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PubMed1983

Pediatric nursing homes. Implications of the Massachusetts experience for residential care of multiply handicapped children.

Pediatric nursing homes were established in Massachusetts in 1971, in response to the crisis created by the deinstitutionalization of children with multiple severe handicaps for whom care in the community was unrealistic. Although these residential beds provided short-term relief for the system, failure both to plan for the improved long-term survival of the children and to develop alternative community services for those whose functional and medical status changed has left fundamental problems unresolved. A review of the 421 residents of pediatric nursing homes since 1972 shows that most have been bedridden and nonverbal, requiring provision of basic care: feeding, dressing, maintaining hygiene, and sensory and motor stimulation. Three quarters of the residents were severely or profoundly retarded and had seizures. About 4 per cent died each year, and another 5 per cent were discharged; few beds were available for new admissions. Low standards of care and financial disincentives have resulted in less than optimal educational and rehabilitative services. Other states are facing similar problems, which can be resolved only through better funding and coordination of the relevant state agencies.

Certification↗
PubMed1994

Hallucinations and ifosfamide-induced neurotoxicity.

BACKGROUND: Hallucinations as a symptom of central neurotoxicity are a known but poorly described side effect of ifosfamide. Most cases of ifosfamide-induced hallucinations have been reported with other mental status changes. METHODS: The authors interviewed six persons with ifosfamide-induced hallucinations in the presence of a clear sensorium. All patients were receiving high-dose ifosfamide as part of their bone marrow transplant procedure. RESULTS: Hallucinations occurred only when the patient's eyes were closed and, in all but one case, were reported as disturbing or frightening. Underreporting of these hallucinations by patients is likely. CONCLUSIONS: Hallucinations may be the sole or first manifestation of neurotoxicity. The incidence may be dose and infusion-time related. The clinician should be alerted for possible ifosfamide-induced hallucinations, which may occur without other signs of neurotoxicity. "Eyes-closed" hallucinatory experiences appear to be an unusual feature of this presentation. Patients anxious about this experience respond well to support and education about this occurrence. Optimal pharmacologic management of disturbed patients is unclear. If agitation becomes marked, high-potency neuroleptics (i.e., haloperidol) may be effective.

Adult↗
PubMedDate not supplied

The lived experience of having a pressure ulcer: a qualitative analysis.

In this descriptive, qualitative, phenomenological study, the researchers explored the phenomena of the lived experience of having a pressure ulcer to determine the essential structure of the experience. The sample included 8 respondents: 4 individuals who currently had a pressure ulcer and 4 who previously had a pressure ulcer that had healed. Four respondents also had a spinal cord injury and 5 had surgical flap reconstruction. Respondents were asked to reflect and reply to the following statements: "Please describe your experience of having a pressure ulcer. Share all the thoughts, perceptions, and feelings you can recall until you have no more to say about this experience." From verbatim transcriptions of interviews, 7 themes evolved with related sub-themes. The themes that emerged were (1) perceived etiology of the pressure ulcer; (2) life impact and changes; (3) psychospiritual impact; (4) extreme painfulness associated with the pressure ulcer; (5) need for knowledge and understanding; (6) need for and effect of numerous, stressful treatments; and (7) the grieving process. In this paper, the essential nature of the experience of living with a pressure ulcer is presented. Pressure ulcers had a profound impact upon the subjects' lives, including physical, social, and financial status; change of body image; and/or loss of independence and control. Those with a Stage IV pressure ulcer and flap repair and/or those with a spinal cord injury experienced the grieving process in some form. Although the experience of having a pressure ulcer has similarities for each individual, each experiences it in a unique manner. Patients with a pressure ulcer with or without a spinal cord injury have significant needs in learning to cope and live with their condition.

Adaptation, Psychological↗
PubMed1990

Cardiovascular response to gait training and ambulation in a hemiparetic heart recipient.

Little has been reported about the rehabilitation of heart recipients who experience disabling neurologic complications. This is of particular interest to physiatrists because the number of cardiac transplants is increasing and the cardiovascular response of the denervated heart to exercise is altered. The case reported here describes a 42-year-old woman who underwent heart transplantation for ischemic cardiomyopathy. One year after transplantation, the patient was hospitalized for evaluation of headaches and mental status changes. A lymphoma involving the left basal ganglia was diagnosed and the patient underwent a course of radiation therapy. She was transferred for rehabilitation of a left hemiparesis and made functional gains in mobility and self-care skills. Weekly recordings of heart rate and blood pressure were obtained before and after ambulation. Small increases in both heart rate and blood pressure were recorded after ambulation to the point of fatigue. In both parameters, the patient's maximum response was below that reported for nondisabled cardiac recipients, highlighting the need for symptom-oriented exercise guidelines in these patients.

Activities of Daily Living↗
PubMed1998

Neuroleptic malignant syndrome. Recognition, prevention and management.

Neuroleptic malignant syndrome (NMS) is a rare but potentially lethal form of drug-induced hyperthermia characterised by mental status changes, muscle rigidity, hyperthermia and autonomic dysfunction. Increased awareness and early recognition will lead to prompt management. The diagnosis of NMS presents a challenge because several medical conditions generate similar symptoms. The presentation and course of NMS can be quite variable ranging from a stormy and potentially fatal course to a relatively benign and self-limiting course. The most important aspect of treatment is prevention. This includes reducing risk factors (e.g. dehydration, agitation and exhaustion), early recognition of suspected cases and prompt discontinuation of the offending agent. All patients with psychosis should be monitored daily for dehydration and elevated temperature, have vital signs checked and agitation should be watched for. Antipsychotics should be used conservatively with gradual titration of doses. The management of NMS should be based on a hierarchy of symptom severity. Following an episode of NMS, the patient should be reassessed for further treatment with antipsychotics and rechallenge should not be attempted at least 2 weeks following resolution of symptoms of NMS. The patient and family should be educated about the episode and consent for further medication use obtained after a clear explanation of the risk-benefit analysis.

Catatonia↗
PubMed1993

Outcome of a multimodal treatment including intensive physical training of patients with chronic low back pain.

A comprehensive 4-week inpatient treatment including intensive physical training was evaluated in 194 chronic low back pain patients of whom 101 were working and 79 were on sick leave. Physical performance was assessed by measurements of spinal mobility, isometric trunk flexion and extension strength, and isokinetic lifting strength. Outcome was evaluated by a functional capacity index and work status changes reported at a 12-month follow-up. There was a 30-50% average increase in physical performance during treatment. At the 12-month follow-up the functional capacity index showed an average increase from 35.4 to 39.3 points (score range 24-48). At follow-up 28% of the sicklisted patients had returned to work and of those employed before treatment 14% were on sick leave. Associations between outcome and the improvement in physical measurements and their level at discharge were determined by stepwise multiple and logistic regression analyses. Among the physical measurements only increase in spinal mobility was associated with functional capacity index in women and return to work in both men and women at the 12-month follow-up. The overall results showed that intensive physical training and improved physical performance did not play crucial roles in the rehabilitation of chronic low back pain patients, at least when return to work was used as the outcome criterion.

Adult↗
PubMed1990

Geriatric nutrition.

The aging process alters body composition so that nutritional status changes as we get older. The aging process shows interindividual variability in its rate of development. Determinants of the rates of aging of systems and tissues are largely genetic. Premature aging of cells and tissues is due to genetic factors and to long-term exposure to physical or chemical environments that cause irreversible tissue damage. Whereas maximal lifespan is fixed for us all, individuals vary in life expectancy both because of variability in the risk of genetic disease which shortens life and because of variable capability for avoidance of those factors in our environment which cause early aging. Early aging as well as geriatric disease foreshorten life, but both can be prevented to some extent by diet or by diet and exercise. Diseases that can be nutritionally prevented, giving us a greater chance of achieving our genetically determined lifespans, include nutritional deficiency states and chronic diet-related diseases such as non-insulin-dependent diabetes, hypertension, coronary artery disease, and cancer. Disabilities resulting from these diseases and from degenerative arthritis are also subject to modulation by diet. The nutritional requirements of the elderly are mostly similar to those of younger people. Elderly usually need fewer calories and similar nutrient intakes compared with those of younger people. Elderly with higher needs for specific nutrients include homebound or institutionalized people who lack sunlight exposure and therefore require more vitamin D. Nutritional requirements to promote longer life expectancy and freedom from disabilities that result from chronic disease include restriction of food energy and fat. Nutritional assessment of the elderly is aimed at identifying not only the presence of deficiency states but also states of nutrient excess and chronic diet-related diseases. There are certain problems in carrying out nutritional assessment in the elderly, but techniques are now available which make valid assessment possible even in the oldest old. Those who live longest have less genetic risk of premature aging, but as a result of native intelligence, education, coping skills, and higher socioeconomic status, they also have a greater likelihood of eating a diet that best meets their long-term nutritional needs. Those most at risk for developing malnutrition as they get older are those who lack food access because of poverty, because of disability resulting from chronic geriatric disease, or because of a combination of these factors. Malnutrition is found in elderly in our society who live in their own homes if they are indigent, isolated, and homebound because of disability.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗
PubMedDate not supplied

Capturing the patient's view of change as a clinical outcome measure.

CONTEXT: Measurement of change in patients' health status is central to both clinical trials and clinical practice. Trials commonly use serial measurements by the patients at 2 points in time while clinicians use the patient's retrospective assessment of change made at 1 point in time. How well these measures correlate is not known. OBJECTIVE: To compare the 2 methods in measurement of changes in pain and disability. DESIGN: Longitudinal survey of patients starting new therapy for chronic arthritis in 1994 and 1995. Surveys were completed at baseline (before intervention) and at 6 weeks and 4 months. SETTING: Community health education program and university medical and orthopedic services. SUBJECTS: A total of 202 patients undertaking self-management education (n = 140), therapy with prednisone or methotrexate (n = 34), or arthroplasty of the knee or hip (n = 28). MAIN OUTCOME MEASURES: Concordance between serial (visual analog scale for pain and Health Assessment Questionnaire for disability) and retrospective (7-point Likert scale) measures, sensitivities of these measures, and their correlation with patients' satisfaction with the change (7-point Likert scale). RESULTS: When change was small (education group), serial measures correlated poorly with retrospective assessments (eg, r=0.13-0.21 at 6 weeks). With greater change, correlations improved (eg, r = 0.45-0.71 at 6 weeks). Average agreement between all pairs of assessments was 29%. Significant lack of concordance was confirmed in all 12 comparisons by McNemar tests (P = .02 to <.001) and by t tests (P = .03 to <.001). Retrospective measures were more sensitive to change than serial measures and correlated more strongly with patients' satisfaction with change. CONCLUSION: The 2 methods for measuring health status change did not give concordant results. Including patient retrospective assessments in clinical trials might increase the comprehensiveness of information gained and its accord with clinical practice.

Aged↗
PubMed2001

Colorectal cancer screening in North Carolina: associations with diabetes mellitus and demographic and health characteristics.

BACKGROUND: Diabetes mellitus (DM) may increase the risk of colorectal cancer, a leading cause of cancer death in the United States. This report examines factors associated with colorectal cancer screening, including DM status. METHODS: Data from the 1993/1995/1997 North Carolina (NC) Behavioral Risk Factor Surveillance System were analyzed to assess self-reported screening rates within guidelines for sigmoidoscopy/proctoscopy (sig/proct) and fecal occult blood test (FOBT). RESULTS: Overall, 28.6, 27.2, and 19.7% received a sig/proct, FOBT, or either test within guidelines, respectively. Screening rates varied according to some demographic variables, but not by DM status. However, DM status changed some relationships between screening and some demographic/health characteristics. CONCLUSIONS: Colorectal cancer screening in NC is similar to national rates, but certain subgroups are less likely to get screened. Persons with DM are as likely to get colorectal cancer screening, but some groups with DM (ethnic minorities, persons of low socioeconomic status) may be at high risk for not getting screened. Educational efforts to increase screening should target these groups.

Age Distribution↗
PubMed2001

Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors.

This study investigated the hypothesis that socioeconomic differences in health status change can largely be explained by the higher prevalence of individual health-risk behaviors among those of lower socioeconomic position. Data were from the Americans' Changing Lives study, a longitudinal survey of 3,617 adults representative of the US non-institutionalized population in 1986. The authors examined associations between income and education in 1986, and physical functioning and self-rated health in 1994, adjusted for baseline health status, using a multinomial logistic regression framework that considered mortality and survey nonresponse as competing risks. Covariates included age, sex, race, cigarette smoking, alcohol consumption, physical activity, and Body Mass Index. Both income and education were strong predictors of poor health outcomes. The four health-risk behaviors under study statistically explained only a modest portion of the socioeconomic differences in health at follow-up. For example, after adjustment for baseline health status, those in the lowest income group at baseline had odds of moderate/severe functional impairment in 1994 of 2.11 (95% C.I.: 1.40, 3.20) in an unadjusted model and 1.89 (95% C.I.: 1.23, 2.89) in a model adjusted for health-risk behaviors. The results suggest that the higher prevalence of major health-risk behaviors among those in lower socioeconomic strata is not the dominant mediating mechanism that can explain socioeconomic disparities in health status among US adults.

Adult↗
PubMed1988

Functional outcome one year following cataract surgery in elderly persons.

We conducted a prospective study of 164 patients aged 70 and over who had undergone cataract removal and intraocular lens implantation to determine variables which predicted change in physical function experienced by the patients one year after cataract surgery. Path analysis was used to estimate direct and indirect effects of ADL change. Direct effects were estimated for mental status (-.35), mental status change (.51), binocular visual disability (-.39), binocular visual disability change over one year (.51), and baseline ADL (.36), with 45% of variance explained. Age and baseline mental status had important indirect effects through mental status change, and presurgical visual disability had important indirect effects through both visual disability change and mental status change. In summary, change in level of function one year after cataract surgery was not explained solely by change in vision, but was conditional on baseline function and baseline mental status and mediated in part by change in mental status.

Activities of Daily Living↗
PubMed1994

Nursing care delivery models and nurse satisfaction.

The relative impact of various nursing care delivery models and management interventions on nurse satisfaction was assessed in 37 New Jersey hospitals. Nurses ranked pay as the most important factor, followed by autonomy and professional status. Changes in scores between pilot and comparison units were significantly different for satisfaction with interactions and task requirements. Change in satisfaction with interaction was significant for all initiatives in aggregate, as well as for each of the five types of initiatives separately. The change in satisfaction with task requirements was significant for all initiatives taken as a group and for those units that implemented reorganization, computer, and education initiatives. Even among nurses who eventually liked the new environment there was a period of initial dissatisfaction.

Humans↗
PubMed1988

The stability of health status in rheumatoid arthritis: a five-year study of patients with established disease.

We employed a health status measure to describe the outcomes of rheumatoid arthritis patients over five years. Of the 410 rheumatoid arthritis patients who were originally administered the Arthritis Impact Measurement Scales (AIMS), 299 completed a follow-up five years later. Data were analyzed using nine health status scales, three components of health status, and an overall arthritis impact item. Results for survivors indicated that there were no clinically important deteriorations in any of these measures. In fact, small improvements on most measures were found. The health status changes were similar for patients originally in a clinical trial and for those receiving routine specialty care. Age was found to positively relate to improvements in psychological status and overall arthritis impact, but we were unable to demonstrate any consistent effects of sex, marital status, education, or disease duration. Our results contrast with other studies that have noted major declines over time in the health status of patients with rheumatoid arthritis. Furthermore, level of education was not a major determinant of morbidity in this group. These results suggest that health status in certain patients with rheumatoid arthritis is more stable than previously thought. This has implications for both clinical practice and clinical research in rheumatology.

Arthritis, Rheumatoid↗
PubMed1987

Profile of Danish women undergoing reversal of sterilization, 1978-1983.

To help identify those women who might regret undergoing sterilization, the Danish women refertilized from 1978 to 1983 were contacted by mailed questionnaire. Eighty-three percent (120/144) responded. These women were younger at the time of sterilization than Danish women sterilized in the same period (mean age 29 years versus 34 years). Furthermore, they had more children at the time of sterilization and had their first and last child at a younger age than Danish women generally, in the same age group. Their social and educational status was lower than the background population and fewer were in gainful employment. At sterilization, most of the women were in an emotionally stressful situation (e.g., marital disharmony (78% of the married women), single parenthood (28%), unwanted pregnancy (27%], or had chronic health problems in the family. Alternative contraceptive methods had not been fully explored. Thirty-eight percent complained of late secondary effects attributable to the sterilization, but the main reason for wanting reversal of sterilization was a new partner (75%). The study suggests that the psycho-social situation and contraceptive alternatives should be carefully evaluated in women requesting sterilization, especially in those below the age of 30.

Adult↗
PubMed2002

[One-year effect of health counseling on life style and risk factors of heart disease].

INTRODUCTION: We examined the need for counselling and the effect on willingness and ability to change life-style, and subsequent changes in risk factors for CHD. MATERIAL AND METHODS: All 152 male employees in a computer company, 25-45 years of age, were invited to participate in a controlled intervention study over one year. The subjects were randomised to an intervention group (I group) and a control group. The I group was divided into subgroups based on baseline behaviour and risk factor status. Changes were evaluated after one year. After an initial health examination, participants in the I group were counselled at baseline and at 5 months. RESULTS: Eighty-five (56%) men participated. Twenty-nine were assigned to a control group and 56 to an intervention group (I group) (dropouts = 8). An exercise group (E group) was advised to take up aerobics exercise three times/week, a diet group to reduce the intake of saturated fat and increase fish products, and smokers to stop smoking. Forty were recommended one or more behavioural changes and eight had no need. Thirty-four were willing to make behavioural changes. Compared to the control group, the fitness level increased (p < 0.01) and body weight decreased in the I group (p < 0.05). DISCUSSION: Individual counselling promotes regular exercise with subsequent improvements in CHD risk factors. The diet and smoking counselling models were less successful in terms of compliance.

Adult↗