The association of nocturia with incident falls in an elderly community-dwelling cohort.

OBJECTIVE: The aim of this study was to examine the association of nocturia with incident falls in a population-based sample of community-dwelling elderly persons. METHODS: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of 1000 community-dwelling older adults in the USA designed to examine factors associated with impaired mobility. Subjects were recruited from a stratified, random sample of Medicare beneficiaries to include equal numbers of black women, black men, white women and white men. Nocturia was assessed at baseline and falls were assessed at baseline and every 6 months for a total of 36 months of follow-up. RESULTS: A total of 692 individuals (mean age 74.5 +/- 6.2, 48% female, 52% black) did not fall in the 12 months prior to baseline. Of these 692, 214 (30.9%) reported falling at least once during the subsequent 3 years. In unadjusted analysis, three or more nightly episodes of nocturia were associated with an incident fall [RR = 1.27, 95% CI (1.01-1.60)]. After multivariable logistic regression, three or more episodes of nocturia were associated with an increased risk of falling [RR = 1.28, (1.02-1.59)]. DISCUSSION: In a racially diverse, community-based sample of older men and women who had not fallen in the previous year, nocturia three or more times a night was associated in multivariable analysis with a 28% increased risk of an incident fall within 3 years. While this study has several advantages over previous reports (longitudinal follow-up, performance-based measures of function, population-based sampling), causality cannot be ascertained. Further research is needed to ascertain the impact of treatments to reduce nocturia as part of a multi-component programme to reduce fall risk.

Dietary factors and cognitive impairment in community-dwelling elderly.

BACKGROUND: Diet may play a role in cognitive impairment. OBJECTIVE: To examine the relationship between dietary factors and cognitive impairment. DESIGN AND METHODS: All subjects (n=1056) were participants in the State-wide Survey of Alabama's Elderly (1986-87). Basic demographic information, Mental Status Questionnaire (MSQ) score, and dietary intake frequency of meat (pork, beef, lamb), fish, chicken or turkey, vegetables, fruit, milk, cheese, desserts, bread or cereal, and dried beans and peas were ascertained during an inhome interview. RESULTS: Most participants were female (67%) and white (73%) with a mean age of 69 years (SD 8.9, min 55 max 94) and mean years of education of 10.7 (SD 3.8, min 1 max 18). Intake of cheese was found to be inversely associated with cognitive impairment in a simple logistic regression analysis, (OR = 0.59; 95% CI: 0.42, 0.84; p=0.003) and in a multiple logistic regression analysis (OR=0.68; 95% CI: 0.47, 0.99; p=0.04), after adjusting for basic socio-demographic factors and for other dietary factors. Increased frequency of cheese intake was associated with decreased cognitive impairment (p=0.0034). In the multiple logistic regression analysis bread or cereal (OR= 0.37, 95% CI: 0.14, 0.97; p=0.044) was inversely associated with, and dessert intake (OR= 1.70, 95% CI: 1.12, 2.59; p=0.013) positively associated with cognitive impairment. CONCLUSION: Dietary intake of cheese is associated with a lower prevalence of cognitive impairment, with a dose-response effect, while intake of dessert is associated with a higher prevalence of cognitive impairment. Possible reasons for a potential protective effect of cheese ingestion are discussed.

Vitamin D and incident urinary incontinence in older adults.

BACKGROUND/OBJECTIVES: The aim of this study is to determine whether vitamin D status is associated with incident urinary incontinence (UI) among community-dwelling older adults. SUBJECTS/METHODS: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of community-dwelling Medicare enrollees. Standardized assessment of UI was conducted using the validated Incontinence Severity Index. The analysis of 25-hydroxyvitamin D [25(OH)D] levels was performed on stored baseline sera. UI was assessed every 6-12 months for up to 42 months. The analyses included multivariable logistic regression and Cox proportional hazard models. RESULTS: Of 350 participants (175 male, 147 black, mean age 73.6±5.8), 54% (189/350) were vitamin D deficient (25(OH)D <20 ng/ml) and 25% (87/350) were vitamin D insufficient (25(OH)D: 20 ng/ml to <30 ng/ml). Among the 187 subjects with no UI at baseline, 57% (107/187) were vitamin D deficient and 24% (45/187) were vitamin D insufficient. A total of 175 of the 187 subjects had follow-up evaluation for incident UI over 42 months, and incident UI occurred in 37% (65/175). After adjustment, cumulative incident UI at 42 months was associated with baseline vitamin D insufficiency (P=0.03) and demonstrated a trend association with deficiency (P=0.07). There was no association between baseline vitamin D status and the time to incident UI. CONCLUSIONS: These preliminary results support an association between vitamin D and incident UI in community-dwelling older adults. Future studies may target specific at-risk groups, such as men with BPH or women with pelvic floor disorders for evaluation of the impact of vitamin D supplementation on urinary symptoms.

Relation of low body mass to death and stroke in the systolic hypertension in the elderly program. The SHEP Cooperative Research Group.

BACKGROUND: There are scant data on the effect of body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) on cardiovascular events and death in older patients with hypertension. OBJECTIVE: To determine if low body mass in older patients with hypertension confers an increased risk of death or stroke. PATIENTS: Participants were 3975 men and women (mean age, 71 years) enrolled in 17 US centers in the Systolic Hypertension in the Elderly Program trial, a randomized, double-blind, placebo-controlled clinical trial of lowdose antihypertensive therapy, with follow-up for 5 years. MAIN OUTCOME MEASURES: Five-year adjusted mortality and stroke rates from Cox proportional hazards analyses. RESULTS: There was no statistically significant relation of death or stroke with BMI in the placebo group (P = .47), and there was a U- or J-shaped relation in the treatment group. The J-shaped relation of death with BMI in the treated group (P = .03) showed that the lowest probability of death for men was associated with a BMI of 26.0 and for women with a BMI of 29.6; the curve was quite flat for women across a wide range of BMIs. For stroke, men and women did not differ, and the BMI nadir for both sexes combined was 29, with risk increasing steeply at BMIs below 24. Those in active treatment, however, had lower death and stroke rates compared with those taking placebo. CONCLUSIONS: Among older patients with hypertension, a wide range of BMIs was associated with a similar risk of death and stroke; a low BMI was associated with increased risk. Lean, older patients with hypertension in treatment should be monitored carefully for additional risk factors.

Prophylactic value of preincision intra-aortic balloon pump: analysis of a statewide experience.

OBJECTIVE: The objective of this study was to determine whether preincision use of an intra-aortic balloon pump improves survival and shortens postoperative length of stay in hemodynamically stable, high-risk patients undergoing coronary artery bypass grafting. METHODS: A post hoc analysis of the Alabama CABG Cooperative Project database was performed by using propensity scores to model the likelihood of receiving a prophylactic preincision intra-aortic balloon pump. Every patient receiving a prophylactic preincision balloon pump was matched with another patient of similar propensity score who did not receive one. We then compared outcomes for matched pairs. RESULTS: There were 7581 patients of whom 592 received a prophylactic preincision balloon pump. Patients with preoperative renal insufficiency, heart failure, or left main coronary artery disease, or who had undergone previous bypass grafting were significantly more likely to receive a prophylactic preincision balloon pump. By using propensity scores, we matched 550 patients who received a prophylactic preincision balloon pump with 550 who did not. Survival did not significantly differ by whether a prophylactic preincision balloon pump was used. However, surviving patients who received a preincision balloon pump had a significantly shorter postbypass length of stay (7 +/- 7.3 days) than did matched patients not receiving a balloon pump (8 +/- 6.2 days; P <.05). CONCLUSIONS: No survival advantage was found for use of a prophylactic intra-aortic balloon pump in hemodynamically stable, high-risk patients undergoing bypass grafting, as opposed to placing a balloon pump on an "as needed" basis during or after the operation. However, the patients receiving the balloon pump had improved convalescence as shown by significantly shorter length of stay.

Ranking: a year three follow-up in a different institution.

Ranking residents as a means of semiobjective evaluation of their overall performance was described in 1985. The predictive nature of pooled faculty ranking of residents was stressed. Ranking of resident total scores on The American College In-training Examination and American Board of Radiology written examination was noted to be statistically related to the pooled faculty ranking. Similarly, the faculty ranking was predictive of itself in subsequent rankings. A cohesiveness of faculty consensus was present such that small numbers (five minimum) were predictive of larger groups of participating faculty. All reported observations persist in the new institution. Exceptions to expected residency level of training stratification (eg, third-year residents ranking in the midst of first-year residents, second-year residents ranking above many third-year residents) continue to be the most useful observation in counseling residents. Additional information reported includes sensitivity of the ranking to improvement or nonimprovement of probated residents.

Age-related variability in the use of cardiovascular imaging procedures.

OBJECTIVE: To determine if older patients undergo fewer cardiovascular imaging procedures (CIPs) than younger patients when admitted to a tertiary care academic medical center for an acute myocardial infarction (MI), after adjusting for disease severity and comorbidities. DESIGN: Non-current prospective cohort study. SETTING: Urban tertiary care academic medical center. PATIENTS: Medical records of 294 patients admitted and diagnosed with an acute MI between January 1990 and April 1991 were reviewed. MEASUREMENTS: The total number of different CIPs performed during hospitalization was determined. Cardiac catheterizations, echocardiograms, radionuclide ventriculograms, and thallium scans counted as CIPs. Disease severity was assessed by the Acute Physiology Score (APS) of APACHE II, admission Killip's Classification, and peak creatine phosphokinase (CPK) levels. Comorbidities were assessed using a modified Comorbidity Damage Index of Charlson. RESULTS: The mean (+/- SD) number of different CIPs performed during hospitalization was significantly less for those > or = 75 years old (1.3 +/- 1.0) than for those < 75 years old (1.7 +/- 1.0) (P = 0.01), and CIP number negatively correlated with age (Spearman r = -0.178; P = 0.01). Mean CIP number decreased from 2.0 +/- 1.1 for those < 45 years old to 0.9 +/- 0.6 for those > or = 85 years old (P = 0.02). Other factors positively associated (P < 0.10) with CIP number were: CPK values in the highest quartile of the study population (> 355 U/L); admission to a cardiology, medical, or family practice service; no CIP performed at an outside hospital prior to transfer; admission Killip's Classification of less than IV, and a Q-wave MI. After adjusting for these variables in a multiple regression model, age > or = 75 remained an independent predictor of decreased CIP use (P = 0.003). The modified comorbidity index score and the APS score, a general measure of severity of illness, were not significantly associated with CIP use. When procedures were examined individually, no significant age-related differences were noted in the use of thallium scans, radionuclide ventriculograms, or echocardiograms. Older patients did, however, remain less likely to undergo cardiac catheterizations (P < 0.001). CONCLUSION: Older patients, regardless of underlying disease severity or comorbidities, undergo fewer invasive cardiovascular evaluations than younger patients when admitted to a tertiary care academic medical center for an acute MI.

Association between Alzheimer's disease and bound autochthonous IgM on T cells.

OBJECTIVE: To determine whether there is an association between the number of peripheral T cells binding IgM per total T cell population (%IgM+ T cells) and dementia. DESIGN: Cross-sectional study. SETTING: Two inpatient and two outpatient sites at a university medical center. PARTICIPANTS: Fifty-three adults. MEASUREMENTS: Peripheral blood was collected from each individual, and the %IgM+ T cells was determined by flow cytometry. The data obtained by medical record chart review were analyzed to determine whether the %IgM+ T cells correlated with cognitive diagnoses, demographic variables, medical diagnoses, or prescribed medications. RESULTS: The %IgM+ T cells was negatively correlated with MMSE scores (r = -.33, P = .016). There was a significant difference in the mean %IgM+ T cells between Alzheimer's disease (AD) and non-AD patients (35.6% +/- 30.2% vs 14.6% +/- 23.9%, P < .001) but no statistically significant association between the mean %IgM+ T cells and age, sex, race, prescribed medications (except gastrointestinal (GI) medications), or medical diagnoses (except stroke). After statistically controlling for GI medications and stroke, AD remained independently associated with the %IgM+ T cells (P = .008). CONCLUSIONS: Patients with AD had significantly more of their T cells coated with IgM than did non-AD patients.

Hospital-acquired pressure ulcers and risk of death.

OBJECTIVE: To evaluate the impact of in-hospital pressure ulcer development on mortality among older, high-risk, hospitalized patients up to 1 year post-hospital discharge, after adjusting for baseline patient characteristics, disease severity, hospital complications, and discharge activity level. DESIGN: A prospective, inception, cohort study. SETTING: An urban, tertiary, acute care, university teaching hospital. PATIENTS: A total of 286 patients aged 55 or older, expected to be confined to bed or chair for at least 5 days, who were admitted to the hospital without a Stage 2 or greater pressure ulcer. MEASUREMENTS: The primary outcome measurement was time to death from admission to 1-year post-hospital discharge. Baseline information included demographic, medical, functional, and nutritional variables known to be associated with increased mortality. Measures of global disease severity and co-morbidity included the admitting physician's estimate of illness severity and life expectancy, the acute physiology score of APACHE II, the Co-morbidity Damage Index, and the Medicus Nursing Classification Score. Baseline infections, incident infections, and noninfectious hospital complications were determined. Functional activity level was determined at hospital discharge. Post-discharge vital status was determined by telephone interviews at 3,6,9, and 12 months after discharge and confirmed by death certificate review. MAIN RESULTS: Development of an in-hospital pressure ulcer was associated with greater risk of death at 1 year (59.5% vs 38.2%, P = .02). However, pressure ulcer development did not remain independently associated with decreased survival after adjusting for other predictors of mortality. Predictors of mortality at hospital admission by multivariate Cox regression analysis included weight loss in the 6 months before admission (RR 2.4, CI 1.6, 3.6), physician estimate of life expectancy (RR 2.1, CI 1.7, 2.6), and the Co-morbidity Damage Index (RR 1.1, CI 1.0, 1.2). Multivariate predictors of 1-year mortality at discharge included physician estimate of life expectancy (RR 2.2, CI 1.8,2.6), weight loss in the 6 months before admission (RR 2.2, CI 1.5,3.2), remaining confined to bed or chair (RR 1.9, CI 1.2,3.1), and the total number of hospital complications (RR 1.3, CI 1.2,1.5). CONCLUSIONS: Pressure ulcers that develop during acute hospitalization are not associated with reduced 1-year survival among high risk older persons after adjusting for nutritional and functional status, global measures of disease severity and co-morbidity, and noninfectious hospital complications.

A preliminary assessment of the medical and functional factors associated with vehicle crashes by older adults.

OBJECTIVES: To examine associations between medical and functional variables and at-fault car crashes in a cohort of older drivers. DESIGN: A case-control study. SETTING: A tertiary care medical center. PARTICIPANTS: Older drivers (ages 55-90 years) residing in Jefferson County, Alabama (n = 174). Cases were drivers who had at least one at-fault crash in the previous 6 years; controls were crash-free during the same period. MEASUREMENTS: Self-reported medical conditions, reported and observed functional measures, and urinary drug screens. The occurrence of one or more at-fault car crashes in the 6 years preceding the 1991 assessment date represented the outcome measure. RESULTS: Ninety-nine older drivers experienced between one and seven at-fault vehicle crashes during the period 1985 through 1991, whereas 75 drivers did not. Logistic regression models indicated that the following variables were independently associated with crash involvement: A 40% or greater reduction in the useful field of view (OR = 6.1; 95% CI, 2.9 to 12.7; P < 0.001), black race (OR = 6.6; 95% CI, 1.7 to 26.2; P = .007), a history of falling in the previous 2 years (OR = 2.6; CI, 1.1 to 6.1; P = .025), and not taking a beta-blocking drug (OR = 4.3; CI, 1.2 to 15.0; P = .023). CONCLUSIONS: Functional assessments, such as a comprehensive test of visual processing, a falls history, and a review of current medications may be of greater relevance than specific medical conditions in the identification of older at-risk drivers. If prospective studies determine that falling and crashing share risk factors, a unified approach to the prevention of these mobility disorders could result. The finding of an independent association of black race with at-fault crashing is in need of further clarification because of the low representation of black drivers in this sample.

Exploratory study of incident vehicle crashes among older drivers.

BACKGROUND: As the number of older adult drivers increases, distinguishing safe from unsafe older adult drivers will become an increasing public health concern. We report on the medical and functional factors associated with vehicle crashes in a cohort of Alabama drivers, 55 years old and older. METHODS: This prospective study involved 174 older adults, on whom demographic, medical, functional, and physical performance data were collected in 1991. Subjects were then followed through 1996 for incident vehicle crashes. RESULTS: Sixty-one subjects experienced between one and four police-reported vehicle crashes during the study period. Following adjustment for age, race, days driven per week, and gender, Cox proportional-hazards models showed the following variables to be associated with crash involvement: reported difficulty with yardwork or light housework (relative risk [RR] = 2.1; 95% confidence interval [CI] 1.1, 4.0; p = .02), or opening ajar (RR = 3. 1; 95% CI 1.4, 6.7; p = .004); at least one crash before 1991 (RR = 2.1; 95% CI 1.2, 3.7; p = .008); using hypnotic medication (RR = 2.9; 95% CI 1.3, 6.6; p = .01); self-reported stroke or transient ischemic attack (RR = 2.7; 95% CI 1.1, 6.6; p = .03); scoring within the depressed range on the Geriatric Depression Scale (RR = 2.5; 95% CI 1.1, 6.0; p = .03), and failing the useful field-of-view test (RR = 1.9; 95% CI 1.0, 3.5; p = .05). CONCLUSIONS: Variables related to function, medication use, affect, neurological disease, and visuocognitive skills were associated with vehicle crash involvement in this cohort. Our findings suggest that multifactorial assessments are warranted to identify at-risk older drivers.

A phase II study to evaluate recombinant platelet-derived growth factor-BB in the treatment of stage 3 and 4 pressure ulcers.

OBJECTIVE: To determine the efficacy of the daily topical application of recombinant platelet-derived growth factor-BB (rPDGF-BB), a recognized vulnerary agent, in the treatment of deep pressure ulcers. DESIGN: Prospective, randomized, double-blind trial. SETTING: Patients were treated in a nursing home or a hospital setting before transfer to a nursing home. PATIENTS: Eligibility criteria included a clean pressure ulcer that had been adequately debrided and the absence of severe cardiac, pulmonary, or renal conditions. The causes of the ulcers were not related to a venous or arterial vascular disorder. The patients were elderly (mean age, 68 to 74 years). INTERVENTIONS: After randomization, patients were given daily topical aqueous rPDGF-BB (dosage, 100 or 300 micrograms/mL) or placebo and saline gauze dressings were applied daily in addition to frequent turning. MAIN OUTCOME MEASURE: Serial volume measurements of the healing wounds were taken using alginate molds. RESULTS: The ulcers of 41 patients were analyzed. At the end of 28 days, median ulcer volumes had decreased to 83%, 29%, and 40% of the initial size in the groups receiving placebo, rPDGF-BB, 100 micrograms/dL, and rPDGF-BB, 300 micrograms/mL, respectively. When adjusted for initial volume, ulcer volume after 28 days of treatment was smaller in the rPDGF-BB-treated groups compared with the placebo group (analysis of covariance, P = .056). Ulcers in the two rPDGF-BB-treated groups were significantly smaller in volume compared with those in the placebo group, using a linear contrast procedure. CONCLUSIONS: Data from this small trial suggest that local application of rPDGF-BB may be of therapeutic benefit in accelerating the healing of chronic pressure ulcers.

Alabama coronary artery bypass grafting Cooperative Project: baseline data. Alabama CABG Cooperative Project Study Group.

BACKGROUND: The Alabama Cooperative CABG Project is a statewide process-oriented analysis of coronary artery bypass grafting (CABG). The purpose of this report is to present the first information generated by this analysis, which will serve as a baseline for subsequent quality improvement projects. METHODS: Medical records of Medicare beneficiaries from Alabama, a comparison state, and a national random sample who had isolated CABG between July 1, 1995, and June 30, 1996, were examined. Fifty-six demographic, procedural, and outcome variables were abstracted. Quality indicators identified by the Alabama Quality Assurance Foundation Study Group included: internal mammary artery use, prescription of aspirin at discharge, duration of postoperative intubation, use of intraaortic balloon pump, readmission to intensive care unit, hospital readmission within 30 days, return to the operating room for bleeding, and in-patient mortality. Benchmark performance rates for quality indicators reflecting care processes were calculated. RESULTS: Alabama, the comparison state, and the national sample consisted of 4,092, 2,290, and 1,119 patients, respectively. The processes of care and outcome, including risk-adjusted mortality, for CABG across the state of Alabama are generally similar to other states and nationwide samples. However, there was considerable variation at the local hospital level in Alabama for each quality indicator. CONCLUSIONS: The data provide a "snapshot" of practice patterns for CABG in Alabama. A specific quality indicator (duration of intubation) was identified as a focus for statewide improvement. Hospital-specific variations in quality indicators suggested opportunities for improvement in other indicators at a number of hospitals.

The prevention and management of pressure ulcers.

Pressure ulcers are a common problem for older persons. Complications associated with pressure ulcers include infection and even death for some patients. Pressure is the primary pathogenic factor, but shearing forces, friction, and moisture are also important. Immobility, nutritional status, and age-related factors seem to be significant risk factors. Preventive care includes use of assessment tools to identify high risk patients, frequent repositioning, air or foam mattresses that reduce pressure over bony prominences, as well as careful attention to optimizing the overall patient condition. When pressure ulcers do develop, the treatment plan should include adequate nutrition including protein, vitamin C, and zinc supplements as indicated; systemic antibiotics for sepsis, cellulitis, osteomyelitis, or the prevention of bacterial endocarditis; and local wound care that eliminates necrotic tissue, decreases bacterial load, and provides a physiologic, pressure-free environment allowing the wound to heal. Specialized beds may be considered in some patients, particularly those with larger ulcers. Surgery is an option in older persons who are operative candidates. For some patients with pressure ulcers, appropriate treatment goals may focus on providing comfort rather than curing the ulcer.

A clinical evaluation of contrast-detail analysis for ultrasound images.

We report on the reproducibility of human observers' vanishing detection thresholds for visual targets in contrast-detail (C/D) analysis of ultrasound B-mode images. The images used in this study contain visual targets which are circular cross sections of constant-contrast conical structures in the C/D phantom. The vanishing threshold diameters for these targets vary as a function of the perceived size of the imaged target, target-to-background contrast, image noise content, and reproducibility of the decision levels of human observers for repeated observations. Our study indicates that the determination of absolute vanishing threshold diameter values for several targets of different contrast by human observers yields a high degree of error that is not predicted by existing theoretical assumptions based on a static threshold detector. We find that systematic error is introduced by the observers during the course of the experiment and that the levels of sensitivity of the observers differ widely at all times, and increase the amount of total observer error. These results suggest that, due to the large total observer error, C/D analysis may be impractical in a clinical environment, unless there is access to a team of observers specifically and extensively trained in this task. We suggest that a computer-based observer may be more reliable for the objective performance of contrast-detail analysis as a method for evaluating ultrasound image quality and comparison of imaging systems.

The neuropathic joint: a neurovascular bone disorder.

The pathogenesis of the neuropathic joint has long been a subject of controversy. Two main theories have evolved: (1) the neurotraumatic theory, which states that the changes result from repeated mechanical trauma to a joint that is insensitive to pain, and (2) the neurovascular theory, which states that the changes result from a neurally initiated vascular reflex that leads to hyperemia and very active bone resorption by osteoclasts. Through clinical, radiographic, and pathologic observation, it is evident that both theories play a role. Initially, the alteration of sympathetic control triggers a persistent hyperemia, leading to active bone resorption. There may or may not be secondary pathologic fractures and subsequent repair. This depends upon whether the joint is insensitive and whether it is subjected to continued weight-bearing; if so, then the neurotraumatic mechanism comes into play, but only secondarily.

Circulatory patterns of deossification.

Bone is a dynamic organ composed of live tissue and inert substance. Thus, an understanding of bone disease has as its foundation the concept of bone as a highly vascular connective tissue in which different nutritional circulatory fields control the deposit and removal of solids in a balanced field. The article offers an explanation of the vascular components of disease and the correlation of anatomically defined nutritional circulatory fields in order to facilitate the necessary breadth and precision of diagnosis.

Neuropathic bone and joint disease.

The pathogenesis of the neuropathic joint has been a subject of controversy for many years. Two main theories of pathophysiologic pathways have evolved: (1) the neurotraumatic, which states that the changes result from mechanical trauma and repetitive injuries to an insensitive extremity or joint and (2) the neurovascular, which states that the changes result from a neurally initiated vascular reflex that leads to hyperemia, angiogenesis, and very active bone resorption by osteoclasts. Through clinical, radiographic, and pathologic observation, it appears evident that both pathways contribute to neuropathic bone and joint disease. Initially, the alteration of sympathetic control triggers a persistent hyperemia, leading to active bone resorption. There may or may not be associated pathologic fractures and subsequent repair. This depends upon the degree of joint insensitivity and whether or not it is subjected to continued weightbearing. If so, the neurotraumatic mechanisms come into play, but only secondarily.

Effect of computerized requisition of radiology examinations on the transmission of clinical information.

RATIONALE AND OBJECTIVES: The authors developed a method to evaluate the availability and accuracy of clinical data proffered by clinicians when ordering radiologic examinations with a computer order-entry system. METHODS: Two thousand consecutive clinical indications for a spectrum of pediatric imaging studies were scrutinized for accuracy by means of computerized chart review, verbal communication with clinical attending staff, and reference to surgical and laboratory results. The indications were classified as appropriate, incorrect, misleading, or incomplete. RESULTS: Of the 2,000 stated indications, 1,464 (73%) provided a reasonable, if minimal, amount of clinical information; however, in 376 (19%) cases the diagnosis or proximate indication was incorrect, in 108 (5%) cases the data were incomplete, and in 52 (3%) cases the information was misleading. CONCLUSION: Computer order-entry systems can improve the transmission of clinical information but they allow misinformation to be provided.

Basic evaluation of older persons with hypertension.

To achieve the objectives of the baseline evaluation of older persons with hypertension, age-related changes that affect blood pressure measurement, assessment of target-organ effects, cardiovascular disease risk, and comorbidities need to be recognized. Careful attention to recommended procedures for blood pressure measurement, conducting a history, performing a physical examination, and using laboratory tests will allow the physician to confirm the presence of hypertension; to assess its effects on target organs; to determine cardiovascular risk status relating to other factors; and to identify other diseases, laboratory abnormalities, or psychosocial factors that may affect subsequent management.