Predictors of Aspiration Pneumonia in Nursing Home Residents

Aspiration pneumonia is a serious problem for the elderly institutionalized person, often requiring transfer to a hospital and a lengthy stay there. It is associated with a high mortality rate and is very costly to the health care system. The current study sought to determine the key predictors of aspiration pneumonia in a nursing home population with the hope that health care providers could identify those residents at highest risk and focus more efforts on prevention of this serious disease. A cross-sectional, retrospective analysis was done, using the Minimum Data Set (MDS) nursing home assessment data for three states (New York, Mississippi, Maine) from 1993 to 1994 (N = 102842). Nursing home residents were aged 65+. Standardized MDS summary scales and their component items were used, including: the Activities of Daily Living (ADL) scale, the cognitive performance scale (CPS), and the Resource Utilization Groups (RUGs). Results of these analyses showed the prevalence of pneumonia among this population was 3% (n = 3118). Results from the logistic regression models indicated 18 significant predictors of aspiration pneumonia. The strongest to weakest predictors of pneumonia were, respectively, suctioning use, COPD, CHF, presence of feeding tube, bedfast, high case mix index, delirium, weight loss, swallowing problems, urinary tract infections, mechanically altered diet, dependence for eating, bed mobility, locomotion, number of medications, and age, while both CVA and tracheotomy care were inversely predictive of pneumonia. The emergence of these significant predictors suggested a different pathogenesis of pneumonia in the elderly nursing home resident from the acute care patient or the outpatient. Nursing home residents have chronic medical conditions that gradually lead to "decompensation" in functional status, nutritional status, and pulmonary clearance. Dysphagia and aspiration are common complications of their medical conditions and may slowly worsen as their status deteriorates. Alternatively, a sudden adverse event may dramatically increase the amount aspirated or the ability to resist infection and lead to sudden decompensation. Clinical staff must identify residents with dysphagia and aspiration and work to prevent decline in functional status in all residents. They must be aware of the dangers of adverse events that lead to sudden inactivity or illness and increase the risk of aspiration pneumonia. Prevention of this disease whenever possible will reduce costs, improve health outcomes, and improve our quality of care.     

Linkage heterogeneity for the IBD1 locus in Crohn's disease pedigrees by disease onset and severity

BACKGROUND & AIMS: There is evidence for the IBD1 Crohn's disease (CD) susceptibility locus on chromosome 16 in several but not all populations studied. Genetic and phenotypic heterogeneity may underlie ability to replicate IBD1. We determined if age and severity stratification could identify a clinical subgroup at risk for IBD1. METHODS: Linkage analysis at microsatellites spanning chromosome 16 was performed in 2 groups of CD pedigrees: group 1, 57 pedigrees with at least one affected relative classified as having "severe" disease, by history of surgical resection or immunomodulator therapy, and with disease diagnosed before age 22; and group 2, 33 pedigrees with no history of early-onset, severe CD. RESULTS: Group 1 pedigrees demonstrated genomewide significant linkage evidence for the IBD1 locus (nonparametric multipoint logarithm of the odds [Mlod], 3.84; P = 1.3 x 10(-5)) with linkage evidence greater than all 90 pedigrees (Mlod, 2.12; P = 9.0 x 10(-4)). Group 2 pedigrees had near zero nonparametric 2-point and Mlod scores for the IBD1 region. Heterogeneity between groups 1 and 2 was significant (P = 0.002). CONCLUSIONS: Presence of early-onset, more severe CD identifies pedigrees at high risk for IBD1. These pedigrees will have more power to refine the IBD1 locus and identify the causative gene.     

Alagille's syndrome associated with cystic renal disease

Although renal abnormalities have been described in children with Alagille's syndrome, cystic kidney disease has not often been documented, and then usually only at necropsy. Three children with Alagille's syndrome are described, in two of whom a unilateral multicystic dysplastic kidney was detected by prenatal ultrasound; in the other, a solitary cortical cyst was found later in childhood. All have normal renal function, growth, and liver synthetic function but continue to have clinical and biochemical signs of cholestasis. These cases show that unilateral cystic kidney disease with or without renal dysplasia may be associated with Alagille's syndrome, that the clinical course is not necessarily unfavourable, and that Alagille's syndrome should be included in the differential diagnosis of cystic kidney disorders associated with cholestatic liver disease. Patients with Alagille's syndrome should be evaluated by renal ultrasound.     

Laparoscopic repair of paraesophageal hernia

Laparoscopic repair of paraesophageal hernias is rapidly replacing the traditional open approach. Regardless of the approach, certain aspects of repairing paraesophageal hernias have proven to be beneficial and others remain controversial. This article addresses the effectiveness of the laparoscopic approach, the accepted and controversial technical aspects of repair, and which patients should undergo surgical correction of the hernia.     

Laparoscopic Heller myotomy and Roux-en-Y gastric bypass: a novel operation for the obese patient with achalasia

Morbid obesity is a disease encompassing multiple, significant comorbidities. The only current, reliable, durable treatment of obesity is surgical intervention, most commonly gastric bypass. Achalasia, a swallowing disorder of esophageal motility and failure of the lower esophageal sphincter (LES) to relax, is rarely seen in the morbidly obese patient. Treatment is directed at disruption of the LES to allow passage of food. As medical management usually fails in both disease processes, surgical treatment is often chosen. The patient with both morbid obesity and achalasia presents an unusual challenge for surgical treatment. The standard surgical approach for each disease does not address the other, and may have deleterious consequences on the other condition if approached unilaterally. We present the first case of a patient treated with a concomitant laparoscopic esophagogastric myotomy (LEM) and laparoscopic Roux-en-Y gastric bypass (LRYGBP).     

Data from a longitudinal study provided measurements of cognition to screen for Alzheimer's disease

BACKGROUND: This article presents a computerized method to help predict individuals at risk for developing Alzheimer's disease (AD). This would be a valuable tool for clinicians in developing treatment plans for potential AD patients. Using the initial level and rates of change in visual memory performance, such a method could predict potential AD patients in a fast and inexpensive manner. A longitudinal case-control study of 52 female and 145 male participants was performed in a gerontology research center using premorbid tests of visual memory and neurologic examinations to identify individuals with and without dementia and AD. METHODS: The classification method for each individual starts on the second examination and proceeds to compute that person's risk of AD one examination at a time based on all the follow-up information of the remaining individuals. RESULTS: By performing a crossvalidation study, the optimal combination of sensitivity and specificity derived from a receiver operating characteristic (ROC) curve showed 65% of the Alzheimer cases and 75% of the noncases were correctly classified for females, while 65 and 60% of cases and noncases, respectively, were correctly classified for males. CONCLUSION: Longitudinal measurements of cognition can be useful in detecting the presence of AD.