MediCaring: development and test marketing of a supportive care benefit for older people.

OBJECTIVES: To develop an alternative healthcare benefit (called MediCaring) and to assess the preferences of older Medicare beneficiaries concerning this benefit, which emphasizes more home-based and supportive health care and discourages use of hospitalization and aggressive treatment. To evaluate the beneficiaries' ability to understand and make a choice regarding health insurance benefits; to measure their likelihood to change from traditional Medicare to the new MediCaring benefit; and to determine the short-term stability of that choice. DESIGN: Focus groups of persons aged 65+ and family members shaped the potential MediCaring benefit. A panel of 50 national experts critiqued three iterations of the benefit. The final version was test marketed by discussing it with 382 older people (men > or = 75 years and women > or = 80 years) in their homes. Telephone surveys a few days later, and again 1 month after the home interview, assessed the potential beneficiaries' understanding and preferences concerning MediCaring and the stability of their responses. SETTINGS: Focus groups were held in community settings in New Hampshire, Washington, DC, Cleveland, OH, and Columbia, SC. Test marketing occurred in New Hampshire, Cleveland, OH; Columbia, SC, and Los Angeles, CA. PARTICIPANTS: Focus group participants were persons more than 65 years old (11 focus groups), healthcare providers (9 focus groups), and family decision-makers (3 focus groups). Participants in the in-home informing (test marketing group) were persons older than 75 years who were identified through contact with a variety of services. MEASUREMENTS: Demographics, health characteristics, understanding, and preferences. RESULTS: Focus group beneficiaries between the ages of 65 and 74 generally wanted access to all possible medical treatment and saw MediCaring as a need of persons older than themselves. Those older than age 80 were mostly in favor of it. Test marketing participants understood the key points of the new benefit: 74% generally liked it, and 34% said they would take it now. Preferences were generally stable at 1 month. In multivariate regression, those preferring MediCaring were wealthier, more often white, more often living in senior housing, and using more homecare services. However, they were not more often in poor health or needing ADL assistance. CONCLUSIONS: Older persons aged more than 80 years can understand a health benefit choice; most liked the aims of a new supportive care benefit, and 34% would change immediately from Medicare to a supportive care benefit such as MediCaring,. These findings encourage further development of special programs of care, such as MediCaring, that prioritize comfort and support for the old old.

Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

OBJECTIVE: To evaluate whether the lack of effect of advance directives (ADs) on decision-making in SUPPORT might arise, in part, from the content of the actual documents. DESIGN: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life-sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives. SETTINGS: Five teaching hospitals in the United States. PATIENTS: A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self-Determination Act. Patients were part of a randomized controlled trial to improve decision-making and outcomes. RESULTS: From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life-sustaining medical treatment, and only 22 of these directed forgoing life-sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff. CONCLUSION: Advance directives placed in the medical records of seriously ill patients often did not guide medical decision-making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases.

Self-reported safety practices in child care facilities.

To determine the prevalence of safety hazards and current injury prevention practices in child care settings, we administered a structured telephone interview to a geographically stratified, randomly selected sample of licensed child care facilities. Representatives of 130 child care facilities responded to questions about current injury prevention practices. Specific hazards assessed were related to burns, falls, poisoning, playgrounds, and emergency telephone numbers. Results indicated that 26.8% of providers who knew the temperature of their tap water stated that it was over 130 degrees F.; 14.1% had space heaters accessible to children; 30.3% of those with stairs accessible to children lacked safety gates; 61.4% of those with playgrounds did not have an impact-absorbing surface under playground equipment; 16.9% of respondents had an unexpired bottle of syrup of ipecac; 55.8% demonstrated that a poison control center telephone number was available to them; and 80% of providers could demonstrate the availability of the telephone number of the local ambulance. We conclude that potential and remedial injury hazards exist in some licensed child care centers and that providers of child care within licensed facilities are a promising target for childhood injury prevention interventions.

Retinal function in Stargardt's disease and fundus flavimaculatus.

Ten patients with Stargardt's disease and 14 with fundus flavimaculatus underwent thorough ophthalmic examinations, retinal photography, and, when possible, fluorescein angiography. Retinal function was also assessed by static and kinetic perimetry, the Farnsworth-Munsell 100-hue test, electro-oculography, and electroretinography. Visual acuity and color discrimination were reduced in all patients (mean visual acuity, 20/120; mean error score, 365). On electroretinography all patients had some significant abnormality of cone function and 24 eyes had abnormal rod function (mean Vmax, 298.3). Electrooculographic findings were abnormal in 24 eyes and borderline in ten others. These abnormalities were similar in both groups but more severe in fundus flavimaculatus. Stargardt's disease and fundus flavimaculatus did not co-exist in any family studied and the mean duration of disease was similar in both, indicating that Stargardt's disease did not progress to fundus flavimaculatus. Both the age of onset and duration significantly affected the severity of fundus flavimaculatus but neither had a significant effect on Stargardt's disease.

Congenital fistulae of the lacrimal gland.

A 15-year-old female was found on routine clinical examination to have bilateral asymptomatic congenital fistulae of the lacrimal glands. The fistulae opened into the conjunctival sac at the external canthus of both eyes. Temporary occlusion of these openings produced an immediate and significant reduction in tear secretion in both eyes.

Osteochondritis dissecans of the knee in children. A comparison of MRI and arthroscopic findings.

The treatment of osteochondritis dissecans (OCD) in children and adolescents is determined by the stability of the lesion and the state of the overlying cartilage. MRI has been advocated as an accurate way of assessing and staging such lesions. Our aim was to determine if MRI scans accurately predicted the subsequent arthroscopic findings in adolescents with OCD of the knee. Some authors have suggested that a high signal line behind a fragment on the T2-weighted image indicates the presence of synovial fluid and is a sign of an unstable lesion. More recent reports have suggested that this high signal line is due to the presence of vascular granulation tissue and may represent a healing reaction. We were able to improve the accuracy of MRI for staging the OCD lesion from 45% to 85% by interpreting the high signal T2 line as a predictor of instability only when it was accompanied by a breach in the cartilage on the T1-weighted image. We conclude that MRI can be used to stage OCD lesions accurately and that a high signal line behind the OCD fragment does not always indicate instability. We recommend the use of an MRI classification system which correlates with the arthroscopic findings.

River Pollution Diagnostic System (RPDS)--computer-based analysis and visualisation for bio-monitoring data.

The importance of biological monitoring for the assessment of river quality is well established. Bio-monitoring programmes, in particular the recording of benthic macroinvertebrate assemblages, produce an abundance of data to support the process of river quality assessment. However, current data analysis techniques are largely based on subjective score systems that do not fully realise the potential information value of such complex multivariate data sets. More advanced techniques of data analysis and visualisation can help to maximise the value of biological data, and hence to more efficiently and effectively direct resources, funding and research. A River Pollution Diagnostic System (RPDS) is described. RPDS was recently developed by the authors for the Environment Agency in England and Wales; it aims to maximise information retrieval from biological and environmental data.

Retrospective self-reported symptoms of attention-deficit hyperactivity disorder: reliability of the Wender Utah Rating Scale.

We measured the internal consistency and four-week temporal consistency and temporal stability of the Wender Utah Rating Scale and its 25-item short form. The Wender scale is a rationally constructed retrospective self-report rating scale for symptoms of Attention-deficit Hyperactivity Disorder. Both scales manifested excellent internal consistency. Over one month, both versions manifested significant temporal consistency and good temporal stability in the nonclinical sample of 83 successful young adults most likely to be referred for an evaluation of suspected Attention-deficit Hyperactivity Disorder. The collegiate group had a considerably higher Wender score than the original normative group, calling into question the adequacy of the limited normative data. However, both forms of the scale are reliable and comprehensive validation research is advocated.

MediCaring: comprehensive support services as a Medicare option.

MediCaring is a feasibility project that aims to develop an alternative benefit for comprehensive, supportive, home-based care to individuals who are enrolled in Medicare. Will Medicare-eligible consumers be willing to relinquish acute care benefits to finance supportive, home-based care?

Fetal maternal case management.

Multiple transfers, multiple specialists, and an unpredictable hospital course can result in ineffective communications among patients and the health care team. Complex care requirements easily become fragmented and lack coordination, thus overwhelming a family and even a well-intended multidisciplinary care delivery team. Because of this concern, the Greater Kansas City Fetal Board originated and implemented a new nursing case management model for high-risk obstetric and fetal patients. Fetal maternal case management crosses traditional hospital and provider boundaries with the pregnant patient. Case management allows parents to identify treatment options, and then create with specialists a plan of care. Case managers work with parents to identify support systems and explore parental preferences. The purpose of this article is to describe the fetal maternal case management model. Readers will better understand the need and value of such a program, as well as gain insight into how to facilitate fetal maternal case management.

The additional pressure-lowering effect in patients with glaucoma of pilocarpine 2 per cent, adrenaline 1 per cent, or guanethidine 3 per cent with adrenaline 0.5 per cent and timolol 0.25 per cent: a double-blind cross-over study.

A group of twelve comparable patients with primary open angle glaucoma were treated with Timolol 0.25 per cent drops to which was added pilocarpine 2 per cent, adrenaline 1 per cent or guanethidine 3 per cent plus adrenaline 0.5 per cent in a cross-over study. The initial intraocular pressure (IOP) reduction due to timolol was statistically significant. The mean additional IOP lowering due to pilocarpine 2 per cent was 1.37 mm Hg, that due to adrenaline 1 per cent was 1.79 mm Hg and that due to guanethidine 3 per cent plus adrenaline 0.5 per cent was 5.29 mm Hg.

Vegetarianism in anorexia nervosa? A review of 116 consecutive cases.

A retrospective study was carried out of 116 consecutive patients with anorexia nervosa to ascertain the extent and nature of vegetarianism in this population. Sixty-three (54.3%) patients were found to be avoiding red meat. In only four (6.3%) of these did meat avoidance predate the onset of their anorexia nervosa. Of the remaining 59 patients (best termed pseudovegetarians), 25 (42.4%) patients continued to avoid red meat by the end of treatment. Pseudovegetarianism was associated with a longer duration of anorexia nervosa, a lower weight during the course of their illness, and living away from the parental home. The reintroduction of red meat into the diet was more likely if vegetarianism were of a short duration.

Bizarre parosteal osteochondromatous proliferation with cortical invasion.

A 15-year-old male presented with an 18-month history of increasing swelling on the radial aspect of his left forearm. Radiographs and MR images showed a partly calcified mass on the lateral border of the radius with erosion of the underlying cortex. Following a CT-guided needle biopsy, the mass was excised by segmental resection of the radial shaft with replacement by a vascularised fibular graft. Histological examination of the resected specimen showed many features typical of a bizarre parosteal osteochondromatous proliferation (BPOP) but with destruction of the underlying cortical bone by cellular spindle cell tissue. Although there were no cytological signs of malignancy, we believe that this unusual disease should be regarded as a particularly aggressive form of BPOP and treated by wide excision. Clinical follow-up of our patient at 2 years shows no sign of local recurrence or metastasis.