Biomedical subjects
W B Greenough
Publications and source records attributed to W B Greenough.
Pitfalls of computerized literature searches.
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Plasma specific gravity for identifying hypovolaemia.
To define ranges of plasma specific gravity useful for identifying volume depletion in older adults, plasma specific gravity was measured in 170 young adults (mean age 28 years) and 100 retirees (mean age 81 years), and ranges of values likely to be associated with volume depletion were defined. Subsequently, measurements of plasma specific gravity were made in 68 older emergency room (ER) patients (mean age 74 years), a few of whom had obvious reasons for being hypovolaemic, e.g. dehydrating diarrhoea, and these results were compared to those for the control groups. Ranges for plasma specific gravity useful for identifying volume depletion were designated as possible hypovolaemia (1.0265-1.0279), probable hypovolaemia (1.0280-1.0294), and hypovolaemia (> or = 1.0295). Using these definitions, there were more older ER patients compared to both young and old control group subjects, respectively, with probable hypovolaemia (21% vs. 5% and 8%; p < 0.03) and hypovolaemia (16% vs. 0% and 0%; p < 0.03). This study establishes ranges for plasma specific gravity for young and old adults likely to be associated with hypovolaemia, and shows that based upon measurement of plasma specific gravity, older ER patients may often be hypovolemic even in the absence of obvious fluid-wasting illnesses. Future studies are needed to identify the risk factors for hypovolaemia in ER patients, and more vigorously substantiate the findings of this study.
Rice oral rehydration solution hastens recovery from dysentery.
Using a three-cell study design over two years, we assessed the efficacy of rice ORS (R-ORS) for home management of dysentery in rural Bangladesh involving 1,911 children of less than five years of age who were matched for socioeconomic status, morbidity, nutrition and other factors. Dysentery was defined as passing blood and/or mucus in the stool, and the total numbers of episodes studies were: 1472, 1335, and 1557 in the R-ORS, glucose ORS (G-ORS), and comparison areas respectively. Packaged R-ORS and G-ORS were supplied free of cost. The comparison area continued the usual treatment of dysentery as practised in the community. During the two-year period, weekly observations were made in all areas on the incidence, management, and outcome of all episodes of dysentery. We demonstrated that the use of R-ORS was associated with reduction in duration and a lower incidence of prolonged diarrhoea compared to treatment with G-ORS or drugs. The mean durations of dysenteric diarrhoea were 7.6 +/- 4.9, 10.1 +/- 6.3, and 14.0 +/- 8.0 days in the R-ORS, G-ORS, and comparison areas respectively. Similarly, the cumulative recovery rates on day 7 of the illness were 61%, 42% and 21% in R-ORS, G-ORS, and comparison areas respectively. Based on these observations, we conclude that R-ORS may be an effective treatment of dysentery and deserves further investigation.
Fever in the nursing home resident.
Body temperature is a convenient and objective indicator of the body's physiologic state. Typical and atypical febrile responses are discussed and their sources reviewed. Diagnosis, treatment, and prevention of fever in nursing home patients are highlighted.
A simple solution: curing diarrhea.
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Approach to acute diarrhea in the elderly.
Diarrhea is a common problem among the elderly that can have catastrophic results. Atherosclerosis predisposes older adults to morbid sequelae from dehydration resulting from diarrhea. Deaths related to diarrheal illnesses are recognized among older adults living in the community as well as among those confined to nursing homes. Outbreaks have most often been associated with excess deaths from diarrhea among nursing-home patients. Although most cases of dehydration from diarrhea result from gastrointestinal infections, noninfectious causes of diarrhea related to prescription of laxatives, side effects of medications, and use of enteral feedings are common. Clostridium difficile infection is particularly common among older adults in hospitals and nursing homes, and relapsing disease in these groups may be more frequent than among younger adults. The approach to an elderly patient with diarrhea is to ensure proper hydration using available oral rehydration solutions, proceed with diagnostic tests likely to yield a positive result, avoid the use of harmful antiperistaltic drugs, and provide adequate follow-up of the nutritional state.
Rice based oral rehydration solutions.
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Impact of vitamin A supplementation on the incidence of infection in elderly nursing-home residents: a randomized controlled trial.
The aim of this study was to determine if vitamin A supplementation reduces the incidence of bacterial infections among elderly nursing-home residents. One hundred and nine patients were enrolled into a double-masked, placebo-controlled trial at an academically affiliated nursing home. Fifty-six patients received a single capsule containing 1,000 IU of vitamin A (placebo) and 53 received a single capsule containing 200,000 IU of vitamin A. Antibiotic-treated infections were enumerated for 90 days after dosing and infection rates were expressed per 1000 days of follow-up. There were 42 antibiotic-treated infections altogether, 21 in each group. The infection rates in the vitamin A and placebo groups were 4.7 and 4.3 per 1,000 days of follow-up, respectively (relative risk 1.1; 95% CI 0.6, 2.0). The findings of this study do not support a role for vitamin A supplements for the prevention of infections among frail elderly nursing-home patients.
Methicillin-resistant Staphylococcus aureus colonization in a long-term-care facility.
OBJECTIVE: To study the prevalence and risk factors for colonization with MRSA at a long-term-care facility. DESIGN: Cross-sectional surveillance culture survey. SETTING: A 233-bed university-affiliated long-term-care facility. MEASUREMENTS: Surveillance cultures for MRSA were performed on patients of two adjacent nursing units and on new admissions to the entire facility over a 4-month period. RESULTS: On the chronic medical unit, where patients known to be colonized had been cohorted, 20 of 38 (52.6%) were colonized vs 3 of 67 (4.5%) on the skilled/intermediate unit (P less than 0.001), suggesting that little intra-facility spread of MRSA occurs. Twenty-four of 55 (43.6%) chronic medical admissions were colonized vs 6 of 63 (9.5%) admitted to the other units (P less than 0.001). Thirteen of 30 (43.3%) admissions were not previously known to be colonized. By univariate analysis, colonized admissions were younger and more often male; had more listed diagnoses, including pressure sores, a previous positive MRSA culture, and urinary incontinence; were more often fed by feeding tube; and had longer durations of hospital stay prior to admission. Logistic regression analysis showed that the most powerful independent predictors of colonization at admission were: a prior positive culture for MRSA (OR 8.8, 95% CI 2.4, 32.4), male sex (OR 8.2, 95% CI 2.3, 29.7), urinary incontinence (OR 3.8, 95% CI 1.4, 10.4), and presence of pressure sores (OR 2.9, 95% CI 0.9, 9.2). CONCLUSIONS: Unrecognized colonization of nursing home residents with MRSA is common, and nursing homes are unwittingly repositories for patients colonized with MRSA following acute hospitalization. Gloving and careful attention to handwashing may limit spread of MRSA within nursing homes, and identification of colonized patients may be facilitated by targeted surveillance cultures of the most debilitated patients at admission.
Colonisation with digoxin-reducing strains of Eubacterium lentum and Clostridium difficile infection in nursing home patients.
Stool specimens obtained from 77 residents of a nursing home were analysed to determine the relationship between colonisation with digoxin-reducing strains of Eubacterium lentum and infection with Clostridium difficile. Patients were categorised according to previous antibiotic treatment, prescription of enteral feedings, and pattern of bowel habits. Colonisation with digoxin-reducing E. lentum was less common in subjects infected with C. difficile, in those treated with antibiotics previously, and in those prescribed enteral feedings. Normal bowel habits were more common in those without C. difficile. The lowest incidence of diarrhoea was seen in patients without C. difficile who were colonised with digoxin-reducing species. This study establishes an inverse relationship between the presence of C. difficile and E. lentum that reduce digoxin which is related to previous treatment with antibiotics and prescription of enteral feedings. Bacterial markers may prove to be a useful tool for predicting clinical disturbances in bowel function.
Oral rehydration therapy: a global perspective.
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Cereal-based oral rehydration therapy. I. Clinical studies.
Studies of "improved" oral rehydration solutions, in which glucose polymers (starch) derived from rice or other cereals were added to improve cotransport of sodium and to promote sodium and water absorption, have been reported. These solutions were administered to decrease diarrhea volume and duration, reduce vomiting, and replace volume loss in stools. In clinical trials of children and adults with high-output diarrhea, such as in cases of cholera, the use of cereal-based oral rehydration solutions (ORS) compared with glucose-based ORS produced significant (20% to 53%) reductions in stool volumes. In one study the duration of diarrhea was shortened by 30%. In noncholera diarrhea in children, cereal-based ORS was as effective as glucose-based ORS. Although the amino acid transport systems were intact in patients with cholera, the addition of glycine to glucose-based or rice-based ORS did not reduce stool volume or duration of diarrhea. The exception was alanine, which reduced stool output and ORS requirements. More research is needed to determine the optimal mix of starch, amino acids, oligopeptides, and proteins that would utilize the absorptive active transport systems maximally to reduce fluid losses and duration of diarrhea.
Cereal-based oral rehydration therapy. II. Strategic issues for its implementation in national diarrheal disease control programs.
Field studies in Bangladesh demonstrated that after proper training, village mothers were able to prepare and use rice-based, salt-enriched oral rehydration solutions containing safe concentrations of sodium, and were capable of achieving significantly fewer treatment failures and a reduction in the duration of diarrhea than with glucose-based oral rehydration solutions (ORS). An additional longitudinal study showed that improved growth and weight gain occurred with the consistent use of ORS; the effect was greater when rice-based ORS were used. In addition, the following possible limitations and benefits of cereal-based oral rehydration therapy, which are relevant to the strategies for its implementation in national diarrheal disease control programs, are discussed: safety, osmolarity, hypernatremia, spoiling, effectiveness, rehydration ability, reduction in diarrhea volume and duration, nutritional effects, effect on food intake, acceptance and usage by care givers, training of health workers, self-reliance of families, effect on other child survival activities, costs, potential problems in changing to cereal-based ORS, and the role of industrial production in packaged cereal-based ORS.
Progress in oral rehydration therapy.
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Treatment of the dehydrated child.
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Can vitamin D deficiency produce an unusual pain syndrome?
An unusual pain occurred in five patients in the presence of compromised vitamin D status and resolved 5 to 7 days after supplementation with vitamin D in the form of ergocalciferol. The pain had a hyperesthetic quality and did not respond to the use of analgesics, including opiate derivatives. Treatment with therapeutic levels of a tricyclic antidepressant did not bring relief of symptoms. In one case, months after treatment and subsequent improvement of vitamin D status and pain, the vitamin D status again declined and the pain recurred. The pain again resolved with vitamin D replacement and improvement of levels. There may be a pain syndrome associated with vitamin D depletion that appears as hyperesthesia worsened by light, superficial pressure or even small increments of movement. This pain restricts mobility and function and may lead to further complications, such as pressure sores.
Postantibiotic colonization with Clostridium difficile in nursing home patients.
Clostridium difficile causes pseudomembranous colitis and is responsible for 20% to 25% of cases of postantibiotic diarrhea. In an earlier study, nursing-home patients with C. difficile infection were noted to have a high mortality rate. Because most of these infected patients had been treated with antibiotics, it was not clear whether this high mortality rate was associated with C. difficile infection or simply with antibiotic treatment. A prospective study was carried out to determine the rate of postantibiotic C. difficile colonization and risk factors for infection in patients in a 233-bed long-term care facility, as well as to determine whether C. difficile infection is associated with increased mortality. During a six-month period 150 courses of antibiotics were prescribed for 108 patients. Stool specimens were collected from 36 (33%) patients following the first course of antibiotic treatment, and 12 (33%) were infected with C. difficile. Risk factors for infection included ward location and stool incontinence. Age, body-mass index less than or equal to 18 kg/m2, and diagnoses of dementia and pressure scores tended to be associated with infection, but not significantly. Early mortality rates did not differ, but 12-month mortality for the infected patients was higher (83% vs 50%, P = .05). Therefore, we conclude that postantibiotic C. difficile infection serves as a marker of death in nursing-home patients, one that can be differentiated from the risk of antibiotic treatment alone. This increased death rate may be related in part to clinically unrecognized pseudomembranous colitis or, alternatively, to absorption of C. difficile toxins or even endotoxin from the gut lumen into the systemic circulation.