Biomedical subjects
P P Coll
Publications and source records attributed to P P Coll.
International medical graduates series inspires readers' comments.
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Clinical risk factors for methicillin-resistant Staphylococcus aureus bacteriuria in a skilled-care nursing home.
OBJECTIVE: To establish the risk factors for methicillin-resistant Staphylococcus aureus (MRSA) bacteriuria in a nursing home population. DESIGN, SETTING, AND SUBJECTS: A case-control study was conducted in a 360-bed skilled-care nursing facility in the northeastern United States that was experiencing an outbreak of MRSA. Fifteen residents were identified as having had MRSA isolated from their urine over an 18-month period and were compared with 40 controls who were randomly selected from all nursing facility residents. RESULTS: In bivariate analysis, MRSA bacteriuria was associated with the presence of an indwelling urinary catheter (odds ratio [OR], 36; 95% confidence interval [CI], 7.0 to 184.2), antibiotic use in the prior 6 months (OR, 2.9; 95% CI, 1.5 to 5.5), and impaired physical function (OR, 5.8; 95% CI, 1.3 to 26.6). Urinary catheter use and antibiotic use remained significantly associated with MRSA bacteriuria even when controlling for impaired physical function. CONCLUSIONS: Methicillin-resistant S aureus is being isolated with increasing frequency in nursing homes, and MRSA bacteriuria may prove to be an important reservoir for the spread of organisms in long-term-care settings. Conservative use of indwelling urinary catheters and of broad-spectrum antibiotics should be investigated as potential control measures to reduce the spread of MRSA in nursing homes.
Nursing home care in 2001.
As we move toward the 21st century, nursing home care will become an increasingly important part of family practice. The number of nursing home residents will grow, their illnesses will become more acute, and the types of medical services provided by nursing homes will broaden. The fiscal difficulty of providing nursing home care will intensify, and a variety of innovative payment programs will be introduced in an attempt to control costs. The only way these will succeed is by a partial reallocation of health care dollars from expensive high-technology hospital care to less expensive low-technology care in nursing homes. As a result of these changes, hospitals will become more involved in the provision of what were traditionally nursing home services. Nursing homes will be used to a larger extent for medical education, and, under congressional pressure, a shrinking pool of federal research dollars will be more fairly allocated to clinical investigation in this setting.
Cytomegalovirus colitis in an older woman, successfully treated with ganciclovir.
Cytomegalovirus (CMV) infections are usually found in immunocompromised persons and rarely present in those who are immunocompetent. We report a case of CMV colitis in an elderly woman presenting with delirium, prolonged fever, and diarrhea. Treatment with ganciclovir, an antiviral agent, resulted in resolution of the colitis within 3 weeks without noticeable side effects. Older adults may be more susceptible to CMV infection by virtue of age-related changes in immune function. The possibility of CMV colitis should be considered in an elderly person with persistent fever, diarrhea, and negative stool cultures.
Methicillin-resistant Staphylococcus aureus in nursing home residents.
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Methicillin-resistant Staphylococcus aureus (MRSA) bacteriuria in nursing home-residents.
Methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly common in nursing homes in the United States. It can cause serious infections and is difficult to eradicate once it becomes established in an institution. We report three representative cases of MRSA bacteriuria occurring in residents of a skilled nursing facility that experienced an outbreak of MRSA beginning in 1988. The clinical options available in such cases are described, and the research methods that should be used to answer important clinical questions arising from the presence of MRSA bacteriuria in long-term care settings are outlined.
Prevalence of mammography use in a nursing home population.
A cross-sectional study was performed to estimate the utilization of screening mammography in a nursing home population. Included in the study were 139 women over 50 years of age who had been residing in a skilled nursing home in Connecticut for at least 1 year. Charts were reviewed to estimate screening mammography and chest x-ray examination use. Functional status of each subject was assessed by supervisory nurses using set criteria. One of the 139 subjects had received a mammogram, whereas 129 subjects (93%) had received chest x-ray examinations. Average length of stay in the nursing home was 6.5 years. No association was noted between functional status and use of mammography. It was concluded that in this clinical setting mammography appears to be underutilized as a screening test for breast cancer. The comparative data on chest x-ray examination use suggest strategies that may be useful in increasing compliance with current screening recommendations for mammography in the institutional setting.
Effects of age, education, and physician advice on utilization of screening mammography.
We investigated the utilization of mammography as a screening test for breast cancer in a middle-income Connecticut suburban community of 30,000 people. The sampling frame was community-dwelling women aged 30 years and over who had telephones. Random digit telephone survey methods were used to identify a sample of 470 eligible subjects. Of those eligible to be included, 350 or 74.4% completed the interview. Analysis of data from the 171 respondents aged 50 years or greater indicated that women aged 65-80 years had a significantly lower rate of screening mammography than did women aged 50-64 years (means 2 = 6.6, P = .01). When further analysis was done to take into account the effects of education and of income on these rates, the association of age with mammography utilization was no longer statistically significant. Among women who recalled their physician advising a mammogram, 88% had had one performed. Among women who could not recall their physician advising a mammogram, 7% had had one. The impact of physician advice was statistically significant (means 2 = 110.3, P less than .001). Physicians recommended screening mammography less for patients with low level of education (means 2 = 21.6, P less than .001), low income (X2 = 7.8, df = 2, P = .02) and greater age (means 2 = 14.2, P = .003). We conclude that utilization of screening mammography in the community studied is related more strongly to education and to income than to age. The bivariate association of mammography utilization with age may be attributable to a cohort effect, rather than an age effect.(ABSTRACT TRUNCATED AT 250 WORDS)
Depression associated with a stroke.
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Successful withdrawal of thyroid hormone therapy in nursing home patients.
BACKGROUND: Studies of community-dwelling patients have indicated that substantial numbers of patients might have had thyroid hormone therapy prescribed inappropriately and that thyroid hormone therapy in some can be discontinued without adverse effects or evidence of clinical hypothyroidism. We wanted to find out whether thyroid hormone therapy in selected nursing home patients could be withdrawn without adverse effect. METHODS: Participants for the study were drawn from four skilled nursing facilities in Connecticut. All patients on thyroid hormone therapy who resided in one of the four facilities at the time the study began were eligible if they met the inclusion criteria and gave consent to participate in the study. We measured baseline thyrotropin (TSH) levels and reduced thyroid hormone therapy by approximately onehalf if baseline TSH levels were 7 mU/L or less. If at a 1-month follow-up measurement a patient's TSH level was 7 mU/L or less, we discontinued thyroid hormone therapy. If TSH levels remained 7 mU/L or less at the next follow-up measurement 1 month later, we measured the free thyroxine (T4) level. If the free T4 level was normal, the patient remained off thyroid hormone therapy, and a final TSH value was measured after a further 2 months. RESULTS: There were 915 patients residing at the four homes at the time the study began. One hundred fifteen were on thyroid hormone therapy; 40 had elevated TSH levels in their nursing home records; and 31 refused to participate in the study. Twenty-two patients were excluded because they died or were discharged before completion of the study, had an elevated baseline TSH reading, or were taking medications that could complicate the accurate measurement of TSH. Twenty-two patients began hormone withdrawal. One patient had an increase in psychiatric symptoms during the withdrawal phase. No other adverse effects were noted. Eleven patients (50%) had the thyroid hormone therapy withdrawn successfully. CONCLUSION: Thyroid hormone therapy was successfully withdrawn from one half of the nursing home residents studied. Previous studies conducted in community-dwelling patients have shown similar findings. Many older patients began taking thyroid hormone therapy when younger either for inappropriate reasons or for what turned out to be transient hypothyroidism. If the findings of this study are generalizable for other nursing home residents, there are important implications for health and health care costs.
Implications of methicillin-resistant Staphylococcus aureus on nursing home practice.
BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is being isolated with increasingly frequency from nursing home patients. There is a limited choice of antibiotics available to treat infections caused by the organism. Control measures for nursing homes have not been well established. METHODS: Using the key words "methicillin," "homes for the aged," and "long-term care," and also using the text term "MRSA," the MEDLINE files were searched from 1966 to 1989 using a CD ROM system. Articles occurring subsequent to this search, until the manuscript was submitted, were accessed using a monthly update from the MEDLINE database using the same key words. RESULTS: MRSA prevalence rates as high as 34 percent have been reported from long-term care settings. Risk factors for developing MRSA include being sick, debilitated, and functionally impaired. Frequent use of antibiotics and invasive devices, such as catheters, are also identified risk factors. The implication of MRSA colonization on patient outcomes is not clear. Vancomycin remains the drug of choice for treating MRSA infections. Control measures include surveillance of new and established cases and the introduction of isolation procedures. Patients colonized with MRSA should not be refused admission to a nursing home because of their MRSA status. CONCLUSIONS: MRSA in nursing homes will continue to increase. There are resulting implications for patient care, health care costs, and admission and discharge policies. Research should first establish what effect MRSA colonization has on clinical outcomes in this setting and, if necessary, go on to develop clinical and cost effective methods of prevention and control.
Advanced directives for homebound patients.
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