CGI) improvement scale (lithium 2.75, olanzapine 2.36; P = 0.163) or the Mania Scale (lithium 13.2, olanzapine 10.2; P = 0.315). Olanzapine was however, significantly superior to lithium on the CGI-severity scale at week 4 (lithium 2.83, olanzapine 2.29; P = 0.025). Olanzapine did not differ from lithium in terms of treatment emergent extrapyramidal side-effects as measured by the Simpson-Angus Scale. Olanzapine appears to be at least as effective as lithium in the treatment of mania.     

Value of a radionuclide limb blood flow technique in the assessment of percutaneous balloon and dynamic angioplasty

In a prospective study, a radionuclide technique was used to evaluate the limb blood flow (LBF) changes in 30 patients undergoing dynamic (n=15) or balloon (n=15) angioplasty for arterial occlusions or stenoses, respectively. The results were compared with Doppler Ankle Brachial Index (DABI) and treadmill exercise tests. Whilst LBF values (ml of blood flow per 100 ml of limb volume per min) were significantly lower in limbs with arterial occlusion than stenosis (4.5±0.46 and 6.4±0.74, respectively; P<0.05), DABI provided no discrimination. Immediately after balloon angioplasty, there was a fall in DABI, from 0.60±0.05 to 0.47±0.04 (P<0.05), which rose 24 h later to 0.73±0.02 (P<0.01). Following dynamic angioplasty, DABI improved from 0.60±0.05 to 0.66±0.02 (P<0.05). At 3 weeks, the LBF improved from 4.6±0.66 to 11.1±0.53 (P<0.001) following dynamic angioplasty and from 6.2±0.68 to 8.53±0.81 (P<0.001) following balloon angioplasty. Normal LBF (> 10 ml/100 ml per min) was achieved in 80% of patients who underwent successful dynamic angioplasty but in only 36% of the balloon group (P<0.05, ²-test). Reproducibility of repeated LBF measurements in control limbs was superior to that of DABI. This was indicated by a lower coefficient of variation, 13.8% compared with 25.2%, and a higher correlation coefficient, r=0.79 compared with 0.27. Treadmill exercise tests were invalid or impossible in 30% of all occasions. There was a good correlation between the improvement in maximum walking distance on the treadmill and that in LBF (r=0.84, P<0.05). In conclusion, measurement of LBF using radionuclide technique is a potentially valuable method for the assessment of patients undergoing percutaneous angioplasty. LBF results are reproducible and correlate well with the improvement in walking ability, which cannot always be assessed objectively. Offprint requests to: A.A. Gehani     

Dual effect of lovastatin and simvastatin on LDL-macrophage interaction.

Lovastatin and simvastatin which are very potent cellular cholesterol biosynthesis inhibitors, significantly affect the plasma lipoprotein concentration. After incubation of plasma with 14C-labelled compounds, radioactivity was found in all lipoprotein fractions but mainly (40%) in high density lipoprotein (HDL), and in the lipoprotein-deficient plasma fraction (20-30%). Drug-treated lipoproteins showed reduced electrophoretic mobility on cellulose acetate in comparison with control lipoproteins. The lovastatin-treated low density lipoprotein (LDL) displayed 28% increased fluidity in comparison with control LDL. The immunoreactivity of drug-treated LDL with monoclonal antibody directed towards the LDL receptor binding domains (B1B6) was significantly less than that of control LDL, suggesting reduced binding to the LDL receptor. When drug-treated LDL was incubated with J-774 A.1 macrophage-like cell line, its binding (at 4 degrees C) was 28% less than that of control LDL, whereas a substantial increase in the cellular cholesterol esterification rate (by 83% with lovastatin and by 67% with simvastatin) was noted. Similarly, the degradation of lovastatin and simvastatin-treated LDL by macrophages was 87-89% greater than that of control LDL. The "apparent Vmax" for the macrophage degradation of lovastatin-treated LDL was 70% greater than that for control LDL. Thus, both drugs may have a dual effect on the macrophage uptake of LDL; they may increase the number of LDL receptors on the cell surface, but they may also reduce the affinity of LDL for its receptor, the former being the major effect.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of cost sharing in health insurance on disability days

We assess how cost sharing for medical services affects restricted activity days (RADs) and work loss disability days (WLDs), using data from a controlled experiment. We grouped the experimental insurance plans into four categories, one providing free care and the other three requiring varying amounts of cost sharing. RADs per person per year decreased by one to two days with greater cost sharing, with the strongest effects among those of average or poor health status, especially the non-poor. Unlike RADs, WLDs showed no systematic differences by plan.     

nNOS inhibitors attenuate methamphetamine-induced dopaminergic neurotoxicity but not hyperthermia in mice

Methamphetamine (METH)-induced dopaminergic neurotoxicity is associated with hyperthermia. We investigated the effect of several neuronal nitric oxide synthase (nNOS) inhibitors on METH-induced hyperthermia and striatal dopaminergic neurotoxicity. Administration of METH (5 mg/kg; q. 3 h x 3) to Swiss Webster mice produced marked hyperthermia and 50-60% depletion of striatal dopaminergic markers 72 h after METH administration. Pretreatment with the nNOS inhibitors S-methylthiocitrulline (SMTC; 10 mg/kg) or 3-bromo-7-nitroindazole (3-Br-7-NI; 20 mg/kg) before each METH injection did not affect the persistent hyperthermia produced by METH, but afforded protection against the depletion of dopaminergic markers. A low dose (25 mg/kg) of the nNOS inhibitor 7-nitroindazole (7-NI) did not affect METH-induced hyperthermia, but a high dose (50 mg/kg) produced significant hypothermia. These findings indicate that low dose of selective nNOS inhibitors protect against METH-induced neurotoxicity with no effect on body temperature and support the hypothesis that nitric oxide (NO) and peroxynitrite have a major role in METH-induced dopaminergic neurotoxicity.