RESUMO
Assessment of older people rarely includes functional domains critical for ensuring optimum outcome of treatment in acute hospital care. We report the development of a new assessment instrument, and illustrate how differences between pre-hospital and hospital admission status can be systematically evaluated using the Minimum Data Set for Acute Care (MDS-AC). Content was developed by literature review and consultation with professionals working in acute areas. Dual independent assessments were conducted on hospital in-patients in 4 countries. Inter-assessor reliability coefficients were calculated for each item. Kappa was calculated for all binary and multi-level nominal variables. Quadratically weighted Kappa was estimated for all ordinal multi-level variables. Where one level of the variable contained 90% or more of the subjects, total observed agreement is reported. Separate reliability estimates were calculated for pre-hospitalization and inpatient items. Subjects had a mean age of 78. Completion of pre-hospitalization and hospital period assessment (combined) required 20 and 30 minutes. Excluding items for which 90% or more of subjects were classified into a single scoring level, average inter-assessor reliability coefficient for the pre-hospital period items was 0.57 and for in hospital 0.58. Overall exact agreement was 83% for pre-hospitalization assessment items, and 79% for the in-hospital items. The reliability achieved in the highly unstable situation of the acute admission phase is sufficient for use in clinical care and research. Differences in pre-hospital and admission status necessary for case-mix adjusted comparison of outcomes were illustrated. Development of a means for systematically comparing changes in older people during the course of illness is of increasing importance when addressing questions of the appropriate and inappropriate use of medical technology.
Assuntos
Doença Aguda , Bases de Dados Factuais/normas , Avaliação Geriátrica , Hospitalização , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Cognição , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação Nutricional , Alta do Paciente , Reprodutibilidade dos TestesRESUMO
BACKGROUND: using data from a cross-national data base we report the prevalence of urinary incontinence in nursing home residents, describe the main factors associated with bladder incontinence, and compare the usage of incontinence-related tests and care practices across countries. RESULTS: urinary incontinence is highly prevalent (43-65%) in the seven countries studied. Dependency in ambulating, cognitive impairment and urinary tract infections are significantly associated with urinary incontinence in nursing home populations in most countries. Large cross-country differences are observed in the percentage of elderly undergoing incontinence-related testing and in the percentage of residents using appliances and programmes to treat or prevent incontinence. CONCLUSION: this study of different cultural approaches and strategies to evaluate and treat urinary incontinence may stimulate a public debate on the quality of care in nursing homes and promote the sharing of care practices designed to reduce urinary incontinence.
Assuntos
Idoso/estatística & dados numéricos , Casas de Saúde , Incontinência Urinária/etiologia , Incontinência Urinária/prevenção & controle , Atividades Cotidianas , Idoso de 80 Anos ou mais , Europa (Continente) , Feminino , Avaliação Geriátrica , Pesquisas sobre Atenção à Saúde , Inquéritos Epidemiológicos , Humanos , Japão , Masculino , Prevalência , Fatores de Risco , Estados UnidosRESUMO
A formal on-site survey of all anaesthetizing locations in the Province of Manitoba was initiated in the Spring of 1988. Serious deficiencies of anaesthetic equipment previously noted on random survey were confirmed. Recognizing a need for improved standards for delivery of anaesthetic services through safe, functional anaesthetic equipment, the province undertook to fund the upgrading of all anaesthetic gas delivery systems under its jurisdiction. Sixty-six hospitals were surveyed for a total of 203 anaesthetic machines (111 urban, 92 rural). One hundred and sixty-seven machines had been used at least once in the previous year. After careful assessment 92 machines were replaced, 66 machines were upgraded and 45 machines were deleted from further service. Although the maintenance and upgrading of medical equipment is the individual health care facility's responsibility, substantial benefit was recognized by a provincial approach. The authors recommend a similar approach for other Canadian provinces.
Assuntos
Anestesiologia/instrumentação , Anestesia por Inalação/instrumentação , Anestesiologia/normas , Desenho de Equipamento , Falha de Equipamento , Segurança de Equipamentos , Equipamentos e Provisões Hospitalares , Hospitais Rurais , Hospitais Urbanos , Humanos , Manutenção , Manitoba , Monitorização Fisiológica/instrumentaçãoRESUMO
Ninety-one elderly male residents of a skilled nursing facility were classified as nonbacteriuric (41%), intermittently bacteriuric (34%), or continuously bacteriuric (25%) on the basis of urine cultures obtained over a 3-year period. Bacteriuric and nonbacteriuric residents were similar in age, number of diagnoses and medications, and mobility. However, bacteriuric residents were more frequently confused or demented, whether continuously bacteriuric (78%) or intermittently bacteriuric (62%) compared with nonbacteriuric residents (42%) (p less than 0.04). In addition, bacteriuria was significantly associated with incontinence of bladder (96% of continuous, 66% of intermittent, and 25% of nonbacteriuric; p less than 0.001) and bowel (52%, 39%, and 5.5%, respectively; p less than 0.002). At 6 years of follow-up there were no differences in survival among the three groups. Urinary tract infection caused or contributed to only two (2.9%) deaths. Thus, in this population, bacteriuria was associated with higher functional disability but not with increased mortality.
Assuntos
Bacteriúria/epidemiologia , Institucionalização , Idoso , Bacteriúria/mortalidade , Doença Crônica , Confusão/complicações , Demência/complicações , Incontinência Fecal/complicações , Hospitais de Veteranos , Humanos , Masculino , Incontinência Urinária/complicaçõesRESUMO
Over a two-year period we obtained monthly urine samples from all noncatheterized male residents on two geriatric wards to determine the occurrence and optimal management of bacteriuria in this population. Among 88 men the prevalence of bacteriuria was 33 per cent, and the incidence was 45 infections per 100 patients per year. Outcomes after single-dose therapy for asymptomatic bacteriuria with 43 courses of trimethoprim/sulfamethoxazole and 23 of tobramycin included 15 cures, 40 relapses, and 11 treatment failures. Thirty-six residents who had a relapse or in whom single-dose therapy failed were randomly assigned to receive therapy to eradicate bacteriuria or to receive no therapy. All 20 residents who received no therapy remained bacteriuric. The 16 residents who received therapy had fewer months of bacteriuria after randomization, but at the end of the study only one remained free of bacteriuria. Mortality and infectious morbidity after randomization were similar in the two groups. These data suggest that asymptomatic bacteriuria is common in elderly institutionalized men and that therapy is neither necessary nor effective.
Assuntos
Bacteriúria/epidemiologia , Idoso , Bactérias/isolamento & purificação , Bacteriúria/tratamento farmacológico , Bacteriúria/mortalidade , Combinação de Medicamentos , Instituição de Longa Permanência para Idosos , Humanos , Masculino , Estudos Prospectivos , Distribuição Aleatória , Sulfametoxazol/administração & dosagem , Tobramicina/uso terapêutico , Trimetoprima/administração & dosagem , Urina/microbiologiaRESUMO
In vitro studies in a "mini-Kiil" dialyser showed that, in spite of presumably adequate heparinization (2.5 IU/ml plasma), 51Cr-labelled platelets and 125I-labelled fibrin(ogen) deposited on membranes and blood lines, when freshly drawn human blood was dialyzed for 30 min. Platelet retention dominated, with a Cr/I ratio 3 times that of blood. Increasing the heparin concentration led to a reduction both of 51Cr- and 125I-activity, with a slight fall in the Cr/I ratio. Heparin was unable to prevent platelet retention in the dialyser, but the platelet aggregating effect of heparin was shown to be of minor importance compared to its anticoagulant activity and effect on thrombin induced platelet aggregation. Platelet retention by the blood lines exceeded that of the dialyser, in spite of a much smaller surface area. Differences in thrombogenicity between cuprophane and silicone rubber as well as different flow characteristics in the two situations were probably contributory. When heparinized tubing was used, the radioactivity retained was negligible, but membrane radioactivity was unaltered. A considerable reduction in blood radioactivity during dialysis, not accounted for by the deposits above, suggests the additional formation of more loosely attached platelet/fibrin(ogen) masses.
Assuntos
Plaquetas , Fibrina , Fibrinogênio , Rins Artificiais/efeitos adversos , Trombose , Contagem de Células Sanguíneas , Testes de Coagulação Sanguínea , Radioisótopos de Cromo , Fibrina/análise , Fibrinogênio/análise , Heparina , Humanos , Radioisótopos do IodoRESUMO
The effect of variations in haematocrit (hct) on the retention of 51Cr-labelled platelets and 125I-labelled fibrinogen from normal, heparinized, human blood, circulated in an experimental "mini-Kiil" dialyzing system, was studied. Platelet retention (PR) on dialysis membranes and blood lines was found to increase with increasing hct. When only platelet rich plasma was circulated, a significantly lower PR was noted on the blood lines. Fibrin(ogen) deposition on the same surfaces showed a similar tendency. When 125I-labelled fibrin monomer was added to normal blood, prior to dialysis, fibrin deposition on the membranes and blood lines was of a much higher degree than in the control. However, PR was not significantly influenced by the presence or deposition of the fibrin monomer. Reduced platelet function, caused by incubation with acetylsalicylic acid prior to dialysis, led to less PR on the blood lines, but not on the membranes. The observed difference was, however, not statistically significant (p = 0.06). Pretreatment of platelets with prostaglandin E1, however, was able to reduce PR significantly both on dialysis membranes and blood lines.
Assuntos
Aspirina/farmacologia , Plaquetas , Fibrina , Fibrinogênio , Hematócrito , Rins Artificiais , Prostaglandinas E/farmacologia , Plaquetas/efeitos dos fármacos , Radioisótopos de Cromo , Fibrina/análise , Fibrinogênio/análise , Heparina/farmacologia , Humanos , Radioisótopos do IodoRESUMO
The haemostatic effect of 51Cr-labelled platelets was studied in 5 rabbits made thrombocytopenic (35,000/micronl blood) by whole body ionizing irradiation. Bleeding times were recorded after standardized cuts on the inner side of the rabbit's ear, a method with an acceptable reproducibility. The animals were then each transfused with concentrates of labelled platelets from 2 healthy donor rabbits. This increased the platelet counts to about 2 x 10(5)/micronl blood. Bleeding time values were markably prolonged before transfusion and became normalized when tested 1 and 4 h after transfusion. In 3 control experiments, where unlabelled platelet rich plasma was transfused to thrombocytopenic recipients, a similar shortening of the bleeding time was observed. It is concluded that 51Cr-labelled platelets retain haemostatic ability comparable to non-labelled platelets, when circulating in a recipient animal.
Assuntos
Plaquetas , Hemostasia , Animais , Contagem de Células Sanguíneas , Testes de Coagulação Sanguínea , Transfusão de Sangue , Sobrevivência Celular , Radioisótopos de Cromo , Coelhos , Trombocitopenia/terapia , Fatores de TempoRESUMO
Dialysis of blood and plasma was performed in vitro, in a 'mini-Kill' dialyser as well as in dialysis bags. A marked shortening of the thrombin-clotting time was observed, indicating fall in heparin anticoagulant effect. The concentration of heparin, however, as measured by polybrene titration, was substantially less reduced. Fibrin formation, as evidenced by the ethanol gelation test, occurred more often in the dialysed than in the control plasma. In conclusion, the discrepancy between concentration and anticoagulant effect of heparin could be partly explained by influx from the dialysate of calcium, magnesium, and acetate ions. The fibrin-polymerizing effect of these ions was confirmed by a shortening of the clotting time with Reptilase, a proteolytic enzyme not influenced by thrombin inhibitors such as heparin. In addition, liberation of platelet factor 4 may be responsible for some reduction in antithrombin activity of heparin. No evidence of heparin being dialysed or adhering to the dialysis membrane was found.