A randomised study of outcomes in a defined group of acutely ill elderly patients managed in a geriatric assessment unit or a general medical unit

The aim of this study was to identify differences in the medical management and clinical outcome in a group of elderly patients admitted to a designated geriatric assessment unit (GAU) or to two general medical units (GMUs). A prospective randomised controlled trial was undertaken in 267 patients aged 70 years and over (mean age = 78.3 years). Following discharge from hospital, patients were followed up at three monthly intervals for a total of 12 months. At the time of discharge, no significant differences were found in inpatient management, length of stay, mortality rates, discharge rates to institutional care or utilisation of community services in patients admitted to the GAU and the GMUs. Similarly, no significant differences were found at three, six, nine, and 12 month follow up in case fatality, activities of daily living indices, mental health status, rates of institutional referral and the level of community service support in patients admitted to the GAU and the GMUs studied. These findings do not show any advantage for the unselected 70 + acutely ill elderly patient who is admitted to a designated geriatric assessment unit rather than to a general medical unit. Therefore, an admission policy to GAU, based solely on age 70 + is medically inappropriate and cost-inefficient. Evidence from other sources suggests that an age cohort of acutely admitted patients beyond 80 years may well have returned more optimistic findings for the GAU. In future, GAUs will require a more selective admission policy to maximise the benefits of their rehabilitative and interdisciplinary approach. (Aust NZ J Med 1991; 21: 230–234.)     

Correlates of carotid artery stiffness in young adults: The Bogalusa Heart Study

Decreased arterial elasticity, an independent risk factor for cardiovascular (C-V) disease, is associated with C-V risk factors in middle-aged and older individuals. However, information is limited in this regard in young adults. This aspect was examined in a community-based sample of 516 black and white subjects aged 25-38 years (71% white, 39% male). The common carotid artery elasticity was measured from M-mode ultrasonography as Peterson's elastic modulus (Ep) and relative wall thickness-adjusted Young's elastic modulus (YEM). Blacks and males had higher Ep (P < 0.05); males had higher YEM (P < 0.0001); and blacks had higher wall thickness (P < 0.01). For the entire sample adjusted for race and gender both Ep and YEM correlated significantly (P < 0.05-0.0001) with age, BMI, waist, systolic and diastolic blood pressures, heart rate, product of heart rate and pulse pressure, triglycerides, total cholesterol to HDL cholesterol ratio, insulin and glucose. In a multivariate regression model that included hemodynamic variables, systolic blood pressure, product of heart rate and pulse pressure, age, triglycerides, BMI, and male gender (for YEM only) were independent correlates of Ep (R2 = 0.38) and YEM (R2 = 0.25). When the hemodynamic variables were excluded from the model, age, triglycerides, BMI, black race (Ep only), male gender, parental history of hypertension, HDL cholesterol (inverse association), and insulin (marginal significance) remained independent correlates of Ep (R2 = 0.20) and YEM (R2 = 16). Both Ep and YEM increased (P for trend P < 0.0001) with increasing number of independent continuous risk factors (defined as values above or below the age, race, and gender-specific extreme quintiles) that were retained in the regression models. The observed increasing arterial stiffness (or decreased elasticity) with increasing number of risk factors related to insulin resistance syndrome in free-living, asymptomatic young adults has important implications for prevention.     

An ovine model of maternal iron poisoning in pregnancy

An ovine model of maternal iron poisoning in pregnancy was used to examine the placental transport of deferoxamine and ferrioxamine and to follow maternal and fetal serum iron concentrations when maternal serum iron levels exceeded total iron-binding capacity. Ewes in the third stage of gestation underwent hysterotomy and delivery of the fetal head through an abdominal incision while under ketamine and halothane anesthesia. The fetal external jugular vein was catheterized for sampling of venous blood while the fetus remained in utero. Administration of deferoxamine mesylate or ferrioxamine mesylate IV to ewes was not accompanied by measurable deferoxamine or ferrioxamine in fetal blood. In a final experiment, four gravid ewes in a control group received 2 mg/kg maternal body wt iron IV over 60 minutes. An experimental group comprising another four ewes received similar doses of iron but then received 50 mg/kg deferoxamine mesylate IV over 15 minutes. Control and deferoxamine ewes reached similar peak maternal serum iron concentrations (2,479 +/- 266 and 2,121 +/- 343 micrograms/dL, respectively). The markedly elevated maternal serum iron concentrations were not accompanied by meaningful elevations in fetal serum iron levels over baseline values. Maternal deferoxamine infusion resulted in a more rapid fall in maternal serum iron concentrations but had no effect on fetal serum iron levels. The ovine fetus appears to be protected from elevated maternal serum iron concentrations in the last trimester of pregnancy. It could not be demonstrated that meaningful quantities of deferoxamine or ferrioxamine cross the placenta in the last trimester.(ABSTRACT TRUNCATED AT 250 WORDS)     

Does mindfulness improve outcomes in patients with chronic pain? Systematic review and meta-analysis

Background

Chronic pain and its associated distress and disability are common reasons for seeking medical help. Patients with chronic pain use primary healthcare services five times more than the rest of the population. Mindfulness has become an increasingly popular self-management technique.

Aim

To assess the effectiveness of mindfulness-based interventions for patients with chronic pain.

Design and setting

Systematic review and meta-analysis including randomised controlled trials of mindfulness-based interventions for chronic pain. There was no restriction to study site or setting.

Method

The databases MEDLINE^®, Embase, AMED, CINAHL, PsycINFO, and Index to Theses were searched. Titles, abstracts, and full texts were screened iteratively against inclusion criteria of: randomised controlled trials of mindfulness-based intervention; patients with non-malignant chronic pain; and economic, clinical, or humanistic outcome reported. Included studies were assessed with the Yates Quality Rating Scale. Meta-analysis was conducted.

Results

Eleven studies were included. Chronic pain conditions included: fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, failed back surgery syndrome, and mixed aetiology. Papers were of mixed methodological quality. Main outcomes reported were pain intensity, depression, physical functioning, quality of life, pain acceptance, and mindfulness. Economic outcomes were rarely reported. Meta-analysis effect sizes for clinical outcomes ranged from 0.12 (95% confidence interval [CI] = −0.05 to 0.30) (depression) to 1.32 (95% CI = −1.19 to 3.82) (sleep quality), and for humanistic outcomes 0.03 (95% CI = −0.66 to 0.72) (mindfulness) to 1.58 (95% CI = −0.57 to 3.74) (pain acceptance). Studies with active, compared with inactive, control groups showed smaller effects.

Conclusion

There is limited evidence for effectiveness of mindfulness-based interventions for patients with chronic pain. Better-quality studies are required.     

Colorectal cancer in patients under close colonoscopic surveillance

BACKGROUND & AIMS: Colonoscopic polypectomy is considered effective for preventing colorectal cancer (CRC), but the incidence of cancer in patients under colonoscopic surveillance has rarely been investigated. We determined the incidence of CRC in patients under colonoscopic surveillance and examined the circumstances and risk factors for CRC and adenoma with high-grade dysplasia. METHODS: Patients were drawn from 3 adenoma chemoprevention trials. All underwent baseline colonoscopy with removal of at least one adenoma and were deemed free of remaining lesions. We identified patients subsequently diagnosed with invasive cancer or adenoma with high-grade dysplasia. The timing, location, and outcome of all cases of cancer and high-grade dysplasia identified are described and risks associated with their development explored. RESULTS: CRC was diagnosed in 19 of the 2915 patients over a mean follow-up of 3.7 years (incidence, 1.74 cancers/1000 person-years). The cancers were located in all regions of the colon; 10 were at or proximal to the hepatic flexure. Although most of the cancers (84%) were of early stage, 2 participants died of CRC. Seven patients were diagnosed with adenoma with high-grade dysplasia during follow-up. Older patients and those with a history of more adenomas were at higher risk of being diagnosed with invasive cancer or adenoma with high-grade dysplasia. CONCLUSIONS: CRC is diagnosed in a clinically important proportion of patients following complete colonoscopy and polypectomy. More precise and representative estimates of CRC incidence and death among patients undergoing surveillance examinations are needed.     

Stress, social support and problem drinking among women in poverty

AIMS: Previous studies have found that stress contributes to problem drinking, while social support can buffer its effects. However, these studies are confined largely to middle-class and general populations. We extend what is known by examining how the unique stressors and forms of social support experienced by women in poverty impact alcohol problems over a 4-year time-period. DESIGN, SETTING AND PARTICIPANTS: This prospective study used generalized estimating equations (GEE) transition modeling and four annual waves of survey data from 392 American mothers receiving Temporary Assistance for Needy Families (TANF) in a large Northern California county. MEASUREMENTS: We examined the effects of neighborhood disorder, stressful life events and economic hardship on psychological distress and problem drinking over time, and whether social support moderated these relationships for women in poverty. FINDINGS: Neighborhood disorder and stressful life events increased significantly the risk for problem drinking, largely through their effect on psychological distress. We found little evidence, however, that social support buffers poor women from the effects of these stressors. CONCLUSIONS: Women in poverty are exposed to severe, chronic stressors within their communities and immediate social networks which increase vulnerability to psychological distress and problem drinking. The finding that social support does not buffer stress among these women may reflect their high level of exposure to stressors, as well as the hardships and scarce resources within their networks. If the 'private safety net' of the social network fails to provide a strong buffer, more effective environmental interventions that reduce exposure to stressors may be needed to prevent alcohol problems in poor women's lives.