Nutrition and Health for Older Persons in Rural America: A Managed Care Model

Health care services and resources for older persons living in rural areas may be highly variable, and integrated service-delivery models are often lacking. This article presents a managed-care model of nutrition risk screening and intervention for older persons in rural areas. Nutrition risk screening was implemented by the Geisinger Health Care System, Danville, Pa, to target all eligible enrollees in a regional Medicare risk program. A single remote clinic site participating in the managed health care system was chosen for further study of a linked screening and case-management effort for undernourished persons. Screening and intervention at the clinic site selected for this study were guided by centralized expertise and resources. Individualized evaluation and intervention plans were developed with the aid of a dietitian and implemented by the clinic case manager. Of the 417 subjects who completed screening at the remote site, 68 met the risk criteria for undernutrition and were selected for case management. Many of the targeted persons received interventions that included evaluations by a physician or physician extender (eg, physician assistant, nurse practitioner) at the clinic and consultations with nutrition, mental health, or social services professionals. Twenty-six of the subjects who took part in the intervention completed a follow-up screening 6 months later. Ten of those persons no longer exhibited risk criteria. This demonstrates the feasibility of a linked screening and case management program for nutrition risk in the managed-care setting. J Am Diet Assoc. 1997; 97: 885-888.     

Use of omeprazole in Zollinger-Ellison syndrome: a prospective nine-year study of efficacy and safety

H⁺, K⁺-ATPase inhibitors such as omeprazole are the antisecretory agents of choice for the management of gastric acid hypersecretory states, including the Zollinger-Ellison syndrome. However, long-term follow-up data on the overall efficacy and safety of these agents in large numbers of patients are lacking. In the current study we examined the long-term efficacy and safety of omeprazole in 116 patients with Zollinger-Ellison syndrome treated with oral omeprazole at a single centre for up to 114 months (mean ± S.E.M. = 38 ± 3 months). The initial omeprazole maintenance dose was established according to the acute upward dose titration method in 89/116 patients (77%). Gastric acid output was effectively controlled using 60 mg of omeprazole once daily in 41/89 patients (46%) and 22/89 patients (25 %) required twice daily omeprazole therapy. The mean ranitidine equivalent dose for patients who required 60 mg omeprazole once daily (2.5 ± 0.2 g/day) was significantly lower than the mean ranitidine equivalent dose for patients who required more than 60 mg omeprazole once daily (4.3 ± 0.3 g/day). Long-term omeprazole maintenance therapy was discontinued in 36/116 patients (31%) but in no cases was discontinuation due either to drug-induced side-effects or uncontrolled gastric acid output. Fasting serum gastrin levels were significantly elevated above pre-treatment levels at only one time point during follow-up and were likely due to tumour growth rather than a drug effect. The final long-term omeprazole maintenance doses were lower than the initial doses but correlated closely with the preomeprazole basal acid output (r= 0.41, P < 0.001) and ranitidine equivalent dose requirements (r= 0.49, P < 0.001). We conclude that omeprazole effectively and safely controls gastric acid hypersecretion in all patients with Zollinger-Ellison syndrome for up to nine years without evidence by tachyphylaxis.     

The effect of naloxone on the preoperative gastric volume and pH

The effect of 4 mg oral naloxone on preoperative gastric volume and pH of gastric aspirate was studied in a double-blind, randomized study. Twenty patients received 10 ml of naloxone (4 mg) mixed with 10 ml of orange juice, and 20 patients received 10 ml of isotonic saline mixed with 10 ml of orange juice, 2 h before surgery. Gastric content was obtained immediately after intubation of the trachea. No significant difference in gastric volume and pH of gastric aspirate was found between the two groups. It is concluded that naloxone does not affect gastric emptying and gastric acid secretion to a degree great enough to protect against aspiration of gastric contents into the lungs.     

ACCURACY OF 94 ANAESTHETIC AGENT VAPORIZERS IN CLINICAL USE

Using the Brüel & Kjæ Anaesthetic Gas Monitortype 1304, we have monitored the output of 94 anaesthetic agentvaporizers (Fluotec 3: 58, Enfluratec 3: 24, Isotec 3. 12),in seven departments of anaesthesia, at different dial settingsand flow rates. The range of output, for one type of vaporizerand dial setting (flow: 6 litre min^–1 was largest withthe Fluotec 3 (0.85–1.55% when dial set to 1%) and smallestwith the Isotec 3 (0.85–1.15% when dial set to 1 %). Indetermining the number of vaporizers with unacceptable inaccuracy,we applied acceptance limits of ± 15% relative on eachvaporizer and each dial setting. Using a flow of oxygen 6 litremin^–1 17% of Fluotec 3, 8% of Isotec 3 and 71 % of Enfluratec3 vaporizers had outputs outside those limits. Even when somespecific conditions (vaporizers giving output beyond the limitsat any two or more dial settings; output beyond the limits inthe clinically relevant range (0.5–2%)) were added, asubstantial number of vaporizers did not perform within thelimits. We found a significantly greater accuracy of the vaporizersafter 3-monthly calibration checks (P < 0.05) compared withvaporizers undergoing service and calibration only annually.Using a questionnaire, we found that fewer than 30% of the anaesthetistsusing the vaporizers would accept aberrance be yond ±10% relative of the dial setting. (Br. J. Anaesth. 1993; 71:453–457)      

Autoimmune reactions in patients with M-component and peripheral neuropathy.

A study of 17 patients with autoimmune axonal or demyelinating peripheral neuropathy in combination with M-component is described. The M-component was associated with MGUS (monoclonal gammopathy of undetermined significance) in 12 patients, CLL in one patient, WaldenstrÖm's disease in one patient, and myeloma in three patients. Immunohistological examination with direct and indirect fluorescence showed binding of antibodies to nerve structures of the same class and light chain as seen in the M-component. In five cases of IgM M-component, the demyelinating neuropathy was caused by binding of the IgM M-protein and complement C3b to myelin-associated glycoproteins (MAG). In 12 cases with axonal neuropathy, binding of IgG to the connective tissue of the peri- and endoneurium was found in 50% of cases, IgM in five cases, and IgD in one case. None of the patients had central nervous system (CNS) symptoms. The clinical and therapeutic difficulties are discussed; only two patients with an acute course responded to immunosuppression. A marked co-expression of other autoimmune phenomena is interpreted in the light of cross-reactions between the autoantibody and similar tissue autoantigens.     

Implantation of Active Can Implantable Defibrillators in the right Pectoral Region

Routinely the active can ICD is placed in the left side pectoral position, which theoretically gives optimal conditions for a low defibrillation threshold. Some patients, bowever, demand a right pectoral position, which possibly could result in a bigger defibrillation threshold. A right pectoral position was used in 3 of 85 active can ICDs implanted in our institution from 1994. the DFT was 12 J in two and 18 f in one patient. Thus, right pectoral implantation is feasible and offers an alternative approach in selected patients.     

Expression of CD43 Epitopes on NK and T Cells

CD43 epitope expression was studied with a panel of monoclonal antibodies (MoAbs) by immuno-histochemistry on freeze sections of lymphoid tissues. The MoAb WEN3 stained most cells weakly in the T areas and scattered splenic red pulp cells strongly, whereas the other MoAbs strongly stained the majority of the cells in the T areas but gave variable staining patterns of cells in the non-T areas. Flow cytometry on CD4 + and CD8 + T cells (T4 and T8 cells), freshly isolated NK cells and LAK cells showed distinct staining profiles for each cell type, with epitope expression patterns of T8 cells lying between those of T4 cells and NK/LAK cells. T8 cells were split by one of the MoAbs, the NK cells, but not LAK cells, were split by two other MoAbs.     

Toxicokinetics of Nickel in Mice Studied with the {gamma}-Emitting Isotope 57Ni

The -emitting isotope ⁵⁷Ni was generated in a cyclotron to allowwhole-body counting of laboratory animals dosed with nickel.⁵⁷NiCl₂ was administered either orally by gastric intubationor by intraperitoneal injection to groups of mice in doses equivalentto the average human daily dietary nickel intake per mass unit.When given orally, the whole-body retention (WBR) was 0.02–0.36%of the administered dose at 45–75 hr. When given intraperitoneally,the WBR was 1–6% at 20–50 hr. After adjustment forthe rapid excretion of systemic nickel, the intestinal absorptioncould be estimated to be 1.7–10%. The relative WBR didnot vary with the magnitude of the dose within 0.05–5µmol Ni/kg given orally or 0.005–0.5 µmol/kggiven intraperitoneally. At 8 hr, the tissue concentration washighest in the kidneys, followed by the carcass, lungs, testicles,liver, and the spleen. After 20 hr, the highest concentrationswere still found in the kidneys followed by the lungs, the liver,and the carcass. At 20 hr after oral administration, 50–70%of ⁵⁷Ni retained in the body was within the carcass. The secondhighest nickel content was found in the kidneys, followed bythe liver and lungs. Whereas nickel in the kidneys was rapidlyexcreted, the elimination from the lungs and liver was relativelyslow, thereby, after 40 hr, resulting in a higher nickel contentin the liver than that in the kidneys. When nickel was givenintraperitoneally, practically no nickel was transported viathe portal vein to the liver after 20 hr, resulting in a lownickel content in the liver and a higher content in the kidney.These results document that the use of ⁵⁷Ni for studies on nickeltoxicokinetics is feasible and useful, and that the method isespecially well suited for comparative studies with a durationof up to 6 days.