Cognitive decline in the middle-aged after surgery and anaesthesia: results from the Wisconsin Registry for Alzheimer's Prevention cohort.

Surgery and anaesthesia might affect cognition in middle-aged people without existing cognitive dysfunction. We measured memory and executive function in 964 participants, mean age 54 years, and again four years later, by when 312 participants had had surgery and 652 participants had not. Surgery between tests was associated with a decline in immediate memory by one point (out of a maximum of 30), p = 0.013: memory became abnormal in 77 out of 670 participants with initially normal memory, 21 out of 114 (18%) of whom had had surgery compared with 56 out of 556 (10%) of those who had not, p = 0.02. The number of operations was associated with a reduction in immediate memory on retesting, beta coefficient (SE) 0.08 (0.03), p = 0.012. Working memory decline was also associated with longer cumulative operations, beta coefficient (SE) -0.01 (0.00), p = 0.028. A reduction in cognitive speed and flexibility was associated with worse ASA physical status, beta coefficient (SE) 0.55 (0.22) and 0.37 (0.17) for ASA 1 and 2 vs. 3, p = 0.035. However, a decline in working memory was associated with better ASA physical status, beta coefficient (SE) -0.48 (0.21) for ASA 1 vs. 3, p = 0.01.

The effect of bone marrow concentrate and hyperbaric oxygen therapy on bone repair.

Neoangiogenesis represents an essential part of bone regeneration. Therefore the improvement of neovascularization is the subject of various research approaches. In addition autologous mesenchymal stem cells concentrate in combination with bone substitute materials have been shown to support bone regeneration. In a rabbit model we examined the proposed synergistic effect of hyperbaric oxygen therapy (HBOT) and bone marrow concentrate (BMC) with porous calcium phosphate granules (CPG) on neoangiogenesis and osseous consolidation of a critical- size defect. The animal groups treated with HBOT showed a significantly higher microvessel density (MVD) by immunhistochemistry. Furthermore HBOT groups presented a significantly larger amount of new bone formation histomorphometrically as well as radiologically. We conclude that the increase in perfusion as a result of increased angiogenesis may play a key role in the effects of HBOT and consequently promotes bone healing.

FDG and FDG-labelled leucocyte PET/CT in the imaging of prosthetic joint infection.

PURPOSE: The demand for arthroplasty is rapidly growing as a result of the ageing of the population. Although complications such as heterotrophic ossification, fracture and dislocation are relatively rare, differentiating aseptic loosening, the most common complication of arthroplasty from infection, is a major challenge for clinicians. Radionuclide imaging is currently the imaging modality of choice since it is not affected by orthopaedic hardware. Whereas FDG PET/CT imaging has been widely used in periprosthetic infection, it cannot discriminate aseptic from septic inflammation. In this study we aimed to evaluate the role of FDG PET/CT and FDG-labelled leucocyte PET/CT in the diagnosis of periprosthetic infection. METHODS: Of 54 patients with painful joint arthroplasty who were imaged by FDG PET/CT for diagnosis of periprosthetic infection examined, 46 (36 women, 10 men; mean age 61.04 ± 12.2 years, range 32-89 years) with 54 painful joint prostheses (19 hip, 35 knee) with grade 2 (above liver uptake) FDG accumulation on FDG PET/CT were included in the study and these 46 patients also underwent FDG-labelled leucocyte PET/CT. Final diagnoses were made by histopathological-microbiological culture or clinical follow-up. RESULTS: The final diagnosis showed infection in 15 (28%) and aseptic loosening in 39 (72%) of the 54 prostheses. FDG PET/CT was found to have a positive predictive value of 28% (15/54). Since patients with no FDG uptake on FDG PET/CT were excluded from the study, the sensitivity, specificity, negative predictive value and accuracy could not be calculated. The sensitivity, specificity, and positive and negative predictive values of FDG-labelled leucocyte PET/CT were 93.3% (14/15), 97.4% (38/39), 93.3% and 97.4%, respectively. CONCLUSION: Since FDG is not specific to infection, the specificity of FDG PET/CT was very low. FDG-labelled leucocyte PET/CT with its high specificity may be a useful method and better than labelled leucocyte scintigraphy in periprosthetic infection imaging.

The progress of early phase bone healing using porous granules produced from calcium phosphate cement.

OBJECTIVE: Bone grafting is a vital component in many surgical procedures to facilitate the repair of bone defects or fusions. Autologous bone has been the gold standard to date in spite of associated donor-site morbidity and the limited amount of available donor bone. The aim of this study was to investigate the progress of bone regeneration and material degradation of calcium phosphate granules (CPG) produced from a calcium phosphate self-setting cement powder compared to the use of autologous bone grafting in the treatment of "critical size defects" on load-bearing long bones of minipigs. METHODS: A critical size defect in the tibial metaphysis of 16 mini-pigs was filled either with autologous cancellous graft or with micro- and macroporous carbonated, apatic calcium phosphate granules (CPG) produced from a calcium phosphate self-setting cement powder. After 6 weeks, the specimens were assessed by X-ray and histological evaluation. The amount of new bone formation was analysed histomorphometrically. RESULTS: The semi-quantitative analysis of the radiological results showed a complete osseous bridging of the defect in three cases for the autograft group. In the same group five animals showed a beginning, but still incomplete bridging of the defect, whereas in the CPG group just two animals developed this. All other animals of the CPG group showed only a still discontinuous new bone formation. Altogether, radiologically a better osseous bridging was observed in the autograft group compared to the CPG group. Histomorphometrical analysis after six weeks of healing revealed that the area of new bone was significantly greater in the autograft group concerning the central area of the defect zone (p<0.001) as well as the cortical defect zone (p<0.002). All defects showed new bone formation, but only in the autograft group defects regenerated entirely. CONCLUSIONS: Within the limits of the present study it could be demonstrated that autologous cancellous grafts lead to a significantly better bone regeneration compared to the application of calcium phosphate granules (CPG) produced from a calcium phosphate self-setting cement powder after 6 weeks. In the early phase of bone-healing, the sole application of CPG appears to be inferior to the autologous cancellous grafts in an in vivo critical size defect on load-bearing long bones of mini-pigs.

Contrast-enhanced magnetic resonance angiography (CE-MRA) of intra- and extra-cranial vessels in dogs.

Until recently intra- and extra-cranial vessels in dogs have been imaged using conventional X-ray or digital subtraction angiography. As both of these methods are surgically demanding and involve the use of complex equipment with potential risks for the animal, they are now mainly used in experimental work. In this study, a method for delineating the intra- and extra-cranial vessels of dogs using contrast-enhanced magnetic resonance angiography (CE-MRA) has been examined. The MR images were acquired on a 1.5-T scanner after a bolus injection of gadolinium contrast medium. CE-MRA showed most of the major intra- and extra-cranial arteries and veins as well as most venous sinuses and plexuses of the brain. Difficulties may arise in differentiating between minor arterial and venous vessels as well as in the measurement of vessel diameter. More frequent use of this diagnostic method in clinical cases will indicate whether MRA of the head and brain is of as much use in veterinary medicine as it has become in human medicine. There is certainly potential value in detecting rare conditions in animals such as aneurysms and vascular malformations, as well as in examining vessels feeding intracranial masses and the investigation of cerebrovascular accidents.

Heavy metal content and element analysis of infant formula and milk powder samples purchased on the Tanzanian market: International branded versus black market products.

Milk powder is a food for malnourished African children and for healthy infants of women with HIV/AIDS. High demand and low purchasing power has resulted in a huge informal, black market in Sub-Saharan Africa. Forty-three milk powder batches were analyzed for 43 chemical elements using ICP-MS One sample (2.3%) was contaminated at a lead concentration of 240 µg/kg dry weight exceeding the European threshold (130 µg/kg dry weight). Macroelement contents revealed a trend decreasing in concentration through skimmed, full cream products to infant formulae. Concentration ranges by dry weight differed in respect of uncertainty intervals of  ±10%. Median Ca, K and P concentrations declined from 11.14 g/kg to 3.21 g/kg, 14.11 g/kg to 4.95 g/kg and 9.12 g/kg to 2.75 g/kg dry mass, respectively. Milk powder samples obtained from the Tanzanian black market were comparable in respect of nutritional and chemical content to international branded full cream products.

CMR-guidance of passively tracked endomyocardial biopsy in an in vivo porcine model.

Endomyocardial biopsy (EMB) is considered to be the diagnostic gold-standard in detection of myocardial-inflammation. EMB is usually conducted under fluoroscopy without any specific target information. Specific target-information provided by cardiovascular magnetic resonance (CMR) may improve specificity of EMB. The aim was to investigate feasibility and safety of CMR-guided and targeted EMB in a preclinical-model using passively-tracked devices. Procedures were performed on a MRI-System equipped with an Interventional Software-Platform for real-time imaging. Ex vivo experiments were conducted to optimize visibility of the guide-sheath. In vivo experiments were conducted in 2 pigs for technical feasibility assessment and in 4 pigs after acute myocardial infarction to test feasibility of guided and lesion targeted EMB. For anatomical real-time imaging a single-shot-balanced-SSFP-sequence was applied. Myocardial targets were identified under real-time imaging (single-shot-T2 (sshT2) and single-shot Late-Gadolinium-Enhancement (sshLGE) sequences). Ex vivo experiments demonstrated best visibility of continuously labelled guide-sheath. CMR-guided EMB was feasible in all cases without major complications. Likewise, lesion-targeting endomyocardial biopsy was feasible in two cases. Biopsies exhibited appropriate sizes and qualities. Real-time lesion sequences revealed comparable CNR values to clinical-protocols. Real-time imaging of lesions showed following signal- and contrast-to-noise ratios (SNR/CNR): SNR of sshT2- and sshLGE was 124 ± 35 and 67 ± 51 respectively, whereas CNR was 81 ± 30 and 57 ± 44. This study demonstrates feasibility and safety of CMR-guided and basically targeted EMB with passively-tracked devices. Signal-to-noise ratios of real-time sequences is non-inferior to standard sequences for lesion detection. CMR-guidance may improve diagnostic accuracy of EMB since CMR can detect myocardial-targets under real-time-imaging.

Do the elderly sue physicians?

We reviewed malpractice data from the state of Wisconsin for 1983 and 1984 to determine the frequency and the outcome of malpractice litigation by the elderly. Research data were obtained from court dockets filed with Wisconsin's Patients Compensation Panel and from 281 attorneys who provided the age for 431 claimants. The results showed that 10.0% of malpractice suits in Wisconsin were filed by the elderly during the study years. When we compared the frequency of litigation with the use of the health care system (number of hospitalizations and inpatient days), the elderly were significantly less likely than younger persons to initiate malpractice litigation despite greater exposure to potential negligence. However, once a malpractice suit was filed, there was no significant difference between older and younger litigants in the disposition of the case or in the likelihood of being the prevailing party when a finding or award was made. These findings suggest that the elderly are less likely to file malpractice claims against health care providers than would be expected given their use of the health care system. This finding may be related to social, economic, and legal barriers to malpractice litigation by older adults.

Temporal association between hospitalization and rate of falls after discharge.

BACKGROUND: Evidence suggests that acute illness and hospitalization may increase the risk for falls. OBJECTIVE: To evaluate the rate of falls, and associated risk factors, for 90 days following hospital discharge. METHODS: We consecutively enrolled 311 patients, aged 65 years and older, discharged from the hospital after an acute medical illness and receiving home-nursing services. Patients were assessed within 5 days of discharge for prehospital and current functioning by self-report, and balance, vision, cognition, and delirium by objective measures. Patients were followed up weekly for 13 weeks for falls, injuries, and health care use. RESULTS: The rate of falls was significantly higher in the first 2 weeks after hospitalization (8.0 per 1000 person-days) compared with 3 months later (1.7 per 1000 person-days) (P =.002). Fall-related injuries accounted for 15% of all hospitalizations in the first month after discharge. Independent prehospital risk factors significantly associated with falls included dependency in activities of daily living, use of a standard walker, 2 or more falls, and more hospitalizations in the year prior. Posthospital risk factors included use of a tertiary amine tricyclic antidepressant, probable delirium, and poorer balance, while use of a cane was protective. CONCLUSIONS: The rate of falls is substantially increased in the first month after medical hospitalization, and is an important cause of injury and morbidity. Posthospital risk factors may be potentially modifiable. Efforts to assess and modify risk factors should be integral to the hospital and posthospital care of older adults (those aged >/=65 years).

Functional outcomes of acute medical illness and hospitalization in older persons.

BACKGROUND: Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization. METHODS: A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning. RESULTS: At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized. CONCLUSION: This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.

The critical size bony defect in a small animal for bone healing studies (I): Comparative anatomical study on rats' femur.

Laboratory rats are small animal models which are often used for scientific investigations in medicine. So far there are only few scientific data about the meaning of these small animal models for in vivo bone healing studies available in literature. Although the rat's femur with its cyclic loadings during gait is an appropriate model for investigations in the field of experimental orthopaedics and traumatology there is a lack of morphometric information with respect to its anatomy. The aim of this study is to evaluate the anatomy of rat femurs in two species, which are often performed in animal experimental medicine. These morphometric data should contribute to develope an appropriated osseous fragment fixation system in the rat's femur. The femurs of Wistar (WR) and Sprague Dawley (SDR) cadavers were prepared and analysed by x-rays in two standard planes. The results were compared with the corresponding data for humans by literature. It could be demonstrated that SDR showed a higher caput-collum-diaphyseal and antetorsion angle, but a lower transcondylar femur valgus angle compared to WR. Cortical thickness, bone marrow cavity diameter and femur length were higher in WR. Wistar rat's femur anatomy shows more similarities to human anatomy than Sprague Dawley rats.

The critical size bony defect in a small animal for bone healing studies (II): implant evolution and surgical technique on a rat's femur.

In the preclinical field of orthopaedic and trauma surgery critical size bony defects (CDS) were used to evaluate the biocompatibility and allow to investigate the osteoinductivity and -conductivity of bone substitutes. Concerning the anatomical size the laboratory rat indicates a lower limit in small animals which are appropriate for experiments on bone. The aim of this study was to define a CSD, to develop a suitable fixation system to stabilize bony fragments in CSD and to point out the specialities of the surgical technique. These informations should help for to design and practice studies concerning bone healing on rat's femur. Based on previously acquired anatomical data of rat's femur, the technical challenges and anatomical specialities of different osteosynthesis techniques in rat's femur surgery are demonstrated. Our experiences with different fixation systems and techniques lead to the development of an external fixator, which guarantees for a stable bone fragment fixation, prevents severe soft tissue damage, allows of a roentgenologic evaluation of the defect zone and prevents from undesired direct biomaterial-implant interactions. Neither the proximal nor the distal femoral nailing technique is appropriate for a stable fixation in CSD of rat's femur. To evaluate the reliability of an own developed external fixator 42 nude rats with a 4.0 mm CSD were investigated clinically and roentgenologically over 10 weeks. The external fixator showed only a small implant failure rate. A solid fusion of the bone fragments was not observed within the 10 weeks follow-up period.

Release of copper from embedded solid copper bullets into muscle and fat tissues of fallow deer (Dama dama), roe deer (Capreolus capreolus), and wild boar (Sus scrofa) and effect of copper content on oxidative stability of heat-processed meat.

When venison with embedded copper bullets was subjected to different culinary processing procedures, the amount of copper released from the embedded bullet was affected more by the retention period of the bullet in the meat during cool storage, than by the different heating protocols. The presence of copper fragments had no significant effect on levels of thiobarbituric acid reactive substances (TBARS). Conversely, TBARS in lean meat (fallow deer, wild boar, roe deer) were significantly affected by culinary treatment (higher TBARS in boiled and boiled-stored meat than in meat barbecued or boiled in brine). In pork-beef patties doped with up to 28mg/kg Cu, TBARS increased after dry-heating and subsequently storing the meat patties. The amount of copper doping had no effect on TBARS for 0 and 7days of storage, but a significant effect at day 14 (fat oxidation retarded at higher Cu doses). Evidence is presented that wild boar meat may be more sensitive to fat oxidation than pork-beef.

Iodine deficiency in pregnant women in Austria.

BACKGROUND/OBJECTIVES: In Austria, iodine deficiency has been considered to be eliminated owing to table salt fortification with iodine, but whether this also applies to pregnant women is unclear. Even mild iodine deficiency during gestation may lead to neurocognitive sequelae in the offspring. SUBJECTS/METHODS: This is a cross-sectional investigation of urinary iodine excretion in 246 pregnant women (first trimester n=2, second trimester n=53, third trimester n=191, gestational diabetes mellitus n=115, no gestational diabetes mellitus n=131). The iodine content of morning spot urine samples was determined using inductively coupled plasma mass spectrometry. RESULTS: Pregnant women in the Vienna area had a median urinary iodine concentration (UIC) of 87 µg/l. Only 13.8% of the cohort were in the recommended range of 150-249 µg/l, whereas 21.5% had a UIC of 0-49 µg/l, 40.2% had a UIC of 50-99 µg/l and 19.5% had a UIC of 100-149 µg/l. In all, 4.9% had a UIC over 250 µg/l. A total of 137 women of foreign origin had a significantly higher iodine excretion compared with Austrian-born women. Maternal or gestational age had no influence on UIC. Although 79 women on iodine supplementation had a significantly higher iodine concentration compared with women without iodine supplementation (97.3 vs 80.1 µg/l, P=0,006), their UIC was below the recommended range, indicating that doses of 100-150 µg per day are not sufficient to normalize iodine excretion. Sodium and iodine concentrations in the urine were tightly correlated (R=0.539, n=61), suggesting that low intake of iodized salt might contribute to insufficient iodine supply. CONCLUSIONS: This study shows that pregnant women in the Vienna area have a potentially clinically significant iodine deficiency and that currently recommended doses of iodine supplementation may not be sufficient.

Treatment of a diaphyseal long-bone defect with autologous bone grafts and platelet-rich plasma in a rabbit model.

INTRODUCTION: Large bone defects are a therapeutic challenge to surgeons and are often associated with a high morbidity. The use of autologous cancellous bone graft represents an essential therapeutic option and is considered the gold standard. However, the use of platelet-rich plasma (PRP) for improving bone defect healing has been discussed controversially. The aim of this study was to evaluate the treatment of a diaphyseal long-bone defect in a rabbit model with a combination of PRP and autologous cancellous bone. MATERIAL AND METHODS: A monocortical long-bone defect in the radial diaphysis of 24 New Zealand white rabbits was filled either with autologous cancellous graft as a control group or with autologous cancellous graft combined with autologous PRP. Histomorphometrical and radiological analysis as well as quantification of platelets and growth factors were performed. The animals were euthanatized after three and six weeks according to the study arms. RESULTS: A significant improvement in bone healing was observed histomorphometrically in the PRP group in the central area of the defect zone (p <0.01) as well as the cortical defect zone (p <0.01). The radiological findings were in accordance with the histomorphometrical results. Comparing native blood and PRP, an enrichment of growth factors and platelets was detectable in the PRP. CONCLUSION: Within this animal study, the combination of PRP and autologous cancellous bone grafts improved bone healing significantly compared to the sole application of autologous bone. Therefore, further efforts should be initiated to establish the composite of PRP and autologous bone for bone healing disorders in clinical use.

Monocyte imaging after myocardial infarction with 19F MRI at 3 T: a pilot study in explanted porcine hearts.

AIM: Inflammation is a hallmark of cardiac healing after myocardial infarction and it determines subsequent cardiovascular morbidity and mortality. The aim of the present study was to explore whether inflammation imaging with two perfluorocarbon (PFC) nanoemulsions and fluorine magnetic resonance imaging ((19)F MRI) is feasible at 3.0 T with sufficient signal-to-noise ratio (SNR) using explanted hearts, an (19)F surface coil and dedicated MR sequences. METHODS AND RESULTS: Acute myocardial infarction (AMI) was induced by balloon angioplasty (50 min) of the distal left anterior descending artery in 12 pigs. One day thereafter, PFCs were injected intravenously to label circulating monocytes. Either emulsified perfluoro-15-crown-5 ether or already clinically applied perfluorooctyl bromide (PFOB) was applied. Four days after AMI and immediately after gadolinium administration, hearts were explanted and imaged with a 3.0 T Achieva MRI scanner. (19)F MRI could be acquired with an SNR of >15 using an in-plane resolution of 2 × 2 mm(2) within <20 min for both agents. Combined late gadolinium enhancement (LGE) and (19)F MRI revealed that (19)F signal was inhomogenously distributed across LGE myocardium reflecting patchy macrophage infiltration as confirmed by histology. In whole hearts, we found an apico-basal (19)F gradient within LGE-positive myocardium. The (19)F-positive volume was always smaller than LGE volume. Ex vivo experiments on isolated monocytes revealed that pig and human cells phagocytize PFCs even more avidly than mouse monocytes. CONCLUSION: This pilot study demonstrates that (19)F MRI at 3.0 T with clinically applicable PFOB is feasible, thus highlighting the potential of (19)F MRI to monitor the inflammatory response after AMI.

Hyperbaric oxygen therapy improves angiogenesis and bone formation in critical sized diaphyseal defects.

Besides the use of autologous bone grafting several osteoconductive and osteoinductive methods have been reported to improve bone healing. However, persistent non-union occurs in a considerable number of cases and compromised angiogenesis is suspected to impede bone regeneration. Hyperbaric oxygen therapy (HBO) improves angiogenesis. This study evaluates the effects of HBO on bone defects treated with autologous bone grafting in a bone defect model in rabbits. Twenty-four New-Zealand White Rabbits were subjected to a unilateral critical sized diaphyseal radius bone defect and treated with autologous cancellous bone transplantation. The study groups were exposed to an additional HBO treatment regimen. Bone regeneration was evaluated radiologically and histologically at 3 and 6 weeks, angiogenesis was assessed by immunohistochemistry at three and six weeks. The additional administration of HBO resulted in a significantly increased new bone formation and angiogenesis compared to the sole treatment with autologous bone grafting. These results were apparent after three and six weeks of treatment. The addition of HBO therapy to autologous bone grafts leads to significantly improved bone regeneration. The increase in angiogenesis observed could play a crucial role for the results observed.

An evaluation of increased mortality rates in Wisconsin nursing homes.

We reviewed mortality data from 80 nonprofit and government-owned skilled nursing facilities (SNFs) to evaluate previously reported increases in deaths occurring in Wisconsin nursing homes since 1983. Comparing nursing home mortality data for 1982 and 1985, we found a 16.6% increase in overall nursing home mortality rates. The increased mortality rates occurred in the sample SNFs regardless of ownership, Medicare certification, bed size, metropolitan area and hospital affiliation. There were two explanations for the increased mortality rates. First, the number of residents dying within 30 days after nursing home admission increased 59%. The majority of these short-lived residents had been discharged from hospitals indicating a transfer of terminally ill patients into nursing homes just prior to death. Second, there was a 27% increase in the mortality rate of residents living in the nursing home for 1 to 5 years suggesting that the population had become sicker between 1982 and 1985. These data reflect both the impact of Medicares Prospective Payment System (PPS) on the study nursing homes and an increase in the severity of illness of Wisconsin's nursing home population between 1982 and 1985. The findings document an increased role for nursing homes in caring for more acutely ill patients since the passage of the PPS, and have implications for nursing home reimbursement policies and quality of care.

Caregivers' utilization of health services: results from the Medicare Alzheimer's Disease Demonstration, Illinois site.

OBJECTIVES: The purpose of this study is to examine the effect of the Medicare Alzheimer's Disease Demonstration and Evaluation (MADDE) conducted in Illinois on the use of health services and Medicare expenditures by caregivers of persons with dementia. DESIGN: Prospective randomized clinical trial. SETTING: The MADDE (1989-1994), Illinois site. PARTICIPANTS: A cohort of 412 Medicare-eligible caregivers of persons with dementia. MEASUREMENTS: Medicare claims files provided data on the number of hospitalizations, hospital bed days, emergency department visits, and total Medicare Part A expenditures. RESULTS: After adjustment for baseline variables, the caregivers in the treatment group, when compared with those in the comparison group, had a lower likelihood of any hospitalization during the study period (odds ratio 0.58 (95% confidence interval (CI)=0.35-0.97), P= .037) and a reduced, but not significant, likelihood of emergency department use (odds ratio 0.66 (95% CI=0.40-1.08), P= .095). For those who were hospitalized, there were no significant differences between the treatment and comparison group caregivers in the number of hospitalizations, hospital length of stay, or Medicare payments. CONCLUSION: These results suggest that enhanced chronic illness case management directed at persons with dementia and their caregivers can reduce the need for acute hospital care.

Risk of falls after hospital discharge.

OBJECTIVES: To determine the incidence of falls within the first month after hospitalization and risk factors associated with falling during this period. DESIGN: Cohort study with 1-month follow-up after hospital discharge. SETTING: 370-bed community hospital. PATIENTS: Consecutive sample of 214 patients, aged 70 years and over, hospitalized for medical illness more than 48 hours and discharged to the community. EXCLUSION CRITERIA: terminal illness, neurologic diagnosis, discharge to skilled nursing facility. MEASUREMENTS: Information was obtained at hospital admission, discharge, and 1 month after discharge. Initial assessment included demographic data, vision, mood, pre-admission function, and use of assistive device. Discharge assessment included length of hospital stay, use of assistive device, need for professional help after discharge, medications cognition, and functional status. Patients were assessed 1 month after discharge for history of confusion and falls. Main outcome measure was falls in the first month after discharge. MAIN RESULTS: Twenty-nine patients (13.6%) fell during the month after discharge. Major risk factors for falls included, at discharge, decline in mobility (P = 0.005), use of assistive device (P = 0.002), and cognitive impairment (P = 0.05), and after hospital discharge, self-report of confusion (P = 0.002). Patients who were functionally dependent and needed professional help after discharge had the highest rate of falls (20.2%). In contrast, only 8.4% of independent patients not requiring professional help fell (P = 0.01). CONCLUSIONS: There is a high incidence of falls after hospital discharge, particularly among patients who are functionally dependent. Further study is needed to determine to what extent acute illness and hospitalization may influence falls risk.