The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation rate: a pilot study.

Osteomyelitis secondary to diabetic foot infections can lead to proximal amputation if not diagnosed in a timely and accurate manner. The authors have found no studies to date that correlate a specific erythrocyte sedimentation rate with osteomyelitis. A retrospective chart review of 29 diabetic patients admitted to the hospital with diagnoses of osteomyelitis or cellulitis of the foot during a 1-year period was performed. Of the various lab values and demographic factors compared, erythrocyte sedimentation rate was the only measure that differed significantly between the two groups. A receiver operating characteristic curve was used to obtain the optimal cutoff value of 70 mm/h, a level above which osteomyelitis was present with the highest sensitivity (89.5%) and highest specificity (100%), along with a positive predictive value of 100% and a negative predictive value of 83%. This study shows that in combination with clinical suspicion in diabetic foot infections, the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the presence or absence of bone infection.

Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients.

We evaluated the occurrence and persistence of delirium in 325 elderly patients admitted to a teaching hospital from either a defined community or a long-term care facility. Of the study participants, 34 (10.5%) had Diagnostic and Statistical Manual of Mental Disorders, Third Edition--defined delirium at initial evaluation; of the remaining patients, 91 (31.3%) developed new-onset delirium. An additional 110 patients also experienced individual symptoms of delirium without meeting full criteria. Preexisting cognitive impairment and advanced age were associated with increased risk of incident delirium in the community sample but not the institutional one. Delirium was not associated with an increased risk of mortality, but it was associated with a prolonged hospital stay and an increased risk of institutional placement among community-dwelling elderly. Only five patients (4%) experienced resolution of all new symptoms of delirium before hospital discharge, and only 20.8% and 17.7%, respectively, had resolution of all new symptoms by 3 and 6 months after hospital discharge. These data suggest that delirium is a common disorder that may be substantially less transient than currently believed and that incomplete manifestations of the syndrome may be frequent.

Risk factors for delirium in hospitalized elderly.

OBJECTIVE: To determine risk factors for delirium in elderly hospitalized patients. DESIGN: Cohort analytic study. Using a reliable and valid instrument for detection of delirium, we prospectively followed up a cohort of elderly patients admitted to an acute care hospital. Using standardized criteria, we collected risk factor data from patient medical records. SETTING: General medical and surgical wards of a tertiary-care hospital. PATIENTS: Patients (n = 325) were 65 years of age or older, from either a geographically defined community or a long-term-care institution. We studied those patients (n = 291) not delirious on first evaluation. Fifty-seven patients or their families refused participation. MAIN OUTCOME MEASURES: Incidence of delirium and risk factors calculated as adjusted odds ratios (ORs). MAIN RESULTS: Delirium developed in 91 patients. By stepwise logistic regression, the independent risk factors for in-hospital delirium included prior cognitive impairment (OR, 8.97; 95% confidence interval [CI], 3.99 to 20.14), age over 80 years (OR, 5.22; 95% CI, 2.60 to 10.46), fracture on admission (OR, 6.57; 95% CI, 2.23 to 19.33), symptomatic infection (OR, 2.96; 95% CI, 1.42 to 6.15), and male sex (OR, 2.40; 95% CI, 1.19 to 4.84). Among medication groups, only neuroleptic use (OR, 4.48; 95% CI, 1.82 to 10.45) and narcotic use (OR, 2.54; 95% CI, 1.24 to 5.18) were independently associated with delirium. Anticholinergic use was not associated with delirium. CONCLUSIONS: Delirium in hospitalized patients is most closely associated with factors already present on admission such as prior cognitive impairment, advanced age, and fracture. In the hospital, use of neuroleptics and narcotics and the presence of infection are less strongly associated with this syndrome.

An empirical study of diagnostic criteria for delirium.

OBJECTIVE: The objective of this study was to determine empirically how many patients are identified as delirious or nondelirious according to DMS-III, DMS-III-R, and ICD-10 criteria. METHOD: Daily, a trained research assistant using a structured instrument to detect the presence of symptoms of delirium evaluated 325 elderly patients who were admitted to a general hospital for acute medical problems. Each patient's symptoms were then compared with these diagnostic criteria sets to determine if the patient met criteria for delirium. RESULTS: DSM-III criteria were the most inclusive: they identified 125 patients as delirious. DSM-III-R identified a somewhat different group of 106 patients as delirious. ICD-10 criteria identified only 30 patients as delirious. CONCLUSIONS: The development of new criteria for delirium (e.g., DSM-IV) will have to balance the need to define a pure group of patients for research purposes with the need to include cases of clinical interest. Changes in criteria should be based on data such as those presented in this paper.

Review of research instruments and techniques used to detect delirium.

Over the past several decades, numerous investigators have studied the syndrome of delirium. Researchers have relied on a number of different case finding methods to detect the syndrome. This paper provides an overview of instruments used in studies of delirium. We assess the validity and reliability of these instruments and compare the advantages and disadvantages of the different methods. We then present the rationale for the development of the Delirium Symptom Interview, an instrument constructed for use in the Commonwealth-Harvard Study of delirium in elderly hospitalized patients.

The consultative role of the gerontological nurse specialist in hospitals.

The role of the GNS in an acute care hospital is a many faceted one. The consultative role is difficult to separate from the practitioner, educator, and researcher roles that the GNS also fills. Examining how the GNS functions as both an informal and a formal consultant gives us only a glimpse into the many ways she may be used as a resource to assist clinical nurses in the care of acutely ill, frail, hospitalized elders.

Simulift: a simulation model of human trunk motion.

In this paper, the authors present a deterministic simulation model, which they call Simulift, of trunk-muscle activity and intra-abdominal pressure during a sagittally symmetric trunk exertion. Simulift is a descriptive model that quantifies the time-varying loading of the spine based on observed internal forces. Recent findings about the time sequence of events during trunk motion and established equilibrium formulas provide the theoretical bases for the simulation. A profile of electromyographic activity in ten trunk muscles and intra-abdominal pressure is updated as simulated time passes, or as the trunk motion is simulated. Input to the model includes a list of motion-event times and a set of profile-component-behavior data. Simulift is an "impulse" model that computes instantaneous and time-integrated statistics on individual muscle activity, intra-abdominal pressure, compression, lateral shear, and anterior shear as the profile components of the simulated subject change. Computer results for the simulation model are presented.

Networks of internal trunk-loading activities under controlled trunk-motion conditions.

Many attempts have been made to describe the activity of the internal trunk-loading components (muscles and intra-abdominal pressure) in response to external forces acting on the trunk, as is often the case in the workplace. Most models that describe the activity of these internal components are static and do not consider the time series of events that occurs during performance of a task under dynamic conditions. This research has investigated the time sequence activity of ten trunk muscles and intra-abdominal pressure in ten males as they produced sagittally symmetric maximum trunk extension motions (lifting motions) at different velocities. These exertions include an isometric exertion and isokinetic exertions equal to 25, 50, 75 and 100% of a subject's maximum extension velocity. Several event times were noted for each internal trunk-loading component, and hypothesis tests were performed to determine which of these event times were statistically different from each other under the various motion conditions. This information was used to construct networks of internal trunk-loading activities under the various motion conditions. Time-series events that occur under all conditions, as well as those that changed as a function of velocity, have been identified. This information will be useful for the construction of dynamic internal trunk models, and will facilitate the assessment of dynamic loading of the lumbar spine in the workplace.

Percutaneous transluminal angioplasty in the treatment of ischemic disease of the lower extremity.

Symptoms of severe peripheral vascular disease in the lower extremity necessitate attempts to revascularize the limb. Patients refusing or unable to undergo direct arterial surgery may be candidates for percutaneous transluminal angioplasty. Combined with realistic goals regarding foot salvage, careful selection of patients for angioplasty may prevent unnecessary amputations and permit local surgical care of the foot. Restoration of pain-free ambulation can follow the procedure. The coordinated efforts of various specialists can now be directed toward treatment of previously unmanageable ischemic complications in the foot.