Necrotizing enterocolitis and its association with the neonatal abstinence syndrome.

OBJECTIVE: The purpose of this study was to describe an identified association between necrotizing enterocolitis (NEC) and prenatal opioid exposure with neonatal abstinence syndrome (NAS) in late preterm and full-term neonates. STUDY DESIGN: In this single-center retrospective cohort study, we analyzed inborn neonates with the diagnosis of NEC discharged from 2012 through 2017. We compared infants with NEC > 35 weeks' gestation to those with NEC<35 weeks' gestation. We compared gestational age, birth weight, age of onset of symptoms, and incidence of prenatal drug exposure between groups. Significance was determined using Mann-Whitney and Fisher's exact tests. RESULTS: Over the study period, 23 infants were identified with NEC, 9 (39%) were babies > 35 weeks at birth and 14 (61%) < 35 weeks. Those > 35 weeks had a higher birth weight, earlier onset of symptoms, and a higher percentage of prenatal exposure to opioids compared to those < 35 weeks' gestation. We further described seven infants with late gestational age onset NEC associated with prenatal opioid exposure. CONCLUSIONS: In this cohort of infants with NEC discharged over a 6 year period we found a higher than expected percentage of infants born at a later gestational age. We speculate that prenatal opioid exposure might be a risk factor for NEC in neonates born at > 35 weeks.

A management strategy that reduces NICU admissions and decreases charges from the front line of the neonatal abstinence syndrome epidemic.

OBJECTIVE: The purpose of this study was to test a specialized needs-based management model for a high volume of babies born with neonatal abstinence syndrome (NAS) while controlling costs and reducing neonatal intensive care unit (NICU) bed usage. STUDY DESIGN: Data were analyzed from inborn neonates >35 weeks' gestational age with the diagnosis of NAS (ICD9-CM 779.5), requiring pharmacologic treatment and discharged from 2010 through 2015. Significance was determined using Kruskal-Wallis and Mann-Whitney as well as χ2 for trend. RESULTS: NAS requiring medication treatment increased from 34.1 per 1000 live births in 2010 to 94.3 per 1000 live births in 2015 (P<0.0001 for trend). Hospital charges were significantly different in the three described locations (P<0.0001). Median per patient hospital charges for medically treated NAS were $90 601 (interquartile range (IQR) $64 489 to $128 135) for NAS patients managed in the NICU, $68 750 (IQR $44 952 to $92 548) for those managed in an in-hospital dedicated unit and $17 688 (IQR $9933 to $20 033) for those cared for in an outpatient neonatal withdrawal center. NICU admission was avoided in 78% of the population once both alternative locations were fully implemented. CONCLUSIONS: In this cohort of infants, a 219% increase in the number of infants treated for NAS overwhelmed the capacity of our traditional resources. There was a need to develop new treatment approaches dealing with the NAS crisis and a growing population of prenatally exposed babies. We found that the described model of care significantly reduced charges and stabilized admissions to our NICU despite the marked increase in cases. Without this system, our NICU would be in a critical state of gridlock and diversion; instead, we have efficient management of a large NAS population.

The work of rehabilitation.

PURPOSE: To describe three years of activity of a rehabilitation unit and to make comparisons between clients who receive different levels of active rehabilitation. METHOD: A retrospective study set in an inpatient rehabilitation facility located in Dunedin, New Zealand, examining 874 inpatient admissions over three financial years (2000--2002). Outcome measures include Functional Independence Scores (FIM) at admission and discharge, length of stay, weekly gains in FIM scores, and changes in FIM sub-scores. RESULTS: Assessment and rehabilitation patients made significant FIM gains in comparison to assessment only and social relief (respite care) patients. Assessment and rehabilitation patients showed greater gains in the Physical dimensions of the FIM in comparison to the Cognitive although this is probably a function of different scaling. Floor and ceiling effects were not present in the FIM. CONCLUSIONS: The interdisciplinary rehabilitation program brings about real functional and cognitive gains in a range of patients as measured with the FIM. This adds to the considerable body of research which documents FIM gains and further provides evidence that physical and cognitive gains differ.

Benefit from admission to a geriatric assessment and rehabilitation unit. Discrepancy between health professional and client perception of improvement.

To determine differences in perception of benefit from a patient's admission to a geriatric Assessment and Rehabilitation Unit, we asked both medical and nursing staff (health team) and the patient and carer (clients) for their evaluation after discharge. The areas studied were functional ability, relief of the principal symptom, education about the principal problem, and development of coping skills. Of 94 patients studied, 58 patients were discharged to the community (52 to carers, 6 to live alone) and 36 to institutions. In the former group, the health team had a consistently higher perception of benefit than the clients (P less than .001). Factors positively predicting health team perception of benefit were a higher carer happiness, improvement in patient independence, and internalization of the patient's locus of control. A negative predictor was an increase in patients' responsibilities. Client perception of benefit was positively predicted by fewer problems with companionship and communication with others. The health team's perception rated the adequacy of patient education and development of coping skills more highly than did the clients. In the patients discharged to the community, their perception of benefit at 1 week was a good predictor of survival in the community to 6 weeks. The possible reasons for these differences in perception of benefit and their implications are discussed.

Traumatic mutism in severe head injury relieved by oral diazepam.

A 34-year-old woman with a severe closed-head injury had many impairments including apparent global aphasia. After a diazepam premedication for a motor point block she was heard to speak a few words. A trial of oral diazepam succeeded in restoring speech adequate to make her needs known, which persisted on a maintenance dose of 5 mg t.d.s. The possible diagnoses and reasons for this phenomenon are discussed. We suggest that diazepam may be useful in assessing speech in selected people with severe head injuries.

Do 'social relief' admissions have any effect on patients or their care-givers?

Dependent patients and their care-givers were studied before and 1 week after a social relief admission in order to assess the effects on physical and psychological problems. Data about care-givers stress and mental health were gathered, as well as patient data. Patients' self-care abilities improved slightly but care requirements remained constant. Care-giver stress levels did not change, but there was a highly significant improvement in their mental health. The results suggest that social relief admissions enabled care-givers to continue to look after very dependent people in the community.

Medical profiles of patients admitted to a geriatric assessment and rehabilitation unit.

A prospective prognostic study of all admissions to a geriatric assessment and rehabilitation unit was carried out which analysed the medical profiles of 205 patients admitted for the first time during a four month period. All patients were followed up for at least six months after discharge. Particularly poor prognosis was noted among patients with renal failure, ischaemic heart disease, depression, pneumonia, congestive cardiac failure, trauma, mental disorder and dementia. Good prognosis was reported in patients with Parkinson's disease, faecal impaction, stroke and adverse drug reactions. Multiple diagnoses were common, and only nine patients had no active medical problems during their admission. The implications for adequate training of geriatricians in medicine are discussed.

Analysis of the activities of a geriatric assessment and rehabilitation unit.

In a four month period 228 patients were admitted to the Wakari assessment and rehabilitation unit in Dunedin, New Zealand. One hundred and seventy subjects came from the community, 35 were transferred from the local public hospital, and 23 were readmitted. Median lengths of stay were 13, 26 and 10 days respectively. Assessment of activities of daily living (ADL) dependency on admission and discharge showed a significant improvement in ability by discharge, which correlated closely with place to which subjects were discharged, and with survival. There was 5% inpatients death rate which cumulated to 18%, 23%, 34%, 39% and 46% by six weeks, three months, six months, nine months and one year respectively. High discharge dependency was closely related to poor survival after discharge. Use of domiciliary services did not change because the savings from those who moved into institutions were cancelled out by those who were discharged back to the community being in need of increased social support.

A survey of ESR and eosinophil count in a racially mixed population in New Zealand.

A volunteer study in a racially mixed community in New Zealand has shown marked differences between ESRS in healthy European, Maori, and Cook Island subjects. As expected, females had higher ESRs than males. In the European group the values fell close to the Westergren normal range, but the Maori group had a significant number abnormal, with Islander group showing more abnormalities. Occult bacterial or parasitic infections may explain high ESRs in Islanders, but mycobacteria and microfilaria are considered unlikely causes. Islanders have a high incidence of elevated eosinophil count, but this is not associated with high ESR, or the converse. The oral contraceptive pill causes significant elevation of ESR in European females. Further study is needed to establish causes of the abnormal ESRs detected.

Stress in caregivers of elderly patients: the effect of an admission to a rehabilitation unit.

OBJECT: to study stress in caregivers of elderly dependent persons after admission to a geriatric assessment and rehabilitation unit. METHOD: in 1986-7 we studied patients admitted to a geriatric assessment and rehabilitation unit in Dunedin to establish the relationship between caregiver stress, their psychological health and social functioning, and patient variables such as physical dependency. RESULTS: of the 64 patients who were admitted from the community and who had a caregiver, 42 were discharged back to the community, and 30 remained there until six weeks. On admission caregiver stress was increased by problems perceived in social function (lack of companionship, excessive responsibilities and financial problems) and decreased when the caregiver had a high sense of psychological wellbeing. It was not associated with high patient dependency or the level of social support. Caregiver stress one week after discharge was lower among those with high emotional support and those with an internal locus of control. If caregiver stress one week after discharge was high there was an increased rate of readmission. CONCLUSION: rehabilitation should include interventions directed towards the psychological health and social function of the caregiver as well as the physical independence of the patient. Improved financial support and the provision of companionship through community support groups may result in reduced caregiver stress, which should help dependent elderly people to continue to live in the community.

Why are the sensitive TSH assay and TRH stimulation test frequently low in very old euthyroid subjects?

Twelve healthy clinically euthyroid subjects 80 years and over were compared with 19 young controls to determine if the sensitive TSH test was more specific for hyperthyroidism in the elderly than the TRH stimulation test. Four of the 12 elderly subjects had a sensitive TSH level below the lower limit of normal for young subjects and four elderly subjects had a TSH rise of less than five IU after injection of 200 micrograms of TRH. Neither test is specific for hyperthyroidism in the elderly. There was a highly significant correlation between the sensitive TSH levels and the TSH rise after TRH stimulation in the old subjects but not in the young. This may be further evidence of an age related impairment in the hypothalamo pituitary-thyroid axis.

Medications and their monitoring in Parkinson's disease in Dunedin.

AIMS: to establish the patterns of drug administration and monitoring in people with Parkinson's disease. METHOD: a total community sample was obtained. One hundred and one of the 116 people with Parkinson's disease in Dunedin, who were alive on 31 July 1990, had a full medical assessment. RESULTS: the general practitioner made the diagnosis in 51%, a neurologist in 22%, a geriatrician in 18%, and other in 9%. The general practitioner provided prescriptions for 51 of the 68 people living in the community, a neurologist for 11, and a geriatrician in six cases. The general practitioner provided prescriptions for 23 of the 33 living in an institution, and a geriatrician in ten cases. Medical review took place more frequently than three monthly in 49 cases. There were 81 general practitioners in practice on the prevalence day in the study area. Thirty-six had no patients with Parkinson's disease, 30 had one or two, and the other 15 had varying numbers. Fifty-eight of the 90 patients taking levodopa were taking it as the only therapy. Eight patients were taking phenothiazines. There was a high incidence of side effects and 70 patients had long term complications including loss of effectiveness over time, the end of dose and the on-off phenomena, and dyskinesias. CONCLUSIONS: monitoring of treatment appeared satisfactory but major concerns about drug management included the high use of levodopa monotherapy and the concurrent use by general practitioners of phenothiazines in eight cases. Because most general practitioners have very few patients with Parkinson's disease they will not develop the experience to manage complicated drug regimens in people whose management tends to become more difficult with time. With selegiline and controlled release levodopa only being available on specialist prescription, we suggest that all people with Parkinson's disease should have the benefit of a specialist review at least every two years.

The cost benefit of rehabilitation of injured workers in New Zealand.

A multidisciplinary rehabilitation centre was established to address the needs of people with mild to moderate disability who had not worked for prolonged periods of time. A fitness based programme assisted 10 of the 20 who had been off work for more than six months to return to activity. Six and eighteen month follow up confirmed the durability of placement of most workers who had returned to work, and that projected benefits were achieved. Benefits were defined as savings in earnings related compensation (ERC), and compared to the costs of establishing and running the centre. Sensitivity analysis ascribing between 100% and 50% of benefit to the programme showed a positive benefit cost ratio, with benefits discounted at a rate of 10% over 10 years. With 75% ascribed, the project produced benefit cost ratio of about 1.5:1 in the first year, 2.8:1 in the second year, and rising to 6.2:1 in the fifth year and 10:1 by the tenth year. With only 50% ascribed, the benefit over the same times was 1.0:1, 1.9:1, 4.1:1 and 6.7:1 by the tenth year. These calculations probably underestimate true benefits.

Osteomalacia in the elderly: investigation and diagnosis.

Osteomalacia in New Zealand and Australia has previously been thought rare. The medical records of 22 elderly inpatients diagnosed as having osteomalacia on biopsy criteria in Dunedin between January 1980 and December 1983 were reviewed. Risk factors, mode of presentation, month of presentation, biochemistry, bone biopsy, bright line counting and bone scans were assessed. Our findings, and a review of the diagnosis of osteomalacia in the elderly are discussed. We conclude that in the elderly, osteomalacia is not uncommon, and recommend increased attention to risk factors and biochemical screening.

The rehabilitation of injured workers in New Zealand: a pilot study.

At the request of the local office of the Accident Compensation Corporation (ACC) we established a centre which offered a multidisciplinary rehabilitation programme consisting of a full assessment and an eight week individually planned and monitored fitness programme. The clients progressed to occupational therapy, work trials, and later to paid work. The programme included education about back care and health maintenance, and relaxation techniques. Of the 48 injured people who attended the centre, 37 were assessed as suitable to enter the programme, and 32 people took part. Outcome, measured as return to work or change in assessed fitness to work, was not related to age, sex, marital status, length of time since accident, or work category. Only 25% of workers returned to jobs in medium or heavy manual work. Sickness impact profile total and physical scores improved over the programme, but did not correlate significantly with return to work or fitness for work. Client perception of benefit was not significantly related to outcome. We analysed data from the 20 clients with claims longer than 6 months separately because matched case controls could not be provided by the ACC. Six months after completion of the programme, four were in paid employment, four in prolonged work trials, one in a job partly paid by the ACC, and one setting up his own business. Their return to the work force demonstrated the effectiveness of the centre in restoring people to function after prolonged periods of inactivity.

Informed consent for cardiopulmonary resuscitation in elderly patients.

OBJECT: to determine if a semistructured interview would enable elderly patients to give adequately informed consent for cardiopulmonary resuscitation (CPR). METHOD: one hundred consecutive patients admitted to Wakari assessment and rehabilitation unit for the elderly, who satisfied study criteria, were randomly allocated to receive a detailed discussion on CPR or to act as controls. Subsequently knowledge about CPR was tested in both groups. RESULTS: of the 49 study subjects, 27 (55%) wished to have CPR in the event of a cardiac arrest. After the interview knowledge about the CPR was significantly better in the study group than the controls, but there was still a lack of appreciation of the possible complications and an overly optimistic view of the likely outcome. CONCLUSIONS: careful explanation of the procedures involved in CPR does increase knowledge and assist in making an informed decision. However, the decision may still be based on poor understanding of the likely outcome and possible complications.