Once-daily irrigation of long-term urethral catheters with normal saline. Lack of benefit.

Urinary incontinence is often managed with a long-term urethral catheter after other methods have failed. Such urethral catheterization is associated with polymicrobial bacteriuria, catheter obstruction, fever, bacteremia, urinary tract stones, and death. Periodic catheter irrigation is a common but untested management procedure intended to prevent catheter obstruction, fevers, and/or bacteremia. To evaluate this technique, we performed a randomized crossover trial comparing ten weeks of once-daily normal saline irrigation with ten weeks of no irrigation in 32 long-term catheterized women. The incidence of catheter obstructions and febrile episodes and the prevalence and species of bacteriuria were similar whether examined as completed crossover patients (N = 23) or as partially completed trials (N = 9). Once-daily irrigation with normal saline of long-term urethral catheters is a time-consuming and costly procedure that is unlikely to have an impact on the morbidity associated with such catheters.

Proxies' decisions about clinical research participation for their charges.

OBJECTIVE: To examine the process by which proxies decide about their charges' participation in clinical research. DESIGN: Using eight hypothetical research studies encompassing a variety of risks and benefits, we interviewed 315 competent persons > or = 65 years old (charges) and, separately, the individuals who would be designated as their proxies if the charges were to become incompetent. The proxies were asked what they thought their charges would decide and what decisions they would make for their charges and for their own participation. SETTINGS: A medical house-call program, two apartment complexes, and three nursing homes. PARTICIPANTS: Charges > or = 65 years old and their proxies. MAIN OUTCOME MEASURE: Comparison of decisions made by charges and by proxies for their charges. RESULTS: The agreement between the proxies' and charges' decisions was not significantly different from random agreement (range of kappa statistics, 0.05-0.15). Rather, proxies' decisions for their charges were significantly related to the proxies' decisions for themselves (kappas, 0.52-0.86). When the paired proxies' and charges' decisions differed, the proxies were protective, more frequently refusing their charges' participation in the perceived riskier research studies. CONCLUSIONS: Proxies did not know what their charges would decide. Their choices for the charges related more to the proxies' decisions about their own participation (which they knew) than to the decisions of their charges (which they didn't know). This is similar to the process of a reasonable person making the decision, a characteristic of decisions made in the best interests of the patient.

Prevalence and characteristics of nursing home-acquired infections in the aged.

OBJECTIVES: This study provides estimates of the prevalence of infections in all patients from a representative sample of 53 Maryland nursing homes; identifies risk factors for these infections; and describes diagnostic procedures carried out. METHODS: The records of 4,259 patients in a stratified random sample of 53 Maryland nursing homes were reviewed for diagnostic procedures, medical, functional, and behavioral status. Infections were identified by signs, symptoms, and laboratory findings. RESULTS: Study patients were characteristic of aged patients in US nursing homes. The prevalence of infections actually acquired in the nursing home (80% of all infections) was 4.4%. Multivariate analysis revealed that skin infections (35% of nursing home-acquired infections) were associated with skin ulcers and inversely with urine incontinence. Fevers of uncertain source (13%) were associated with bladder catheters. Symptomatic urinary infections (12%) and lower respiratory infections (12%) were associated with bedfast status, and the latter with tracheostomy and lung disease. Skin ulcers, urethral catheters, and bedfast status were markers for nursing home-acquired infection. The prevalence of infection in patients with all three markers was 32%; in patients with none, 2%. Fewer than a quarter of the four most common nursing home-acquired infections received an evaluation which met minimal diagnostic criteria established by a panel of infectious disease specialists and geriatricians. Patients with dementia, those in large homes (greater than 150 beds), and those in urban homes were less likely to be evaluated in a manner meeting these criteria. CONCLUSIONS: Use of three characteristics (ie skin ulcers, urethral catheters, bedfast status) to identify patients at risk for nursing home-acquired infections may allow targeted infection surveillance and prevention programs. In addition, nursing home-acquired infections are not evaluated uniformly across patients and facilities, suggesting the need to establish, through further study, guidelines for such evaluations.

Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation.

OBJECTIVE: To determine the prevalences of chronic pyelonephritis and chronic renal inflammation in elderly nursing home patients at the time of death and to assess correlation with urethral catheterization and other putative risk factors. DESIGN: Prospective assessment of risk factors with the prevalences of chronic pyelonephritis and renal inflammation at autopsy. SETTING: A 240-bed long-term care facility. PARTICIPANTS: All residents > or = 65 years old who died and were autopsied during a 2-year period. MEASUREMENTS: Antemortem assessment of risk factors for renal inflammation, including a search for any urethral catheterization in the person's life. Prospective assessment of urethral catheterization, catheter obstruction, and use of anti-inflammatory medications and urine cultures. Urinary tract pathology was assessed for gross and microscopic evidence of inflammation and urinary tract stones. RESULTS: The duration of catheterization was significantly associated with increasing prevalence of bacteriuria, polymicrobial bacteriuria, chronic pyelonephritis, and chronic renal inflammation. The prevalence of chronic pyelonephritis at death was 10 percent (5/52) for patients catheterized > 90 days during their last year of life and zero (0/65) when catheterized < or = 90 days (P < 0.02; Fisher's exact test). Chronic pyelonephritis was significantly associated with renal stones and hydronephrosis. The prevalence of chronic renal inflammation without chronic pyelonephritis was significantly greater than that of chronic pyelonephritis: the prevalence was 43 percent (20/47) when catheterized > 90 days and 18 percent (12/65) when < or = 90 days (P < 0.05). Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension. CONCLUSION: Chronic pyelonephritis and chronic renal inflammation are associated with long-term catheterization.

A practical method of estimating stature of bedridden female nursing home patients.

Accurate measurement of stature is important for the determination of several nutritional indices as well as body surface area (BSA) for the normalization of creatinine clearances. Direct standing measurement of stature of bedridden elderly nursing home patients is impossible, and stature as recorded in the chart may not be valid. An accurate stature obtained by summing five segmental measurements was compared to the stature recorded in the patient's chart and calculated estimates of stature from measurement of a long bone (humerus, tibia, knee height). Estimation of stature from measurement of knee height was highly correlated (r = 0.93) to the segmental measurement of stature while estimates from other long-bone measurements were less highly correlated (r = 0.71 to 0.81). Recorded chart stature was poorly correlated (r = 0.37). Measurement of knee height provides a simple, quick, and accurate means of estimating stature for bedridden females in nursing homes.

An external urine collection device for incontinent women. Evaluation of long-term use.

Urinary incontinence is common in aged women, may precipitate nursing home admission, and may prompt use of a urine collection device, usually an indwelling urethral catheter. The safety and efficacy of a new external urine collection device for women that is affixed to the perineum by an adhesive developed for ostomy bags was evaluated. Applied to 26 aged women, 78% of 2,264 devices were leak-free for 24 hours and 49% for 48 hours. The incidence of new bacteriuria was less than half that found in our earlier studies of long-term urethral catheters in the same institution. Perineal erythema was infrequent and preexisting decubitus ulcers improved or did not change. Four patients were withdrawn, one each because of periurethral itching, diminished urine output, recurrent wetness, and fracture of the proximal femur associated with severe osteoporosis. This device may offer an alternative to urethral catheters for management of urinary incontinence but should not be used on women with urine retention and should be used with care on women with severe osteoporosis. Controlled trials must determine effects upon bacteriologic complications and health-care costs.

Medical aspects of the multidisciplinary assessment and management of osteoarthritis.

Osteoarthritis, the most common form of arthritis, influences a person's mental well-being, ability to work or perform activities of daily living, and personal and family relationships. Ideally, the management of this disease is multidisciplinary, involving not only the use of medication but also exercise instruction, dietary counseling, and psychosocial interventions. The effects of such a comprehensive treatment program have not been well studied. A 12-week trial of multidisciplinary assessment and management of osteoarthritis was conducted. In addition to receiving the anti-inflammatory agent sulindac, patients were evaluated and followed up by health professionals in the disciplines of medicine, physical therapy, occupational therapy, nutrition, social work, and psychology. An initial assessment of the degree of pain, swelling, tenderness, stiffness, and ability to conduct activities of daily living was made, which represented patients' entry status. Subsequent assessments were made by the multidisciplinary team every two weeks for 12 weeks. Seventy-seven patients completed at least ten of the 12 weeks. On entering the study, two thirds of the patients had pain, tenderness, or swelling affecting the hip, knee, or hand. At the end of 12 weeks, 80% of the patients had improvement in their osteoarthritis, and 71% improved in their ability to conduct activities of daily living. The results support the view that a comprehensive approach to osteoarthritis can significantly reduce disability and pain.

Diflunisal and ibuprofen: effects on gastric and duodenal mucosa in patients with osteoarthritis.

Patients with osteoarthritis make up the largest group of users of nonsteroidal anti-inflammatory drugs (NSAIDs), but the effects of these agents on the gastrointestinal mucosa of such patients have not been well studied. This article describes a short-term comparison of two widely used NSAIDs, diflunisal and ibuprofen, in patients requiring these medications for their osteoarthritis. Efficacy, tolerability, and endoscopically documented effects of these drugs on the gastric and duodenal mucosa were assessed. Consenting, eligible patients were randomly assigned to one of the two study drugs for a two-week course. Clinical assessments were made after each week of treatment. Fiberoptic endoscopy and laboratory tests were performed before and after the treatment period. Thirty patients completed the study: 16 received diflunisal and 14 received ibuprofen. Similar improvements in pain, joint mobility, functional capacity, and joint swelling and tenderness were observed in both treatment groups. Transient, mild abdominal cramping was reported by two patients in each group; one patient receiving ibuprofen complained of transient dizziness. No patient withdrew from the study because of side effects. Follow-up endoscopy revealed slight (grade 1) changes in the gastric mucosa of two patients in each treatment group. An additional patient in the ibuprofen group had gastric erosions (grade 2) at the end of the study. Endoscopic changes were not correlated with symptoms. Diflunisal and ibuprofen were found to be similarly effective and well tolerated in the treatment of osteoarthritis. Their use may be associated with some gastrointestinal side effects even during short-term use.

Occupational therapy in the multidisciplinary assessment and management of osteoarthritis.

As part of the multidisciplinary assessment of osteoarthritis, two occupational therapists evaluated the signs and symptoms of osteoarthritis in the hands of 77 patients. The patients were seen every two weeks for 12 weeks. Initially 58% considered themselves disabled; their mean disability score, on a scale of 0 to 3, was 1.7. Crepitus and pain of the joints and tendons occurred in 36% of the patients. Three hundred fifty-five cysts/nodules, primarily bony, were identified, the mean number being significantly greater (P less than 0.05) for women (8.8) than for men (5.3). Despite considerable disability due to osteoarthritis, none of these patients had ever consulted an occupational therapist. At the end of the study, the mean disability score was 1.2, significantly (P less than 0.05) lower than the initial score. Osteoarthritis of the hand was associated with considerable disability, more so in women than in men, and improvement was evident when an occupational therapist participated in the management of this disease.

Health promotion: physicians' beliefs, attitudes, and practices.

There is a paucity of research describing the health-promotion beliefs, attitudes, and practices of physicians. Self-reported data from a survey of 1,040 primary care physicians showed that a majority of physicians (97 percent) believed they should modify patients' behaviors to minimize risk factors and rated a variety of health behaviors as important in promoting health. While most physicians gathered information about risk factors and believed they were prepared to counsel patients, only a small percentage (3-18 percent) reported being very successful in helping patients achieve behavioral change. However, given appropriate support, physicians reported that they could be up to six times more successful in influencing behavioral change. This study indicated that physicians have strong beliefs and interests in health promotion, are interested in continuing education about health promotion topics, and desire a variety of new skills to help patients modify their health behaviors.

Dietary habits, weight history, and vitamin supplement use in elderly osteoarthritis patients.

Osteoarthritis is a chronic disabling disease in the elderly, but few studies have examined nutritional parameters of osteoarthritis patients. For 82 ambulatory elderly osteoarthritis patients, a registered dietitian assessed the following: consumption of 72 food items, using a food-frequency questionnaire; weight history, by measuring current weight and asking the weight at age 20, maximum adult weight, and minimum adult weight; dietary habits; and vitamin supplement consumption. Joint pain and activities of daily living (ADL) were assessed by a physician. On the basis of the Four Food Group guidelines, dietary intakes were suboptimal in the dairy and grain groups, which are important sources of calcium, vitamin D, thiamin, iron, and riboflavin. Eighty percent of the sample were obese (BMI greater than or equal to 27). The average weight change since early adulthood was a gain of 59 lb. Current joint pain and ADL restrictions were not related to obesity or weight gain. Vitamin/mineral supplements were consumed by 37% of the sample.

Organ-limited autopsies. Obtaining permission for postmortem examination of the urinary tract.

OBJECTIVE: To develop a systematic pre- and postmortem program for obtaining permission for autopsies limited to the urinary tract. DESIGN: Comparison versus historical control of autopsy permission using a new process comprising premortem education, modification of the permission process, and autopsy limited to the urinary tract. PARTICIPANTS AND SETTING: Patients, family members, and healthcare providers associated with a nursing home. INTERVENTION: Education of healthcare providers and family members and modification of autopsy consent and performance. MAIN OUTCOME MEASURE: Permission rate and demographic characteristics of patients and family members giving permission. RESULTS: Of the 361 patients who died during the study, we received permission for postmortem examination of the urinary tract for 129 (36%). This was substantially better than the autopsy rate in the year prior to the study, 0.6%. A significantly higher permission rate was associated with patients and contact persons of white race, a higher level of education of the contact person, a nonrelative contact person, and two or fewer individuals making the decision. CONCLUSION: Permission for organ-limited autopsies can be obtained with a systematic approach.

NAPCRG abstracts 1977-1987: analysis of research designs and methods.

Research techniques reflect the approach of a discipline to the issues it faces. The annual North American Primary Care Research Group (NAPCRG) meeting has been a forum for family medicine research since 1973. A cross-sectional content analysis was conducted on all 1,295 printed NAPCRG abstracts from 1977 to 1987, classifying the research design and methods. The number of abstracts per meeting increased from 58 in 1977 to 149 in 1987. The predominant research design was cross-sectional (58%), followed by prospective (15%), experimental (15%), and retrospective (3%). The major methods were surveys (34%), chart reviews (24%), or surveys combined with chart reviews (7%). One fourth of all abstracts were cross-sectional surveys. NAPCRG research designs and methods have not changed substantially during these 11 years.

Prevalence of protein-calorie malnutrition in an extended care facility.

The prevalence of protein-calorie malnutrition has been documented in the acute care hospital. Thirty randomly selected patients at an extended care facility were studied as to their nutritional status. Anthropometric measurements of height, weight, arm circumference, and triceps skin fold were obtained as well as laboratory studies of hematocrit, while blood cell count, albumin, and transferrin. Between 47 and 66 percent of the patients had moderate or severe protein-calorie malnutrition by anthropometric measurements, and 60 percent had a serum albumin level less than 3.5 g/100 mL. There was a significant correlation (r greater than .5) between the percent of standard weight/height and arm muscle circumference (r = .601, P less than .001) as well as triceps skin fold (r = 6.13, P less than .001). Serum albumin was highly correlated to hematocrit (r = .721, P less than .001). Sixty percent of the patients were anemic and 24 percent were leukopenic. There was no correlation between length of stay and serum albumin. Physicians will need to increase their awareness and observation of this problem in patients in extended care facilities and become cognizant of the potential detrimental effects protein-calorie malnutrition may have on the rehabilitative process.

The vitamin-mineral supplement history.

The prolonged use of vitamin or mineral supplements in amounts greater than their recommended dietary allowance (RDA) can lead to medical complications or interfere with the treatment of some diseases. A vitamin-mineral supplement history is necessary to determine whether patients may be contributing to a medical problem and for physicians to counsel patients about the appropriate use of vitamins and minerals. This article provides a three-phased guide for obtaining a comprehensive history of vitamin-mineral supplement use. Phase 1 determines current and past behaviors with respect to kind, dosage, frequency, duration, and constancy of supplement intake. Phase 2 considers patient beliefs about taking supplements and outcomes of supplement usage. Phase 3 outlines considerations important for patient guidance. A vitamin-mineral supplement history should be a routine component of every complete medical history.

Treatment of mild to moderate pain of acute soft tissue injury: diflunisal vs acetaminophen with codeine.

Acute soft tissue injuries create pain and limitation of function. Treatment requires analgesia and time for full recovery. Acetaminophen with codeine (650 mg plus 60 mg, respectively, every 4 to 6 hours) is used frequently as the analgesic of choice. Diflunisal (1,000 mg initially then 500 mg twice a day) vs acetaminophen with codeine was prospectively studied in the treatment of acute mild to moderate pain from soft tissue injuries. Thirty-five patients with acute strains, sprains, or low back pain were randomized to treatment (17 acetaminophen with codeine vs 18 diflunisal). Both groups were similar in the amount of pain and type of injury at initiation of therapy. Patient pain rating went from 3.3 +/- 0.6 to 1.6 +/- 1.5 for acetaminophen with codeine and from 3.3 +/- 0.6 to 1.3 +/- 1.1 for diflunisal. However, 65 percent of acetaminophen with codeine patients experienced side effects, with 35 percent of these patients stopping the medication because of intolerable side effects. In the diflunisal group, 28 percent of the patients experienced side effects and 5 percent had to stop the medication early. Diflunisal was found to be an effective analgesic in mild to moderate pain of acute soft tissue injuries, and caused fewer and more tolerable side effects than did acetaminophen with codeine.

Nutritional supplement utilization in an urban family practice center.

A survey of 128 patients in an urban family health center examined their use of nutritional supplements and found that 31 percent currently used supplements, primarily multivitamins and other vitamins. The patients' desire to increase their energy and to ensure good nutrition were the major reasons for their taking supplements, along with prevention of illness, desire for strength, and dealing with stress. Patients reported that they were influenced by their physicians' advice and were willing to change their supplement use upon physician recommendation. The resident physicians who cared for these patients were also surveyed, and they estimated that an average of 23 percent of their patients used nutritional supplements. Residents did not consider discussion of nutritional supplements to be of high priority, nor did they usually discuss them with their patients. Discussion about the use of nutritional supplements can contribute to the role family physicians play in nutrition education.