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Objective: To describe the differences in prevalence of tube feeding among states and to examine possible factors that could explain practice patterns., Design: Analysis of random samples from an interstate data bank comprised of the Minimum Data Set (MDS), a standardized, federally mandated assessment instrument for nursing home residents., Setting: Nursing homes in four states participating in a federal demonstration project of case mix payment plus five others with existing MDS data systems., Participants: Individuals 65 years of age and older (N = 57,029), who had very severe cognitive impairment, including total dependence in eating, and who resided in nursing homes during 1994, the most recent year for which uniform data were available., Measurements: State-by-state differences in prevalence of tube feeding, controlling for demographic and clinical variables., Results: The prevalence of tube feeding ranged from 7.5% in Maine to 40.1% in Mississippi. Each state had a significantly elevated prevalence of tube feeding compared with Maine, with odds ratios (ORs) ranging from 1.50 to 5.83, P < .001. Specific directives not to provide tube feeding (OR 0.41, P < .001), and white race (OR 0.45, P < .001) were strongly and negatively associated with tube feeding., Conclusions: Wide regional variations exist in the use of tube feeding of nursing home residents with equivalent impairments. Sociodemographic factors could be important, but more study is needed to determine whether physician characteristics, such as race, attitudes, or knowledge, have an impact and to clarify medical standards for the use of tube feeding in this population.

Context: Universal tuberculin skin testing of children has been shown to be costly and inefficient. In response, several authorities have recommended targeted screening based on epidemiological risk. In 1996, the New York City Department of Health (NYCDOH) developed questions to identify children who require a tuberculin skin test., Objective: To determine the sensitivity, specificity, and predictive validity of the NYCDOH tuberculosis risk assessment questionnaire., Design: Prospective criterion standard study in which tuberculin skin tests and the NYCDOH questionnaire were administered simultaneously between August 1996 and January 1998. Specific questions asked about contact with a tuberculosis case, birth in or travel to endemic areas, regular contact with high-risk adults, and human immunodeficiency virus infection in the child., Setting: Ambulatory clinic in South Bronx, New York, NY., Participants: Consecutive sample of 2920 children aged 1 to 18 years., Main Outcome Measures: Sensitivity, specificity, positive and negative predictive values of the questionnaire, and odds ratio (OR) of reactive skin test results., Results: The NYCDOH questionnaire identified 413 children (14%) as having at least 1 risk factor. Of these, 23 (5.6%) had a positive skin test result; 4 (0.16%) of the 2507 without risk factors had a positive result. Results for the full NYCDOH questionnaire were sensitivity, 85.2%; specificity, 86.0%; negative predictive value, 99.8%; positive predictive value, 5.4%; and OR, 35.2 (95% confidence interval, 12.1-102.4)., Conclusion: The NYCDOH questionnaire is a valid instrument for identifying children for tuberculin skin testing.

Objectives: We investigated the hypothesis that children with cystic fibrosis (CF) and their parents would show more maladaptive behaviors during dinner than children without CF and their parents., Study Design: Children with CF (n = 32) and their parents were compared with 29 children without CF and their parents on the rate and frequency of parent-child behaviors during a typical dinner in the families' homes by using multivariate analyses of variance., Results: When the rate of behavior, controlling for meal length, was examined, no differences were found between groups. However, parents of children with CF were found to differ from parents of control subjects in the frequency of direct and indirect commands (P <.05), coaxes (P <.01), physical prompts (P <.01), and feeding their child (P <.05). Children with CF were found to engage in more talk, spend more time away from the table, refuse food, and exhibit more noncompliance toward commands to eat than control children (P <.05 for all child variables). When behaviors were examined as a function of meal phase, parents of children with and without CF both showed an increase in commands (P <.01), coaxes (P <.05), feeds (P <.01), and physical prompts (P <.01) in the second half of the meal as compared with the first. Children with CF and the control children showed an increase in behaviors incompatible with eating during the second half of the meal compared with the first (P <.01). When faster eaters were compared with slower eaters, faster eaters consumed a higher percentage of the recommended daily allowance of energy (P <.01) than slower eaters and showed a trend to be at higher weight percentiles for age and sex (P =.08) regardless of group (CF or control)., Conclusions: Children with CF and their parents do not differ from children without CF and their parents in the rate of behaviors exhibited or types of strategies used to encourage eating. However, children with CF and their parents engage in these behaviors more frequently. Our data do not support typical parenting behaviors as effective in meeting the CF dietary requirements. Additional support in the form of child behavior management training may be needed to assist parents in meeting their child's caloric requirements.

Study Objectives: To assess the validity of purified protein derivative (PPD) readings by patients and trained health-care professionals as compared with a calibrated model., Design and Participants: Survey of a group of patients, nurses, medical assistants, and physicians at five neighborhood health centers in the Bronx, NY., Interventions: Participants were asked to read a calibrated model with four PPD indurations measuring 0 mm, 3 mm, 7 mm, and 13 mm. Indurations > or = 5 mm were to be considered "positive" reactions., Measurements and Results: Data were obtained from 233 patients and 80 trained professionals. All patients correctly measured the 0-mm induration site and were able to detect the presence of an induration in 99.3% of possible observations. Compared with professionals, patients had more variability in measurements and interpretations of the 3-, 7-, and 13-mm sites. Professionals detected 100% of all indurations. Patients' specificity for the 0- and 3-mm sites was 97.4% and 62.7%, respectively; whereas sensitivity for the 7- and 13-mm sites was 68.2% and 89.3%, respectively. Professionals' specificity for the 0- and 3-mm sites was 98.7% and 65.3%, respectively; their sensitivity for the 7- and 13-mm sites was 86.7% and 97.3%, respectively. Seventy percent of professionals agreed that the model was a realistic representation of PPD indurations., Conclusions: Patients can reliably distinguish between the presence and absence of an induration at a PPD injection site. They are not as reliable in the measurement and interpretation of test reactions. Professionals had considerable variability in their assessments of PPDs but were more precise overall in their assessments than patients.

Objective: To determine factors predictive of failure to return for colposcopy among women with significant abnormalities on Papanicolaou smears in a high-risk clinical population., Design: Telephone survey., Setting: An urban community health center., Participants: Two hundred seventy-nine women randomly selected from all women seen at the health center with abnormal Papanicolaou smears requiring colposcopy during 1993 to 1994. Six (2%) refused participation, and 19% could not be reached for inclusion. Subjects were mostly minority women receiving Medicaid., Main Outcome Measure: Completion of colposcopy., Results: Of the 279 selected women, 79% were interviewed. The rate of adherence with colposcopy was 75% for the respondents. Women who did not know the results of their smear or who incorrectly understood their results were significantly less likely to return for colposcopy (P = .001). Younger women, especially teenagers, were less likely to return (P = .02). Socioeconomic status, education, primary language, health beliefs, fear of cancer, and clinician's gender or discipline were not associated with rate of follow-up. Barriers involving transportation, child care, and insurance also did not predict follow-up., Conclusions: Effective communication of results is the most important factor related to follow-up after abnormal Papanicolaou smear in this setting. In other settings, other factors may be of greater importance.

Background and Objectives: Clinicians in community health centers find it difficult to balance the demands of increased productivity and effective teaching. We hypothesized that precepting third-year students would decrease clinical productivity and that many elements related to the quality of the learning experience (e.g., amount of patient contact, student autonomy) would be adversely affected by pressure to see increasing numbers of patients., Methods: Students and preceptors in a 6-week family medicine clerkship completed daily surveys that measured the presence of quantifiable elements of the ambulatory teaching experience. They also rated the overall quality of learning during each session., Results: For 62 sessions for which both students and preceptors completed evaluations, students rated the overall quality of learning more highly than preceptors. For students, the elements most positively associated with quality of learning were total teaching time and the frequency with which family issues were raised. For preceptors, the elements that predicted quality of learning were the number of patients that students saw independently and total teaching time. The clinical productivity of preceptors did not differ for sessions with and without a student., Conclusions: Preceptors can be effective teachers who encourage student autonomy and who model behaviors central to family practice, without decreasing productivity.

Many people on the waiting list for organ donation die each year without receiving organs. The shortage of organs is even more pronounced in minority communities. Despite the fact that minorities are at higher risk, they may be less likely to support or consent to organ donation. This investigation was undertaken to study racial factors in organ donation, by focusing on differences in awareness, attitudes, and behavior. Three family practice centers in the Bronx with racially diverse but socioeconomically homogenous communities were studied. The study population consisted of a convenience sample of 163 patients who were approached for participation while they waited to see a doctor. Respondents filled out a 25-item survey that measured demographic information; their exposure to, awareness of, and attitudes toward organ donation; and whether they had signed an organ donor card. The results demonstrated overwhelming support for organ donation across all racial groups. Racial differences were found on awareness of and attitudes toward organ donation, and in the signing of organ donation cards. In contrast to other studies, racial minorities were not less likely than whites to support organ donation. These results suggest that making it easier for racial minorities to obtain organ donor cards could increase their rates of consenting to donate organs.

Study Objective: To investigate calorie intake, behavioral eating styles, and parent perception of eating behavior of school-age children with cystic fibrosis (CF) compared with healthy peers., Design: A two-group comparison study., Setting: A clinical sample of 28 school-age children with CF and a community sample of 28 healthy peers matched for age (6 to 12 years) and socioeconomic status., Measurements and Main Results: The children with CF consumed more calories per day (2175 cal/d) than the control children (1875 cal/d) and achieved a significantly higher recommended daily allowance (RDA) of energy (128% of the RDA) than the control children (91.61% of the RDA). Fifty-four percent of the CF sample were achieving the CF dietary recommendations of 120% of the RDA. Despite this energy intake, the CF sample was significantly below the control sample on weight (24.56 vs 31.23 kg), height (125.48 vs 133.06 cm), and z score for weight (-0.811 vs 0.528) and height (-0.797 vs 0.371). On measures of behavioral eating style, the CF sample had significantly longer meals (23.90 min) than the control sample (17.34 min) and had a significantly slower pace of eating (43.27% 10-second intervals with bites) than the control sample (51.29% 10-second intervals with bites) but did not differ significantly on the number of calories consumed during dinner. On a measure of parent report of mealtime behaviors, parents of the children with CF rated mealtime behavior problems of "dawdles" and "refuses food" as more intense (mean, 3. 46) than did the parents of control children (mean, 2.67). For the CF sample, a significant correlation was found between the parent intensity ratings of problem behavior in general and meal duration (r = .48), and a significant negative correlation was found between the parent intensity ratings of problem mealtime behaviors and the percentage of intervals with bites (pace of meal) (r = -.533)., Conclusions: Although the school-age children with CF were consuming more calories per day than their healthy peers, and more than 50% of the children in the CF sample were at or above the CF dietary recommendations, the children in the CF sample were significantly below the control children on measures of weight and height. The behavioral data suggest that increased caloric intake is not without cost, because the CF sample spent an additional 7 minutes per day at dinner and ate their meals at a slower pace than their healthy peers. These data were associated with higher intensity ratings of mealtime behaviors by parents of children with CF. These findings point to the need for individualized assessment of energy needs for school-age children with CF and comprehensive programs that teach parents behavioral strategies to motivate their children to meet these higher energy requirements in an adaptive manner.

The diastereoselectivities of several chiral acylnitroso dienophiles (9a-h, 12 and 15) derived from optically pure, N-protected alpha-amino hydroxamic acids (2a-h, 4 and 7) were determined in an intermolecular hetero Diels-Alder reaction with cyclopentadiene. The diastereomeric excesses ranged from 0 to 72%. Hydroxamic acids with polar functionality were examined extensively to determine the effect of hydrogen bonding on the cycloaddition. The largest increase in diastereoselectivity was observed with increasing the steric bulk at the alpha-position of the hydroxamic acids and not with potential hydrogen bonding interactions. The cycloadditions afforded synthetically useful quantities of functionally rich, enantiomerically pure heterocycles (10a-h, 11a-h, 13, 14, 16 and 17), which have been elaborated into a variety of biologically interesting products.

Objective: To determine the effectiveness of physician-initiated counselling on the rate of health care proxy appointment., Design: Observational study of an intervention in a convenience sample., Setting: A geriatric outpatient clinic in a tertiary care teaching hospital, New York, New York., Participants: A total of 687 patients enrolled in the geriatric clinic during the study period March 1991 through June 1993., Intervention: Physician counselling about the New York State Health Care Proxy Law, distribution of educational materials and healthcare proxy forms, and reminders in 331 of 466 eligible patients., Measurements: Rate of healthcare proxy appointment in eligible and counselled groups; predictors of appointment and non-appointment; time elapsed from counselling to appointment; reasons for non-appointment; characteristics of the proxy appointment process., Results: A healthcare proxy was appointed for 31.5% of patients eligible for counselling and for 44% of patients who actually received the intervention, compared with a 2.3% proxy appointment rate at baseline. Eighty-one percent of the patients completing the proxy appointment process did so at or before their third clinic return visit after the counselling intervention. Of the counselled patients who did not appoint a proxy, 25% explicitly declined, and 75% had not come to a decision by the end of the study period. Proxy completion was associated with ethnicity, education, and more frequent clinic visits. Of those who appointed a proxy, 97% had good or fair comprehension of the procedure, 92% discussed the appointment with their designees, 63% appointed a daughter or son, and 80% discussed their wishes for care at the end of life with their proxy., Conclusions: Physician counselling of older outpatients is an effective means of increasing healthcare proxy appointments.

Study Objective: To investigate calorie intake, behavioral eating styles, and parent perception of eating behavior of preschool children with cystic fibrosis (CF) compared with healthy peers., Design: A two group comparison study., Setting: A clinical sample of 32 preschool children with CF (aged 2 to 5 years) and a community sample of 29 healthy peers matched for age and socioeconomic status., Measurements and Main Results: The two groups did not differ on the total number of calories consumed per day or the percentage of calories derived form fat. The CF sample achieved a significantly higher percent of the recommended daily allowance (RDA) of energy (95% RDA) than the control group (84% RDA), P < .05, but did not achieve the CF dietary recommendations of 120% RDA. On measures of behavioral eating style, the CF sample had significantly longer meals (24.63 min) than the control group (18.57 min), P < .01, but did not differ on pace of eating or calories consumed per bite. On a measure of parent report of mealtime behavior, parents of the CF sample identified mealtime behaviors of "dawdles" and "refuses food" as more problematic (M = .93) than parents of control children (M = .22), P < .05., Conclusions: While preschool children with CF consume as much or more than healthy peers, they are not achieving the CF dietary recommendations. Furthermore, there appear to be behavioral differences in eating and parent perception of CF children's eating that may contribute to the failure to achieve dietary recommendations.

A comparative study was made of the utilization of cardiovascular drugs in a long-term-care facility for the aged for 1987 and 1992 during which the age and sex distributions and incidence of usage were similar. There were statistically significant declines in the usage of diuretics and potassium supplementation, digoxin, antihypertensives, antiarrhythmics, and beta blockers and a rise in the use of calcium-channel blockers. There was a slight fall in the use of antianginal drugs. The ACE inhibitors introduced after 1987 were taken by 6.1%. The dosages of digoxin and diuretics decreased as management was adequate and toxicity avoided and usage of digoxin reduced in accordance with the concept that digoxin is useful in failure only when left ventricular output is impaired.

1. There is no single pathognomonic sign, symptom, or clinical or laboratory test for making the diagnosis of dementia. A key element of the examination must be the inclusion of a mental status evaluation. 2. The FROMAJE--an acronym for Function, Reasoning, Orientation, Memory, Arithmetic, Judgment, and Emotion--Mental Status Guide (FMSG) has the advantage of a clear relationship between the acronym and the characteristics being measured. 3. The FMSG is meant to serve as a guide for the primary care clinician, who may have little experience in formal mental status testing. It is a convenient cognitive screening instrument to detect dementia in the elderly.

Objective: The GDS (Geriatric Depression Scale) has demonstrated validity among ambulatory elderly but is less useful in nursing home (NH) populations, probably because of high rates of cognitive impairment. We, therefore, sought the lowest level of Mini-Mental Status Exam (MMSE) score for which the GDS would remain valid., Design: Validation Study., Setting: Nursing Homes in New York City., Participants: A total of 66 of 168 newly admitted residents to the NH were able to complete psychiatric assessment, undergo an MMSE, and complete the GDS. The psychiatrists and testers (all non-MDs) were blinded to each others' results. Using a cutoff of 10 or greater on the GDS to indicate depression, the GDS's validity (when compared with the psychiatric diagnoses) was sought at ever decreasing levels of cognitive function as measured by the MMSE., Results: The results of all participants (n = 66) revealed a sensitivity of 63% and a specificity of 83%. When only those with an MMSE score > or = 15 (the best cutoff score) were included, 44 (64%) participants were selected, with a sensitivity and specificity of 84% and 91%, respectively., Conclusions: The two-step procedure of first selecting those with MMSE scores > or = 15 and then giving the GDS significantly increases the utility of the GDS in detecting depression in NH residents and should improve the diagnostic process for this widely underdetected problem.

Three mildly malnourished children with cystic fibrosis and their parents participated in a behavioral group-treatment program that focused on promoting and maintaining increased calorie consumption. Treatment included nutritional education, gradually increasing calorie goals, contingency management, and relaxation training, and was evaluated in a multiple baseline design across four meals. Children's calorie intake increased across meals, and total calorie intake was 32% to 60% above baseline at posttreatment. Increased calorie consumption was maintained at the 96-week follow-up (2 years posttreatment). The children's growth rates in weight and height were greater during the 2 years following treatment than the year prior to treatment. Increases in pace of eating and calories consumed per minute were also observed 1 year posttreatment. These findings replicated and extended earlier research supporting the efficacy of behavioral intervention in the treatment of malnutrition in children with cystic fibrosis.

This study supports the importance of assessing the intrinsic and extrinsic attitudes and perceptions of staff on physical restraints. Any program developed to remove physical restraints in nursing homes should focus on safety issues and behavioral interventions that prevent injury to staff and resident. Environmental adaptations that would enhance residents' safety, such as alarms and wedge cushions, would be useful in a restraint reduction program. Educating staff about the risks of physical restraints and about safe alternative interventions might change their attitudes. By developing an educational program that focuses on a few residents at a time and by involving a multidisciplinary team, a truly individualized approach to restraint-free care for residents might be developed.

Background: Cardiopulmonary resuscitation, a potentially lifesaving procedure, is initiated on hospitalized patients who have an arrest in the absence of a written do-not-resuscitate (DNR) order. New York State Law specifies that attending physicians may write a DNR order on an adult patient either with his/her consent or that of a surrogate. Under specified circumstances, concurring physician and witness signatures are also required. This study examines potential obstacles physicians may encounter when implementing a DNR order for a hospitalized patient., Methods: Sixty house staff officers and 45 attending physicians at two New York City medical centers responded to a questionnaire listing 18 potential problems in obtaining a DNR order. Using a Likert scale, respondents rated the prevalence of each problem., Results: Analysis of the data indicates that attending physician's failure to discuss DNR issues with patients and situations involving surrogate decision making are considered major obstacles to obtaining a DNR order. Procedural regulations, including abundant paperwork and witnessed signatures, are not identified as major obstacles., Conclusions: This study suggests a need for improved communication among physicians, patients, and surrogates about advance directives, when feasible, either prior to hospitalization or early in its course, in an effort to comply with DNR legislation in a manner that reflects the patient's wishes and best interests.

Food we eat has an important influence on health and well-being. Many eating habits are established in childhood. 456 children aged eight to 12 years participated in this survey of food eaten at school. Of all the food items eaten as a snack, 48.6% were categorised as junk. 75.8% of the sandwiches brought to school for lunch were made with white bread. Of the remaining food items brought for lunch 63.5% were of the junk variety. Compared with those who brought a snack or lunch from home, those given money to buy their own were more likely to eat junk (p < 0.01). Food eaten at school reflects approximately one third of a child's daily food intake but health food practises for even a third of food intake may be of a value for health and long term eating habits. Nutritional education with the reinforcement of high nutritional standards in schools could improve the situation.

Objective: To determine the influences of age and risk group on the survival of AIDS patients. We concentrated on transfusion because it is the commonest risk factor for AIDS in patients over 70 years of age., Design: Survival curve regression analysis., Participants: Patients aged 13 years and over with AIDS acquired through transfusion, and patients 65 years or older with AIDS as a result of intravenous drug use (IVDU). Data were obtained from the New York City Department of Health., Main Outcome: The patients were divided into four groups, ages 13-40 years, 41-64 years, and 65 years and over with AIDS as a result of transfusion, and 65 years and older with AIDS as a result of IVDU. The survivals of the three transfusion-related AIDS groups were compared, as were the 65 years-and-over groups with AIDS as a result of transfusion or IVDU. AIDS-defining diagnoses between those over and under 65 years with AIDS as a result of transfusion were also compared., Results: The median survival for the three transfusion-related AIDS groups were 273 days, 58 days, and 60 days, respectively. There was a significant association between shorter survival and increasing age. This was largely due to the longer survival of the patients aged 13-40 years. There was no difference in AIDS-defining diagnosis between those over and under 65 years with transfusion-related AIDS. The survival curves of the elderly with AIDS as a result of transfusion or IVDU were not different., Conclusion: Age over 40 years is an independent risk factor for poor survival among transfusion-related AIDS patients. Among the elderly, patients with transfusion-related AIDS have similar survivals to patients with IVDU-related AIDS.

The prevalence of tuberculous infection in residents of a large nursing facility in New York City was assessed. The population was predominantly female (80%) and white (86%), with almost one-half (49%) being foreign born. The mean age of the group was 86.1 years. Four hundred and fifty-five residents were given tuberculin skin tests using the two-step Mantoux test procedure. The prevalence of tuberculous infection was 27.5% with only slight differences being noted between the native-born (28.8%) and foreign-born (26.1%) residents. A 10% booster effect was noted. Tuberculous infection rates were higher in non-white than white residents. A progressive decline in the prevalence of tuberculous infection was noted with increasing age. No cases of tuberculosis were detected. Our study provides a model for collecting and evaluating epidemiologic data to assess infection prevalence and tuberculosis transmission in a long-term care facility.

While postural hypotension was present in almost 20% of ambulatory patients of this long-term institution, associated symptoms were infrequent. A comparison of the groups with and without a history of falls in the prior year revealed no relationship to the presence of postural hypotension and no relationship to a number of medications which have been reported to be associated with orthostatic hypotension. Blood pressure readings should be obtained at 1,3 and 5 min after assuming the erect position as significant falls in blood pressure were found at each interval.

We reviewed the clinical characteristics and outcome of cases of acute myocardial infarction occurring from January 1, 1985, through December 31, 1987, in the population of a long-term care institution for the elderly. The total number of patients in the series was 43. Comparisons were made between those patients transferred to a general acute-care hospital and those who remained at the facility. The most common initial symptoms of acute myocardial infarction in 32 of 48 patients were, in order, dyspnea, dizziness or syncope, precordial pain, and abdominal pain. Nine (of 43) patients were asymptomatic. In the 14 (of 43) patients transferred to an acute-care hospital, cardiac failure, arrhythmias, and cardiogenic shock were much more frequent than among those retained in the long-term care facility. We concluded that a high index of suspicion for the diagnosis of acute myocardial infarction in the institutionalized elderly is indicated. Patients with mild infarction can be retained in long-term care institutions; resulting mortality from cardiac disorders should be low in adequately staffed and equipped long-term care institutions.

Objective: To determine how closely high court decisions regarding tube feeding are a reflection of the situations that occur in the general population., Design: A retrospective review was conducted of memos recording inquiries made to the Society for the Right to Die (SRD), a patient advocacy organization. Characteristics of clients were compared to characteristics of individuals considered in landmark "right-to-die tube feeding cases during the same period of time., Results: Information from 116 memos of inquiries made from 1985 through mid-1990 was compared to 20 court cases, and significant differences were identified. The average age of the SRD clients was 77.6 (+/- 18.4) years compared to 55.1 (+/- 22.8) years for the court cases (P less than 0.001). Of the clients, 79% were 70 years of age or older and 28% were 90 or older; in contrast, 7 (35%) of subjects in the court cases were 70 years of age or older, and none was over 90 (P less than 0.001). In addition, whereas 14 (70%) of the court cases dealt with individuals in a persistent vegetative state, only 17 (15%) of SRD clients carried that diagnosis (P less than 0.001), with the remainder suffering from dementia, various stages of coma, or a variety of other debilitating disorders. The sex distribution, year of inquiry or year of court decision, and geographic distribution were similar. Some states were overrepresented in both groups., Conclusion: High court cases may inadequately reflect the majority of situations that arise on a day-to-day basis. Elderly individuals, in particular those who are not in a persistent vegetative state, are significantly underrepresented.

X-irradiation of the neonatal rat hippocampus produces a selective hypoplasia of fascia dentata granule cells, locomotor hyperactivity, perseverative movements and deficits in passive avoidance. We previously reported that transplantation of fetal hippocampal tissue into the adult (age = 182 +/- 4 days) brain produced a partial recovery of these behavioral deficits. Since graft/host interconnections are more prominent when transplants are conducted soon after radiation-induced hippocampal damage, in this study we transplanted hippocampal or cerebral cortex neurons when host rats were 33 +/- 5 days of age (i.e. only 16 days after radiogenic brain damage). Behavioral evaluations were conducted 80 and 182 days after transplantation or surgical control procedures. In the first test series only, selective components of locomotion (e.g. stereotypy and total distance traveled) and perseverative turning (e.g. mean bout length and turning speed topography) were normalized by the hippocampal grafts. Radiation-induced changes in passive avoidance were less prominent in these studies than in past experiments. Still, transplantation of hippocampal tissue improved performance on this learning task as well. Cerebral cortex grafts did not produce reliable improvements in most behavioral measures. These data suggest that hippocampal grafts placed soon after X-ray induced fascia dentata hypoplasia reduce a broad range of behavioral deficits. However, these benefits are transient and, for the most part, depend on the use of transplant tissues homologous with those damaged.

The terminal phase of dementia is initiated by the inability to swallow. New techniques of enteral alimentation permit more effective, longer intubation. To assess the application of these new techniques to late-stage demented aged patients, all current intubations in a teaching nursing home were reviewed. Of 52 feeding intubations, 26 had been in situ for more than 1 year. A randomly selected comparison group of nonintubated patients was also studied. Weight increased for 48% of the intubated group versus 17% of the nonintubated group (P less than .01). Aspiration pneumonia occurred more often in the intubated group (58%) than in the nonintubated group (17%) (P less than .01). Decubitus ulcers were also more common in the intubated group (21%) than in the nonintubated group (14%). Restraints were used more in the intubated group (71%) than in the nonintubated group (56%). These differences did not reach statistical significance. All of the intubated patients were severely demented, with MMSE scores of zero. Seventy-one percent of the nonintubated group were demented, with MMSE scores of less than 23. Prolongation of the terminal phase of dementia in the aged by tube feeding is now feasible. The implications of this change in the life-span of demented nursing home patients need attention by families, nursing homes, and those who make public health policy.

This case-control study examines the relationship between falls and drug use in elderly residents of a long-term care facility. The drug use and functional status of 57 first-time fallers were compared retrospectively with those of 90 residents who had never fallen. Fallers were taking significantly more drugs than controls. Hypnotic/anxiolytics and cardiac drugs carried a twofold increase in the risk of falling. Fallers were restrained less often, were more often ambulatory, and had been at the institution for a shorter time than controls. Previous studies have failed to use control groups or have selected controls by length of stay, possibly introducing bias into the results. A large prospective study is needed to determine whether these results are generalizable to the elderly institutionalized population as a whole.

Localized X-irradiation of the mitotic cells in the neonatal rat hippocampus produces a discrete hypoplasia of the fascia dentata granule cell layer. This brain damage inhibits the acquisition of a passive avoidance task, and stimulates spontaneous perseverative turning (without reversals) in a plastic hemisphere apparatus. Here we report how transplantation of fetal brain tissue can attenuate these radiation-induced behavioral deficits. The partially shielded cerebral hemispheres of neonatal rats received fractionated exposures to 13 Gray (Gy) of X-rays during the first 16 days post partum. This procedure depleted 90% of the hippocampal granule cells while sparing other brain areas. Control animals were sham irradiated. Baseline behavioral tests were conducted when subjects reached an average age of 147 +/- 4 days. We recorded behavioral parameters known to be sensitive to hippocampal damage: (1) passive avoidance performance, and (2) perseverative spontaneous turning without reversals. Irradiated subjects later (average age = 182 +/- 4 days) received intracerebral transplants of either fetal (E20-21) neurons/neuronal precursors from the fascia dentata or cerebral cortex (control grafts). Additional controls (both irradiated and sham-irradiated) experienced sham surgical procedures or received no surgical manipulation. Two post-surgical behavioral retests were accomplished when rats were 265 +/- 5 and 351 +/- 6 days old. Rats were then sacrificed and brains were treated histologically to assess radiation-induced brain damage, graft survivability and graft locus. Both hippocampal and cerebral cortex grafts generally facilitated performance on the passive avoidance task. This effect was most prominent during the first post-surgical test. Hippocampal transplants (especially those found to reside in the damaged hippocampus) also significantly attenuated perseverative spontaneous rotation at the time of the final post-surgical test series. Cortex grafts found within the damaged hippocampus did not ameliorate perseverative movements, while cortex grafts located outside the hippocampus significantly reduced this behavioral deficiency. These data suggest that selected behavioral deficits may be attenuated by transplanting fetal neural tissue long after early radiation-induced brain damage. The success of these procedures depends on a number of factors including: (1) the behaviors chosen for analysis, (2) the time after transplantation that behavioral tests are conducted, and (3) the source and final location of the donor neural tissue.

Morphine induces a dose-dependent stereotypic locomotor hyperactivity in the C57BL/6J mouse. Although morphine is the prototypical opioid mu receptor agonist, it also binds at delta sites. This has led to speculation as to which set(s) of receptor subtypes mediate opiate-induced locomotor hyperactivity. Here we use selective mu and delta receptor agonists as well as a sophisticated activity measuring apparatus to investigate the neuropharmacology of opioid-induced locomotion in the mouse. Male C57BL/6J mice were implanted with chronic bilateral cannula aimed at the lateral ventricles. Following recovery from surgery, mice received a series of bilateral 1 microliter intraventricular (i.vent.) injections of [D-Ala2-MePhe4-Glyol5]enkephalin (DAGO) (0.1, 1.0, 2.0 micrograms), [D-Pen2, D-Pen5] enkephalin (DPDPE) (2.5, 5.0, 10.0, 30.0 micrograms) (compounds with respective mu and delta opioid receptor selectivity), morphine sulfate (10.0, 20.0, 60.0 micrograms), or saline. Injections were separated by at least 3 days and were presented in a randomized order. We measured several locomotor parameters following each injection. DAGO, DPDPE and morphine each produced horizontal locomotor hyperactivity and lengthened the average distance per move. While morphine and DAGO significantly reduced vertical activity (rearing) and produced thigmotaxis (wall-hugging), DPDPE-injected mice were similar to controls on these locomotor parameters. These data reveal that mouse locomotor hyperactivity can be observed following injections of either morphine or more-selective opioid mu or delta receptor agonists. However, within the drug/dose regimens used here, we noticed qualitative differences in the locomotor topography produced by the selective mu and delta receptor agonists.

To assess the utility of bedside diagnostic measures to detect prognostically significant peripheral vascular disease, we examined 60 nursing home residents by physical examination, Doppler sphygmomamometry and pneumatic oscillometry, and recorded the clinical history. Eighty-eight percent of the cases had tibial/brachial arterial systolic pressure indices below 0.95, the lower limit traditionally considered normal. Yet, no more than 5% of the patients carried a previous diagnosis of peripheral vascular disease or had intermittent claudication, leg ulcers or gangrene. Approximately half of the patients had tibial/brachial pressure indices less than 0.7, and one year later in these cases, there was significantly greater morbidity and nearly twice the mortality of patients with less severe disease. We conclude that simple bedside diagnostic tests of arterial disease used in this study discloses a high prevalence of disease in institutionalized elderly patients and identifies a group at particular risk for morbid complications.

A case-control study of patients ranging in age from 52 to 88 years was done to determine any possible relationship between health factors and senile macular degeneration. Thirty cases and 30 controls were pair-matched according to age, sex, and race. Chart reviews and telephone interviews were the methods of data collection used. The patients were interviewed concerning a history of vascular disease and other health characteristics. The data were analyzed by a paired-sample method. The results of the study showed a definite relationship with age and sex. Moreover, a significant relationship between refractive error and senile macular degeneration was noted. Such an association has not been previously reported. No relationship was found between vascular disease and senile macular degeneration.

We evaluated 4 treatment regimens using single and multiple injections of epinephrine for the initial treatment of acute asthma in children. Twenty-five patients received 2 injections of epinephrine followed by Sus-Phrine (Group EES) given 20 min apart, 25 received Sus-Phrine only (Group S), 24 received Sus-Phrine followed by 2 placebo injections 20 min apart (Group SPP), and 14 received epinephrine only (Group E). Clinical score and pulmonary function were assessed over a 2-h period. The failure rate was similar in Groups EES, S, and SPP (combined failure rate, 17.8%). The failure rate (46%) in Group E was significantly greater (p less than 0.05). The clinical score and pulmonary function was significantly better 5 min after the first injection in Group EES than in Groups S and SPP, but no significant differences were noted thereafter. At 25 min the pulmonary function was similar whether 1 or 2 epinephrine injections were administered. The number of patients exhibiting side effects was significantly greater in the groups receiving epinephrine than in the groups receiving Sus-Phrine only (p less than 0.05). The relapse rates during the 24-h period after the emergency room treatment were similar in Groups EES, S, and SPP (combined relapse rate, 14.3%). We conclude that repeated injections of epinephrine are necessary to sustain bronchodilation but that they do not have a cumulative effect. Furthermore, there is little therapeutic advantage of these repeated injections over a single injection of Sus-Phrine for the initial treatment of acute asthma.

The age distributions in different anatomic areas of the colorectum were compared in 410 patients. The average age for patients with right-sided cancers (71.3 yr) was significantly higher than that for patients with left-sided cancers (67.5 yr). In addition, there was a significantly higher percentage of patients over the age of 70 (mean age of the whole group) in the right colon group as compared with the left colon group. It was concluded that the older age distribution of right-sided cancers might be explained by the delayed effect of an environmental carcinogen in a population with a longer life expectancy.

Although 10% to 15% of patients admitted to acute care hospitals are in a state of delirium, few patients are given this diagnosis by their clinician. We field-tested the Diagnostic and Statistical Manual III (DSM-III) criteria for diagnosing delirium on 133 consecutively admitted patients to an acute medical ward. Twenty patients were delirious using DSM-III criteria, 19 more patients than were reported by the primary clinician. Seven delirious patients were less than 65 years of age (range, 32 to 64 years). Sixty-five percent of patients with delirium died, whereas significantly fewer (3.3%) of patients without delirium died (P less than .0001). We found that delirium could be readily and reliably detected (kappa coefficient of agreement = 0.62 for interrater reliability) using the DSM-III criteria. Clinicians should routinely screen hospitalized patients of all ages using DSM-III criteria to identify delirious patients for an immediate evaluation and treatment.

In an attempt to identify indicators of risk for psychosocial maladjustment in new nursing home residents, we evaluated the first-year course of 88 new nursing home residents. These 88 study patients constituted all the new residents admitted in 1987 to the Kingsbridge Center of the Jewish Home and Hospital for Aged, Bronx, NY, and assigned to the health-related floors (indicating less serious impairments). Social work intake and progress notes were abstracted to evaluate their utility in identifying indicators of risk for medical and psychosocial maladjustment among these patients. Patients admitted from home fared worse (had more medical visits) than those admitted from hospitals. Lack of additional findings suggests that more uniform and structured intake and progress assessments be made.

The relation between mode of therapy and mortality rate and incidence of primary ventricular fibrillation was studied in 265 patients with diabetes mellitus and acute myocardial infarction. Sixty patients were being treated with diet only, 54 were receiving insulin and 151 were taking oral hypoglycemic agents. Fourteen patients (5.3 percent) had primary ventricular fibrillation, and all but one died. No statistically significant association was found between the incidence of primary ventricular fibrillation and the type of treatment for diabetes mellitus. Sixty-four (24.2 percent) of the 265 patients died during hospitalization. Mortality was greater among diabetic patients receiving oral therapy. However, after adjusting for age and sex, the difference among these three treatment regimens did not reach the P less than 0.05 level of significance.

A health seminar seemed to modify knowledge, attitudes, and reported behavior of a self-selected audience which was already well informed and motivated to change. Therefore, the health seminar appears to be a useful educational approach in this context. The question remains: How can those who are neither informed nor motivated be reached? This study suggests that the public seminar may not be an efficient vehicle for this purpose.

Plasma androgen sulfates were measured in 92 patients with myasthenia gravis. Plasma androgen sulfates were strongly associated with thymic pathology. The presence of germinal centers was associated with decreased androgen levels. A weak but significant positive correlation existed between androgen sulfates and lymphocyte counts. Low lymphocyte counts in patients with germinal centers were associated with subnormal androgen concentrations. Plasma androgen sulfate levels decreased immediately after thymectomy, but overall no significant differences were found between prethymectomy and post thymectomy levels. A trend toward higher concentrations of plasma androgens was noted 5 or more years post thymectomy. Plasma androgen sulfate levels in myasthenia gravis patients with breast cancer were markedly depressed. The lowest androgen sulfate levels were observed in patients who had previous bilateral breast cancer and those who, subsequent to the determination of the steroid sulfates, developed a second primary lesion of the breast.

This study found a new behavioral correlate of lesions specific to the dentate granule cell layer of the hippocampus: spontaneous perseverative turning. Irradiation of a portion of the neonatal rat cerebral hemispheres produced hypoplasia of the granule cell layer of the hippocampal dentate gyrus while sparing the rest of the brain. Radiation-induced damage to the hippocampal formation caused rats placed in bowls to spontaneously turn in long, slow bouts without reversals. Irradiated subjects also exhibited other behaviors characteristic of hippocampal damage (e.g., perseveration in spontaneous exploration of the arms of a T-maze, retarded acquisition of a passive avoidance task, and increased horizontal locomotion). These data extend previously reported behavioral correlates of fascia dentata lesions and suggest the usefulness of a bout analysis of spontaneous bowl turning as a measure of nondiscrete-trial spontaneous alternation and a sensitive additional indicator of radiation-induced hippocampal damage.

A significant association between body weight and estrogen receptor protein (ERP) was noted in 83 women with primary and metastatic breast cancer. Thirteen of 34 (54%) women with weight greater than 150 lb had low or absent receptor protein (less than 10 femtomoles/mg of cytoplasmic protein) compared to 15 of 59 (25%) women with weight less than 150 lb (P less than 0.025). The observed association was stronger in the group of 62 postmenopausal women (P less than 0.01). The findings suggest that the endocrine and metabolic milieu in women with increased weight favors autonomous growth of breast cancer, and adjuvant treatment in this group should be planned accordingly.

Although the news media has occasionally reported deaths and injuries related to fraternity hazing in the past, little, if any, attention has been given to the subject in the medical literature. In light of the medicolegal implications surrounding many of these incidents, it is important that medical examiners be aware of the problem. One hundred sixty-eight (168) cases of injuries and deaths related to fraternity hazing activities occurring in the past 60 years in the United States have been collected from secondary sources. A descriptive statistical analysis of the data is presented.