Patterns and predictors of nursing home placement over 14 years: Dubbo study of elderly Australians

Objective: To describe patterns and predictors of nursing home placement. Methods: This is a longitudinal study of an elderly cohort living in Dubbo, New South Wales, Australia. A total of 1233 men and 1572 women aged 60 years and older living in the community were examined in 1988 and followed for 14 years. The incidence of nursing home placement and underlying clinical diagnoses were assessed. Results were modelled for baseline predictors of placement using Cox proportional hazards regression. Results: From 2805 subjects in the study there were 244 (8.7%) nursing home placements, 95 in men (7.7%) and 149 in women (9.5%). A total of 44% placements were primarily due to dementia, but dementia was a secondary diagnosis in another 20% of cases. The other principal diagnoses were stroke (16%) and coronary heart disease (14%). Median time to death in a nursing home was 10.5 months in men and 9.0 months in women. In a Cox proportional hazards model using baseline characteristics, the hazard of nursing home placement increased significantly with age (hazard ratio = 1.13), urinary incontinence (1.66), impaired peak expiratory flow (3.19), physical disability (1.59) and depression (1.85). The hazard of placement was significantly reduced by alcohol intake (0.55) and female gender (0.55). Socioeconomic factors were not significant. Conclusions: Dementia and disability‐related care burdens rather than other health conditions are the dominant causes of nursing home placement in an unselected elderly community. Risk factors such as incontinence, impaired respiratory function and depression have been identified and these are potentially amenable to intervention.     

IRON DEFICIENCY ANAEMIA IN GENERAL PRACTICE: PRESENTATIONS AND INVESTIGATIONS

Twenty-six patients over the age of 50 years with proven iron deficiency anaemia were identified, investigated and followed up in general practice over a five-year period. The anaemia was symptomatic in 50% of patients but only 20% had symptoms related to the gut. Faecal occult blood testing was positive in five patients only and negative tests occurred in three patients with significant disease, including one caecal carcinoma. All patients agreed to oesophagogastroduodenoscopy (OGD) and fibreoptic sigmoidoscopy carried out on the same occasion. In eight patients, significant abnormalities were found on OGD and in two patients on sigmoidoscopy. Four patients declined barium enema examinations, two of whom had significant OGD abnormalities. Barium enema examination of the other 22 patients showed polyposis of the colon and a caecal carcinoma and initially missed one carcinoma of the caecum which was found subsequently. The likelihood of finding significant disease in iron-deficient patients over 50 years of age is high and should be assumed to be due to blood loss into the gut. Investigation by OGD, sigmoidoscopy and barium enema in the first instance seems warranted and is a condition that can be safely managed by the GP. (Br J Clin Pract 1997; 51(2) : 78-80)     

Guinea pig MSEL-neurophysin. Sequence comparison of eight mammalian MSEL-neurophysins

The amino acid sequence of guinea pig MSEL-neurophysin has been determined using tryptic peptides derived from the performic acid-oxidized protein and staphylococcal proteinase peptides obtained from the reduced-carboxamidomethylated neur-ophysin. Guinea pig MSEL-neurophysin consists of a 93-residue polypeptide chain that shows 12 substitutions and 2 deletions when compared to bovine MSEL-neurophysin. It displays the highest number of variations among known mammalian MSEL-neurophysins. These variations are mainly found in the C-terminal region (residues 88–93). Moreover guinea pig MSEL-neurophysin, like rat homologous protein, exhibits substitutions in positions 2, 5, 29 and 81 and lacks an arginine in the penultimate position. Comparison between eight mammalian MSEL-neurophysins reveals a highly conserved region (residues 1 to 88) and a hypervariable region (residues 89 to 93/95). On the other hand the eight species examined are endowed with arginine vasopressin except pig, which has a lysine vasopressin. In the vasopressin-MSEL-neurophysin precursor, the hormonal moiety and the MSEL region of neurophysin (residues 1–9) are encoded by a common exon in ox, rat and man; it can be concluded that this exon is evolutionarily conservative in contrast to the one encoding the C-terminal region of MSEL-neurophysin.     

Patient suitability and outcome in short-term individual psychotherapy

The effects of short-term (time-limited), dynamically oriented individual therapy and the patient characteristic quality of object relations (QOR) were studied in a controlled clinical trial involving 8 experienced therapists and 144 psychiatric outpatients. A comprehensive set of outcome scores was monitored at 5-month intervals including a follow-up assessment. A strong treatment effect that was maintained at follow-up was found. The effect was evident in terms of statistical significance, effect size, and clinical significance. Evidence for an additive effect of the combination of treatment and QOR was also found. The best results were attained by high QOR therapy patients, and the worst results were attained by low QOR control patients. The results were suggestive of an optimal match between type of patient and type of therapy.     

Erythropoietin kinetics in rats: generation and clearance

Detailed studies to analyze the early events of erythropoietin (Ep) secretion and clearance were performed in a rat model using a double antibody radioimmunoassay. Ep clearance was determined following intravenous injection of 1 mL of Ep-rich plasma, 1,080 mU/mL, obtained from phlebotomized rats. Analysis revealed a disappearance curve that conformed to a two-compartment model with an alpha half-life t1/2 of 3.6 minutes and a beta t1/2 of 86 minutes. The volume of distribution was similar to the calculated plasma volume. In anephric animals, there was no change in the plasma clearance rate or the volume of distribution. Rapid Ep secretion was elicited by a single 15 mL/kg phlebotomy (hematocrit decrement 45% to 30%), so that levels reached 20 to 30 times baseline (524 +/- 76 v 24 +/- 7 mU/mL) at five hours, whereas they plateaued for at least 33 hours. The increase in the rate of secretion was geometric, from 9.9 mU/h baseline secretion to 429 mU/h. These data identify a very sensitive and rapidly responsive system for Ep modulation in the rat.     

Team management of dysphagia in the institutional setting

The capacity to swallow effectively and safely is a basic human need, yet nearly 40% of Americans over age 60 experience dysphagia. Since the resources in acute-care hospitals often are unavailable in institutional settings, the daily involvement of nursing and the dietitian's screening and continuous assessment are critical to timely, effective dysphagia identification, referral, and management. Upon referral, the speech pathologist executes comprehensive evaluation, leading the design and implementation of a team treatment plan. Literature highlighting a sample of dysphagia screening tools and interventions, care transitions and aspiration prevention strategies is reviewed herein to guide current practice and future research.     

tcaA inactivation increases glycopeptide resistance in Staphylococcus aureus

The experimental deletion of the tcaRAB region has been shown to increase teicoplanin resistance in Staphylococcus aureus. By sequential genetic complementation of a tcaRAB mutant, we identified tcaA as the key gene within tcaRAB that is responsible for changes in glycopeptide resistance levels. Northern blot analysis of the tcaRAB region showed that the tcaA gene is expressed only weakly over the growth cycle and is strongly inducible by teicoplanin. Among some clinical isolates tested, glycopeptide-intermediate-resistant (GISA) strains Michigan and SA137/93G were found to have truncated tcaA genes. While the former carries a nucleotide insertion that creates a premature stop codon, the latter was found to harbor an IS256 insertion. Complementation of these two GISA strains with a functional tcaA allele reduced their levels of teicoplanin and vancomycin resistance five- to eightfold and twofold, respectively. The data presented here indicate that inactivation of tcaA contributes to and plays a relevant role in glycopeptide resistance in S. aureus clinical isolates.