Nutrient intake and BMI as predictors of severity of ADL disability over 1 year in homebound elders.

PURPOSE: Although it is well-recognized that good nutrition is essential to health, quality of life, and disease management, evidence of the role of nutrition, especially dietary intake, in the development of health-related disability among the more vulnerable older men and women in the community is largely unavailable. METHODS: We examined self-reported and performance-based measures at baseline (demographic, psychosocial and health-related factors, BMI, burden of disease, dietary intake from 3 24-hour dietary recalls, lower extremity physical performance, and activities of daily living [ADL]) and 1-year follow-up (ADL) from a randomly recruited sample of homebound elders. Structural equation modeling was used to simultaneously evaluate the direct and indirect relationships among baseline factors and severity of disability in activities of daily living (ADL) at 1-year in 253 homebound elders. results: Almost 32% of the homebound sample reported increased severity of disability over 1 year. The full structural model fit the data very well and revealed that better summary intake of calcium, vitamin D, magnesium, and phosphorus was directly linked to better lower extremity performance (LEP) and indirectly to less severity of disability at one year, after controlling for baseline disability and the interrelationships of other factors. Greater BMI was directly associated with worse LEP and indirectly with greater severity of disability. CONCLUSIONS: The findings from this study acknowledge aspects of the complex direct and indirect relationships between nutrient intake, BMI, and disability among homebound elders. These results suggest that nutrient intake and BMI may be reasonable targets for intervention with multiple functional outcomes.

Gastrointestinal cryptosporidiosis in a puppy.

An 8-week-old female Yorkshire terrier with a history of weakness, diarrhea and intestinal isosporiasis was euthanized and a post mortem examination performed. Histologically, there was severe gastrointestinal cryptosporidiosis, severe intestinal isosporiasis and thymic lymphoid depletion. PCR revealed visible bands for the actin and 18S rRNA genes but not for the acetyl CoA synthetase gene for Cryptosporidium spp. The PCR product for the actin gene was sequenced and found to have a 97.6-99.8% similarity to that of Cryptosporidium canis. To our knowledge, this is the first report of gastric cryptosporidiosis in a canine.

A randomized controlled trial of the psychosocial impact of providing internet training and access to older adults.

The Internet (electronic mail and the World Wide Web) may provide new opportunities for communication that can help older adults avoid social isolation. This randomized controlled trial assessed the psychosocial impact of providing Internet access to older adults over a five-month period. One hundred volunteers from four congregate housing sites and two nursing facilities were randomly assigned to receive Internet training or to a wait list control group. The pre & post measures included the UCLA Loneliness scale, modified CES Depression scale, a measure of locus of control, computer attitudes, number of confidants, and overall quality of life. Participants received nine hours of small group training in six sessions over two weeks. Computers were available for continued use over five months and the trainer was available two hours/week for questions. At the end of the trial, 60% of the intervention group continued to use the Internet on a weekly basis. Although there was a trend toward decreased loneliness and depression in intervention subjects compared to controls, there were no statistically significant changes from baseline to the end of trial between groups. Among Internet users (n = 29) in the intervention group there were trends toward less loneliness, less depression, more positive attitudes toward computers, and more confidants than among intervention recipients who were not regular users (n = 19) of this technology. Most elderly participants in this trial learned to use the Internet and the majority continued to use it on a weekly basis. The psychosocial impact of Internet use in this sample suggested trends in a positive direction. Further research is needed to determine more precisely, which older adults, residing in which environmental contexts are more likely than others to benefit from this rapidly expanding information and communication link.

Relationship between self-reported disability and caregiver hours.

OBJECTIVE: In a large, population-based cohort of patients with spinal cord dysfunction, we assessed the relationship between self-reported physical function and hours of care received. DESIGN: Data were obtained by a cross-sectional, self-administered survey used to help establish a national registry of veterans with spinal cord dysfunction. Participants were originally identified from Department of Veterans Affairs databases as having a high probability of spinal cord dysfunction. All 13,542 respondents reporting spinal cord dysfunction and also having complete data on physical function and caregiver hours (CGHs) were included. Physical function was measured using the Self-Reported Functional Measure, and CGHs were obtained from a self-report of hours of caregiving received during the last 2 wk. RESULTS: The relationship between self-reported disability and CGHs was strong (Spearman correlation = -0.70). Subjects with moderate levels of disability had the most variability in CGHs. After stratifying by total Self-Reported Functional Measure score, the strongest predictors of CGHs were instrumental activities of daily living and individual Self-Reported Functional Measure items, explaining a moderate amount of variation in CGHs. CONCLUSION: These data support the construct validity of the Self-Reported Functional Measure and suggest that self-reported disability measures can be of use in describing the clinical epidemiology of patients with spinal cord dysfunction.

The self-reported functional measure: Predictive validity for health care utilization in multiple sclerosis and spinal cord injury.

OBJECTIVE: To examine the predictive validity of the Self-Reported Functional Measure (SRFM), a new measure derived from the FIMtrade mark instrument, for health care utilization in multiple sclerosis (MS) and spinal cord injury (SCI). DESIGN: Prospective cohort study using a mailed survey in 1995 and administrative records from 1996 and 1997. SETTING: Veterans Health Administration hospitals and outpatient clinics. PATIENTS: A total of 6361 veterans with SCI and 1789 veterans with MS. MAIN OUTCOME MEASURES: SRFM score was compared with subsequent outpatient visits, hospitalizations, hospital lengths of stay (LOSs), and residence peri-hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for these variables. RESULTS: A total of 3836 subjects (47.6%) were hospitalized during 1996-1997, and all but 874 (10.7%) had 1 or more outpatient visits. SRFM score predicted inpatient, but not outpatient health care utilization. Persons in the lowest SRFM quartile were over 90% (OR = 1.91, 95% CI = 1.71-2.13) more likely to be hospitalized compared with those in the highest SRFM quartile; also, they were over 2 times (OR = 2.18, 95% CI = 1.85-2.57) more likely to have a LOS greater than 7 days, were over 2 times (OR = 2.41, 95% CI = 1.62-3.58) more likely to die in hospital, and were nearly 3 times (OR = 2.86, 95% CI = 2.00-4.08) more likely to be discharged to an institution. CONCLUSIONS: SRFM had excellent predictive validity for hospitalization, LOS, and discharge destination among patients with MS or SCI.

Descriptions of two new species of Eimeria (Apicomplexa: Eimeriidae) and of Eimeria chinchillae-like oocysts from the plains vizcacha Lagostomus maximus (Desmarest, 1817) (Rodentia: Chinchillidae) from Argentina.

Of 163 fecal samples collected between March 1997 and February 1999 from the plains vizcacha, Lagostomus maximus (Rodentia: Chinchillidae), 19 (12%) were found to be positive for coccidia. All species are from the genus Eimeria and 2 are described here as new. The third species is consistent with the description of Eimeria chinchillae De Vos and Van der Westhuizen, 1968. Sporulated oocysts of Eimeria lagostomi n. sp. are ellipsoidal to subspheroidal, 35.7 x 30.9 (26-36 x 30-41), with a length:width (L/W) ratio of 1.2 (1.0-1.3), without a micropyle (M) or polar granule (PG), but with an oocyst residuum (OR) comprised of a round, compact mass of many small granules. The sporocysts are lemon-shaped, 14.2 x 10.2 (9-11 x 11-16), with an L/W ratio of 1.4 (1.2-1.7) and have a Stieda body (SB) and sporocyst residuum (SR). Eimeria vizcacho n. sp. has sporulated oocysts that are subspheroidal, 26.4 x 23.4 (21-27 x 23-31), with an L/W ratio of 1.1 (1.1-1.2), lack an M and OR, but have 1-2 PGs. Sporocysts are elongate-ellipsoidal, 14.3-9.0 (8-10 x 13-15), with an L/W ratio of 1.6 (1.4-1.8), lack an SB, but have 2 SR; the first a small mass of granules lying between the sporozoites in the middle or at 1 end, and the second also of many small granules, always at the opposite end. Sporulated oocysts of the E. chinchillae-like organism are ellipsoidal to subspheroidal, 20.7 x 17.5 (15-22 x 17-24) with an L/W ratio of 1.2 (1.0-1.3), lack an M and OR, but have 0-3 PGs. Sporocysts are ellipsoidal, 10.7-6.9 (6-8 x 8-13) with an L/W ratio of 1.55 (1.3-1.8) and have an SB and SR.

Assessment of chronic care need and use.

The needs assessment process is indeed complex in the social service context. Whereas most contexts can start with a presumption of "no need," the social service context frequently must start with an assumption of "need met-->change." In addition, underlying values--the individual's, the assessor's, the society's--all play a part in the judgment process. The assumption that the involvement of another in performing the task automatically implies a limitation on the part of the recipient is not warranted, nor is the assumption that the reliance on another by one in need automatically implies the need is met. For purposes of population needs assessments, it is possible to rely on presumptive categorizations as a function of simple response profiles. For individual care planning, however, additional information is essential.

Rediscovering the patient's role in receiving health promotion services.

OBJECTIVE: This study examined differences in the odds of receiving health promotion/disease prevention services recommended by the US Preventive Services Task Force among three subgroups of patients. It tested the hypotheses that those most uninvolved in their own health (as exemplified by the lack of knowledge of blood pressure and cholesterol levels despite having been tested) would receive the least other health promotion services, and those being treated for both high blood pressure and hyperlipidemia would receive the most additional services. METHODS: A mail survey was sent to a random sample of 68,422 veterans who had obtained primary care from any of the 153 Veterans Health Administration facilities in 1996. The adjusted response rate was 68%. Subgroup analyses were performed on three subgroups who reported having been tested for both hypertension and hyperlipidemia in the previous year (n = 5,113). RESULTS: Both hypotheses were supported. Uninvolved patients were the least likely subgroup to report obtaining other recommended health promotion services, and the dually treated were most likely. The uninvolved subgroup was significantly more likely to report being female, physically inactive, current smokers, and heavy alcohol drinkers, and to report having a problem with alcohol, and significantly less likely to report being > or =50 years of age and overweight, to almost always wear seat belts, and to obtain at least 90% of their health care at the Veterans Health Administration. CONCLUSIONS: Clinicians need to encourage all patients to receive health promotion services, but in particular they should be aware that those who do not know their last hypertension and cholesterol levels despite having been tested are particularly in need of attention.

Spinal deformity and mobility self-confidence among women with osteoporosis and vertebral fractures.

This study evaluated the direct and indirect effects of spinal deformity on confidence in mobility among 185 older women with osteoporosis and vertebral fractures. We administered multidimensional tests of physical and psychosocial impairment and function to female residents of continuing care retirement communities, and used path analytic regression methods to delineate relationships between spinal deformity, pain, function and mobility self-confidence. No direct effect of spinal deformity on confidence in mobility was observed. However, important indirect paths mediated by functional limitations were confirmed. A pattern of indirect effects was observed for a broad array of impairment-level constructs. These results support current models of the disablement process that propose functional limitations as the major pathway to disability. However, they also suggest that the impact of impairment-level constructs might be overlooked unless we evaluate indirect, as well as direct effects, on disability.

Effects of natural habitat fragmentation on an endemic scrub lizard (Sceloporus woodi): an historical perspective based on a mitochondrial DNA gene genealogy.

The Florida scrub lizard, Sceloporus woodi, is endemic to scrub habitat patches along the central portion of the Florida peninsula and xeric coastal regions. Scrub ecosystems are the patchily distributed remnants of previously widespread habitats formed during the Pleiocene and early Pleistocene. Scrub lizards appear to have limited dispersal capabilities due to high habitat specificity and low mobility. To assess the population structure and phylogeography of S. woodi, 135 samples were collected from 16 patches on five major ridges in Florida, USA. Analysis of 273 bp of mitochondrial DNA (mtDNA) cytochrome b reveals a very strong geographic distribution of genetic diversity. Haplotype frequencies are significantly different in 63 of 66 comparisons between patches. With one exception, samples from the five major ridges are characterized by fixed differences in haplotype distribution and deep evolutionary separations (3-10%). Fixed genetic differences were also observed between northern and southern segments of several ridges. Analysis of molecular variance (AMOVA) shows an estimated 10.4% total genetic variation within patches, 17.5% among patches (within ridges), and 72.1% among ridges. This strong population structure among patches within ridges indicates that the distribution of S. woodi is tightly linked to sandy scrub habitat and that the discontinuous distribution of scrub habitats significantly inhibits dispersal and gene flow. Phylogeographic analyses indicate a pattern of dispersal down the Florida peninsula during the late Pliocene-early Pleistocene, followed by habitat fragmentation and variant isolation events. Therefore, the deep genetic structuring among scrub lizard populations on separate ridges is attributed to ancient isolation events induced by a shift from dry (xeric) to wet (mesic) conditions on the Florida peninsula. These findings indicate that some scrub lizard populations have persisted in isolation for time frames in excess of 1 Myr, providing a case history on the genetic consequences of habitat fragmentation.

Reliability of physical performance tests in four different randomized clinical trials.

OBJECTIVES: (1) To assess the test-retest reliability of physical performance tests in subject groups with different levels of impairment and disability, and (2) to assess the stability of these tests over different time intervals. DESIGN: Test-retest, repeated measures reliability design. SETTING: (1) A university's center for aging and research center, (2) a continuing care retirement community, and (3) an extended care and rehabilitation center at a Veterans Affairs medical center. SUBJECTS: Twenty-four community-dwelling elders, 15 community-dwelling elders with Parkinson disease, 12 older women with vertebral osteoporosis and compression fractures, and 14 elderly nursing home residents. MEASURES: Lower extremity isometric strength (ankle dorsiflexion, hip abduction), spinal configuration (thoracic kyphosis, lumbar lordosis), lumbosacral motion (flexion, extension), and timed measures of the ability to get in and to get out of bed at a usual pace. RESULTS: Most of the within-group intraclass correlation coefficients (ICCs) were good to excellent (.70 to .97). Overall, ICCs for all groups combined were between .70 and .96, and no decrement in reliability was noted after controlling for group membership. In addition, no decrement in the ICC was observed for short (1 day) vs. longer (1 week) intervals of testing. CONCLUSIONS: These performance-based measures may be used reliably across a wider range of testing environments and elderly populations than has been reported.

The validity in persons with spinal cord injury of a self-reported functional measure derived from the functional independence measure.

STUDY DESIGN: A cross-sectional, mailed survey on impairment and function using 6361 respondents to the Spinal Cord Dysfunction National Veterans Survey who reported spinal cord injury as the sole cause of their spinal cord dysfunction. OBJECTIVES: To establish the concurrent and construct validities of a Self-Reported Functional Measure appropriate for use in patients with spinal cord injuries. SUMMARY OF BACKGROUND DATA: Functional assessment is of increasing importance in clinical care, quality assurance, and national health-care planning. There is a conspicuous need for validated functional assessment measures that are rapid, reliable, and appropriate for use in the disabled population. METHODS: The correlation was examined of hours of personal assistance, number of affected limbs, amount of motor impairment, and amount of combined limb-motor impairment to Self-Reported Functional Measure response tertile (scores, 13-32, 33-45, 46-52; lower scores indicated worse function). RESULTS: There were statistically significant correlations between Self-Reported Functional Measure score and hours of personal assistance (P < 0.001), the number of affected limbs (P < 0.001), the amount of motor impairment (P < 0.001), and the amount of combined limbmotor impairment (P < 0.001). For example, 87% of people with the most limb-motor impairment (four affected limbs and no useful movement) were in the lowest Self-Reported Functional Measure tertile, compared with 3% of people in the least-affected category of limb-motor impairment. Furthermore, visual, sensory, or memory impairment did not influence the correlation between limbmotor impairment and Self-Reported Functional Measure score. CONCLUSION: The Self-Reported Functional Measure shows good concurrent and construct validities.

Patient factors related to the odds of receiving prevention services in Veterans Health Administration medical centers.

OBJECTIVE: To examine the association between patient characteristics and the odds of receiving 13 health promotion/disease prevention services recommended by the US Preventive Services Task Force (USPSTF) for average-risk individuals. METHODS: A mail survey was sent to a random sample of 68,422 veterans who obtained primary care from any of the 153 Veterans Health Administration facilities in 1996; 44,304 responded (adjusted response rate was 68%). Multivariate logistic regression models were used. RESULTS: Demographic factors, health risk behaviors, and self-reported health were associated with the odds of receiving prevention services. Current smokers, heavy alcohol drinkers, and females were less likely to receive many health promotion services, whereas regular exercisers, overweight individuals, males, those reporting poorer health, individuals reporting high or controlled blood pressure, and those reporting high or controlled cholesterol levels were more likely to receive USPSTF-recommended prevention services. CONCLUSION: Substantial proportions of veterans were likely to obtain prevention services recommended by the USPSTF for average-risk individuals. Nevertheless, veterans who reported being current smokers, heavy drinkers, or female were less likely to obtain these services. These subgroups may benefit from additional initiatives.

Disability fingerprints: patterns of disability in spinal cord injury and multiple sclerosis differ.

BACKGROUND: Models for causation of functional disability differ as to whether different diseases lead to common expressions of disability versus producing unique "disability fingerprints." Multiple sclerosis (MS) and Spinal Cord Injury (SCI) both affect the spinal cord; however, their pathophysiologies differ (progressive vs. nonprogressive; multifocal vs. unifocal). METHODS: Patterns of disability were compared among veterans who reported in a national survey that they had MS (n = 1789) or SCI (n = 6361) as the sole cause of their spinal cord dysfunction. The study used self-reported information on disease duration, physical impairments, and self-care skills to compare the two samples for differences in disability overall and after stratification according to (a) disease duration, and (b) specific physical impairments. RESULTS: Patterns of disability differed significantly among persons with MS compared to SCI (p = .001). Differences in level of disability between the two samples remained statistically significant after stratification on disease duration. There were substantial, statistically significant differences between the two samples in the amount and kinds of physical impairment. However, differences in level of disability between the two conditions remained highly significant after stratifying on number of affected limbs (p = .003), amount of useful movement (p = .001), overall motor impairment (p = .003), amount of sensation (p = .001), impairment in memory and thinking (p = .001), and visual impairment (p = .001). CONCLUSIONS: This study shows differing diseases indeed have unique disability fingerprints, which remain unique after controlling for disease duration and for population-specific differences in physical impairment. These findings point out the need to explain the disablement process more fully.

The receipt of prevention services by veterans using VA versus non-VA facilities.

OBJECTIVES: This paper compares the health promotion/disease prevention services received by veterans who reported receiving 90%+ of their care inside Veterans Health Administration (VA) facilities with counterparts who reported receiving 90%+ of their care outside VA facilities. Results are compared with the U.S. Healthy People 2000 goals. METHODS: Random samples were drawn of 300 men and 150 women visiting primary care clinics in six VA facilities. A 66% adjusted response rate was achieved after two mailings (n = 1,703). For this analysis, those veterans who reported receiving 90%+ of their care inside VA facilities (n = 909) were compared with veterans who reported receiving 90%+ of their care outside VA facilities (n = 185). RESULTS: Of the 13 health promotion¿disease prevention services, 6 were significantly influenced by source of care. Five of the significant differences reflected statistically higher prevalence rates for those receiving 90%+ of their care inside the VA (mammograms and counseling for alcohol, nutrition, exercise, and seatbelt use). One reflected a higher prevalence rate for those receiving 90%+ of their care outside the VA system (tetanus boosters). CONCLUSIONS: Veterans receiving 90%+ of their care in VA facilities obtained more preventive services than counterparts using non-VA providers. Assessment and counseling services need to be targeted to more veterans to comply more fully with U.S. Preventive Services Task Force recommendations and Healthy People 2000 objectives.

Prevention services received by veterans visiting VHA facilities.

OBJECTIVES: This paper presents rates with which veterans report receiving 13 recommended health promotion and disease prevention services. Results were compared with the U.S. Healthy People 2000 goals. METHODS: Random samples of 300 men and 150 women visiting primary care clinics in six Veterans Health Affairs facilities were drawn. A 66% adjusted response rate was achieved after two mailings (n = 1,703). Weighted averages for each prevention service were calculated. RESULTS: For preventive services targeted to all age groups, both male and female veterans currently exceed the Year 2000 goal in hypertension detection and tobacco counseling. Female veterans also exceed the Year 2000 goal in "almost always" using seat belts. For prevention services targeted to specific age-gender subgroups, both male and female veterans currently exceed the Year 2000 goals for four of the six primary and secondary prevention services. CONCLUSIONS: Both male and female veterans exceed Year 2000 goals for the receipt of nearly half of the preventive services. Nevertheless, additional screening and counseling services should be made available to veterans of all age categories.

Accuracy of survey questions for geriatric urinary incontinence.

PURPOSE: Risk factors, natural history, consequences, therapeutic responses and costs are all likely related to type of urinary incontinence, for example stress or urge. Yet few epidemiologic type specific data are available and only 1 study has been validated urodynamically. We compare the accuracy of a typical questionnaire used in a large epidemiologic study with the criterion standard of multichannel video urodynamic testing. MATERIALS AND METHODS: The questionnaire was administered before urodynamic testing to 132 subjects 65 years old or older, of whom 80% were women, all were mobile and none was severely demented. Responses to questionnaire items were compared to the criterion standard, singly and in combination, using a total of 4 a priori and post hoc strategies, including a computerized regression tree program. RESULTS: Overall, no analytic strategy correctly classified more than 67% of patients and none accurately classified even a single type of incontinence, including stress incontinence. CONCLUSIONS: Short questionnaires commonly used in epidemiologic studies correlated poorly with video urodynamic testing in incontinent older adults. Previously published information regarding prevalence of the types of incontinence should be reviewed in the light of these data.