Can a house call by a public health nurse improve the quality of the discharge process for geriatric patients?

OBJECTIVE: To determine whether there was any benefit from a single house call by a health visitor (a public health nurse) to an elderly person after discharge home from a geriatric hospital. METHODS: A randomized controlled trial with blind assessments at 28 days was conducted. Subjects included residents of Bath, England, with an average age of 83 years, who were discharged consecutively from a geriatric hospital to their homes. Intervention was a single visit by a health visitor 72 hours after discharge, to ensure the patient was settled at home, or normal post-discharge care. Outcome measures taken at 28 days by a research nurse included survival, hospital readmissions, nursing home admissions, cognitive and physical function, services requested and supplied, and drug therapy. RESULTS: There were no important differences between the intervention and control groups at 28 days on any of the outcome measurements. The control subjects did better than the study subjects on many of the outcome measures. CONCLUSION: A house call by a health visitor to elderly patients after discharge from geriatric wards does not measurably improve the quality of the discharge.     

Indocyanine green angiography of choroidal tumors

Background: Fluorescein angiography (FA) has been widely used in the diagnostic evaluation of cboroidal tumors. Indocyanine green angiography (ICG-A), which permits better visualization of choroidal vasculature than FA, has been recently introduced into clinical practice. Only few reports exist on the ICG-A characteristics of choroidal tumors. Methods: The fluorescein and indocyanine green angiograms of 61 patients were assessed. These included 14 patients with choroidal nevi, 30 with malignant melanomas, 7 with suspected melanomas or atypical nevi, 5 with hemangiomas and 5 with metastases. Results: The outline of pigmented tumors was more accurate on ICG-A than on FA. Characteristic patterns were seen in all intra-ocular tumors with ICG-A, so it was possible to distinguish hemangiomas from malignant lesions. Characteristic features of malignant melanomas include abnormal vascular pattern and marginal late dye leakage. None of the benign lesions showed these features. In suspected melanomas, the presence of abnormal choroidal vascular patterns and/or late dye leakage on ICG-A may indicate malignancy. Conclusion: The study suggests that ICG-A can yield additional information that is useful in differentiating amongst choroidal tumors. Better delineation of pigmented lesions with ICG-A allows more accurate treatment planning and follow-up.     

In Vivo Evaluation of a Colon-Specific Drug Delivery System: An Absorption Study of Theophylline from Capsules Coated with Azo Polymers in Rats

Azo polymers based upon 2-hydroxyethyl methacrylate, methyl methacrylate, and methacrylic acid, and containing N,N-bis [(methacryloyloxyethyl)oxy(carbonylamino)]azobenzene as azo aromatic agent were evaluated in vivo as coatings for colon-specific drug delivery. The gastrointestinal absorption of theophylline from capsules coated with the azo polymers was examined in the proximal part of the small intestine and the cecum of male Wistar rats. The capsules were surgically inserted in the region of interest. The plasma concentration of the drug was higher when the capsules were inserted in the cecum as compared to the small intestine. The appearance of theophylline in the plasma when capsules were administered in the small intestine can be attributed to simple diffusion of the drug through the swollen polymer coating. Release and absorption from the cecum is the combined result of diffusion and degradation of the azo polymer coatings by bacterial azo reductase.     

Effects of response cost and unit dose on alcohol self-administration in moderate drinkers

Alcohol self-administration by nonhumans and alcoholic humans decreases as the response requirement to obtain the drug increases. Also, increases in dose or concentration of alcohol, increase consumption up to a maximum in these populations, after which further increases in dose decrease intake. In the present study, the effects of response cost and dose on alcohol self-administration were investigated in moderate drinkers (12-45 drinks/week). Three male volunteers self-administered alcohol (commercial beer) during 2h sessions twice weekly. Alcohol was available under a fixed-ratio (FR) schedule of reinforcement. Response requirement (FR100-1600) and dose (2 and 4oz of beer) were varied separately across sessions using a within-subjects design. As response cost increased, consumption and overall rates of responding generally changed in an inverted U-shaped manner. Maximal consumption was observed at the 4oz dose. These orderly relations between response cost, dose and alcohol self-administration extend prior findings in nonhumans and alcoholics to moderate drinkers. Such consistencies support a position that a common set of variables control alcohol self-administration across these populations.     

Construction,quality assurance and calibration of spherical isotropic fibre optic light diffusers

Spherical isotropic fibre optic light diffusers are used in photodynamic therapy either as a light source or as a light detector. The construction of light diffusers using different materials is described, viz. an optical method involving local polymerization of a dental fissure sealant, which is referred to as the Henderson method, and a second method using plastic or ceramic pre-fabricated spheres. Quality tests necessary for reliable clinical use are presented for the mechanical strength, output power and isotropy. The maximum pull-off force and blow-off output power for the different kinds of diffusers were determined. The calibration procedures are given for measurement of the output power and wavelength of the light emitted by a diffuser and for measurement of the fluence rate by a light-detecting diffuser, using a compact integrating sphere device. With all types of diffusers described, an isotropy can be obtained of better than ± 20% measured over a 320° angle for spheres as small as 1 mm. Larger ceramic diffusers are particularly suitable for delivering high output powers. A 3-mm-diameter ceramic diffuser mounted on a 600-m-core fibre can emit up to 5 W of continuous wave (CW) visible light in air. Diffusers used for light detection can measure the light fluence rate in tissue with 15% accuracy or better if calibration factors are determined for each individual probe.     

Medicaid and state health care reform: process, programs, and policy options

Health care reform is a continuously evolving process. The States and the Federal Government have struggled with policy issues to combat escalating Medicaid expenditures while ensuring access and quality of care to an ever-expanding population. In the absence of national health care reform, States are increasingly relying on Federal waivers to develop innovative approaches to address a myriad of issues associated with the present health care delivery system. This article provides a summary of State health care reform efforts that have been initiated under Federal waiver authority.     

The vibratory innocent heart murmur in schoolchildren: A case-control Doppler echocardiographic study

Summary In 810 schoolchildren (aged 5–14 years) the prevalence of a grade 1–3/6 vibratory innocent heart murmur (VIHM) is 41%. Restricted to a grade 2 or 3 VIHM, the prevalence is 14%, decreasing from 21% in the age-class 5–6 years to 8% for children 13–14 years of age. The prevalence of a grade 3 VIHM is 1%. Together with a matched control, 84 children with a grade 2 or 3 VIHM underwent further cardiologic examination including electrocardiography, phonocardiography, and Doppler echocardiography. A positive correlation was found between the presence of a VIHM and higher left ventricular voltages on the ECG, but within the normal range; lower heart rate; smaller diameter of the ascending aorta (AAO); and higher blood flow velocity and higher maximal acceleration of the blood flow in the LVOT and the AAO. In 40% of the children with a VIHM, a systolic aortic valve vibration was seen with a frequency 100 Hz and an amplitude 1 mm, whereas this type of vibration was present in only one case control. No significant difference was found concerning the prevalence of false tendons in the left ventricle, systolic and diastolic diameter of the left ventricle, systolic time intervals, and shortening fraction of the left ventricle. The VIHM is strongly associated with a smaller AAO, with higher velocity and acceleration of the blood flow in the LVOT and AAO, and with a vibratory phenomenon of the aortic valve, pointing towards the LVOT-aortic valve region as the site of origin of the VIHM.     

Evaluations of primary metals from NHEXAS Arizona: distributions and preliminary exposures. National Human Exposure Assessment Survey.

NHEXAS AZ is a multimedia, multipathway exposure assessment survey designed to evaluate metals and other analytes. This paper reports the analyte-specific concentration distributions in each of the media examined (air, soil, house dust, food, beverage, and water), for various methodologies used (inductively coupled plasma-atomic emission spectroscopy and hydride generation-atomic absorption spectroscopy). Results are reported for the five primary metals (Pb, As, Cd, Cr, and Ni). Ingestion was the most important pathway of exposure. Metal concentrations in air were very low (ng/m3) and found only above the 90th percentile. Metals were commonly found in house dust and soil. Exposure transfer coefficients minimize the importance of this component for those over the age of 6 years. When ranked by exposure, food, beverage, and water appeared to be the primary contributors of metal exposure in NHEXAS AZ. For instance, at the 90th percentile, Pb was undetected in air, found at 131 and 118 microg/m3 in floor dust and soil, respectively, and measured at 16 microg/kg in food, 7.1 microg/kg in beverage, and 2.0 and 1.3 microg/l in drinking and tap water, respectively. We calculated preliminary estimates of total exposure (microg/day) for each participant and examined them independently by age, gender, and ethnicity as reported by the subjects in the NHEXAS questionnaire. At the 90th percentile for Pb, total exposures were 64 microg/day across all subjects (n=176); adult men (n=55) had the greatest exposure (73 microg/day) and children (n=35) the least (37 microg/day). Hispanics (n=54) had greater exposure to Pb (68 microg/day) than non-Hispanics (n=119; 50 microg/day), whereas non-Hispanics had greater exposure for all other metals reported. These results have implications related to environmental justice. The NHEXAS project provides information to make informed decisions for protecting and promoting appropriate public health policy.     

Cost-effectiveness of a post-exposure HIV chemoprophylaxis program for blood exposures in health care workers.

We performed a cost-effectiveness analysis of a post-exposure chemoprophylaxis program for health care workers who sustained exposures to blood. We analyzed a program of (1) treatment with zidovudine alone versus no treatment and (2) treatment with three-drug therapy versus no treatment. Assuming that 35% of exposures were to HIV-positive sources, the zidovudine regimen prevented 53 HIV seroconversions per 100,000 exposures, at a societal cost of $2.0 million per case of HIV prevented. The cost per quality-adjusted life year saved was $175,222. A three-drug chemoprophylactic therapy program (postulating 100% effectiveness and 35% source HIV positivity), prevented 66 seroconversions per 100,000 exposures, at a cost of $2.1 million per case of HIV prevented and $190,392 per quality-adjusted life year saved. Treating sources known to be HIV-positive and treating severe exposures were the most cost-effective strategies.