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According to the practice guidelines of the American Bum Association on burn shock resuscitation, intravenous (i.v.) fluid therapy is the standard of care for the replacement of fluid and electrolyte losses in burn injury of > or = 20% of the total body surface area. However, in mass burn casualties, i.v. fluid resuscitation may be delayed or unavailable. Oral rehydration therapy (ORT), which has been shown to be highly effective in the treatment of dehydration in epidemics of cholera, could be an alternate way to replace fluid losses in burns. A prospective case series of three patients was carried out as an initial step to establish whether oral Ceralyte 90 could replace fluid losses requiring i.v. fluid therapy in thermal injury. The requirement of the continuing i.v. fluid therapy was reduced by an average of 58% in the first 24 hours after the injury (range 37-78%). ORT may be a feasible alternative to i.v. fluid therapy in the resuscitation of burns. It could also potentially save many lives in mass casualty situations or in resource-poor settings where i.v. fluid therapy is not immediately available. Further studies are needed to assess the efficacy of this treatment and to determine whether the present formulations of ORT for cholera need modification. [ABSTRACT FROM AUTHOR]

Background: Acutely ill older persons often experience adverse events when cared for in the acute care hospital.Objective: To assess the clinical feasibility and efficacy of providing acute hospital-level care in a patient's home in a hospital at home.Design: Prospective quasi-experiment.Setting: 3 Medicare-managed care (Medicare + Choice) health systems at 2 sites and a Veterans Administration medical center.Participants: 455 community-dwelling elderly patients who required admission to an acute care hospital for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis.Intervention: Treatment in a hospital-at-home model of care that substitutes for treatment in an acute care hospital.Measurements: Clinical process measures, standards of care, clinical complications, satisfaction with care, functional status, and costs of care.Results: Hospital-at-home care was feasible and efficacious in delivering hospital-level care to patients at home. In 2 of 3 sites studied, 69% of patients who were offered hospital-at-home care chose it over acute hospital care; in the third site, 29% of patients chose hospital-at-home care. Although less procedurally oriented than acute hospital care, hospital-at-home care met quality standards at rates similar to those of acute hospital care. On an intention-to-treat basis, patients treated in hospital-at-home had a shorter length of stay (3.2 vs. 4.9 days) (P = 0.004), and there was some evidence that they also had fewer complications. The mean cost was lower for hospital-at-home care than for acute hospital care (5081 dollars vs. 7480 dollars) (P < 0.001).Limitations: Possible selection bias because of the quasi-experimental design and missing data, modest sample size, and study site differences.Conclusions: The hospital-at-home care model is feasible, safe, and efficacious for certain older patients with selected acute medical illnesses who require acute hospital-level care. [ABSTRACT FROM AUTHOR]

Antibiotic-associated diarrhoea (AAD) is a common cause of morbidity and mortality. Older individuals in long-term care facilities are particularly vulnerable due to multisystem illnesses and the prevailing conditions for nosocomial infections. Lactoferrin, an antimicrobial protein in human breastmilk, was tested to determine whether it would prevent or reduce AAD, including Clostridium difficile in tube-fed long-term care patients. Thirty patients were enrolled in a randomized double-blind study, testing eight weeks of human recombinant lactoferrin compared to placebo for the prevention of antibiotic-associated diarrhoea in long-term care patients. Fewer patients in the lactoferrin group experienced diarrhoea compared to controls (p = 0.023). Based on the findings, it is concluded that human lactoferrin may reduce post-antibiotic diarrhoea. [ABSTRACT FROM AUTHOR]

Objectives: To determine the outcomes of chronically ventilated patients outside the setting of intensive care units., Design: Systematic review., Setting and Participants: Studies evaluating patients on chronic invasive mechanical ventilation in different care settings., Methods: A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion., Results: Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death., Conclusions and Implications: Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources., Competing Interests: The authors declare no conflict of interest.

Background: Hand hygiene, a simple and low-cost measure, remains the leading intervention for reducing the burden related to healthcare-associated infections (HAIs). While many interventions have been tested to improve staff hand hygiene compliance, hospital visitors continue to have low compliance rates, which increases the risk of HAIs and resistant organisms' transmission into hospitals and out to the community., Aim: To assess the effectiveness of educational speech intervention (ESI) for increasing hand hygiene compliance rate among hospital visitors., Methods: This interventional study was conducted from March to June 2019 in an inpatient unit of a large academic hospital. Visitor hand hygiene compliance was observed before and after implementation of ESI. The purpose of providing ESI to the visitors in the intervention phase was to remind them about the importance of hand hygiene and the proper method for cleaning hands. Post-intervention data were collected using the survey questionnaires. Unpaired t-test compared the hand hygiene compliance rate before and after the intervention., Findings: Baseline hand hygiene compliance rate was 9.73% while hand hygiene compliance rate post-intervention increased to 87.06% (P<0.001). Barriers to hand hygiene compliance included occupied hands, improper location of hand hygiene supplies, and past habit of not practising hand hygiene. Visitors preferred to be reminded about hand hygiene by verbal reminder (57%), followed by signage (38%), and wristband notices (5%)., Conclusion: The ESI substantially increased visitors' hand hygiene compliance rate. Further studies are warranted to assess the sustainability of ESI and address other barriers to visitors' hand hygiene compliance., (Copyright © 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Introduction: Among survivors of intensive care, many remain dependent on mechanical ventilation and are discharged to long-term chronic ventilator units or to skilled nursing facilities. Few long-term outcome data are available on patients transferred from long-term chronic ventilator units., Methods: We retrospectively followed subjects discharged from a long-term chronic ventilator unit from 2010-2012. We determined where these subjects went, evaluating whether location of discharge had an effect on mortality., Results: We followed 79 subjects who were 64.9 ± 15.9 y old. Average stay in the long-term chronic ventilator unit was 38.5 ± 20.1 d. Within the first year after discharge, 24 (30.3%) subjects died: 17 in a skilled nursing facility, 7 at home. Of those who survived the first year, 28 had been discharged to a skilled nursing facility and 27 to home. Survivors were younger (62.6 ± 12.4 vs 70.4 ± 13.1 y, P = .03), had shorter intensive care unit lengths of stay (10.4 ± 5.0 vs 16.4 ± 11.5 d, P = .03), and were more likely discharged home from long-term chronic ventilator unit (49.0% vs 29.1%, P = .040)., Conclusions: Subjects discharged from an long-term chronic ventilator unit and were alive at 1 y had shorter stays in the ICU and were more likely to be discharged home. Further attention is warranted to assure the survival of critical care patients once they are discharged from intensive care units., (Copyright © 2017 by Daedalus Enterprises.)

A 27-year-old patient with spina bifida and a high output loss of water and electrolytes from her ileostomy was successfully liberated from dependency on total parenteral nutrition and intravenous fluid and electrolyte replacement by the use of a rice-based oral rehydration therapy (ORT). This allowed her to return home to the care of her mother. We suggest that ORT can be effective in the context of modern high-technology settings, as well as in resource-poor situations.

Purpose: Skilled nursing facility ventilator units (SNF) are a recent attempt to reduce the costs of an increasing number of patients who are in acute intensive care units and are not able to be liberated from ventilators. Transfers of such patients from long-term care chronic vent units (LTCVs) to SNFs in Maryland began in 2006. The safety of these transfers needs to be assessed., Methods: We retrospectively followed up all patients designated as eligible by their insurance for transfer from our LTCV units to SNF from July 1, 2008 through June 30, 2010 looking only at survival. Those patients who refused transfer and appealed and remained in our LTCV were compared to those who were transferred to SNF ventilator units. The analysis was by Kaplan-Meier statistics., Results: There was an increased mortality (P=.025) of those transferred to SNF ventilator facilities as compared to those remaining in the LTCV., Conclusion: We recognize that bias may occur in patients choosing to remain in our LTCV compared to those accepting transfers, the magnitude of the difference in mortality indicates the need for more comprehensive well designed analysis investigating the outcome of all transfers occurring to and from LTCVs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Heat-related injury presents significant threats to the health and operational effectiveness of Soldiers and military operations. In 2012, active component, U.S. Armed Forces experienced 365 incident cases of heat stroke and 2,257 incident cases of ?other heat injury.? Most of these occurred among recruit and enlisted personnel and most were under the age of 30. In conditioned military personnel, a rice-based oral rehydration solution was superior to water alone at maintaining body weight and, by inference, enabled Soldiers to better maintain their the state of hydration during prolonged exercise in high ambient temperatures. In view of the health risks associated with dehydration and their effects on training and operations, this study suggests that the consumption of beverages containing electrolytes and a rice-based carbohydrate is superior to the consumption of water alone in preventing dehydration and heat related illness., (2013.)

Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea in elderly patients, accounting for 15% to 25% of all cases of antibiotic-induced diarrhea in those patients. Virulent forms of this organism have developed, increasing the associated morbidity, mortality, and complication rates. The average patient undergoing total joint arthroplasty is at particular risk of CDI because of advanced age, the use of prophylactic antibiotic coverage in the perioperative period, multiple comorbid conditions, and length of hospital stay. In addition, patients who have had one CDI are at risk of another; the rate of recurrent CDI (RCDI) is 15% to 30%. To review the available information on RCDI, we conducted an extensive literature search, focusing on its epidemiology and the management strategies for its treatment and prevention. We found the management of RCDI is a controversial topic, with as yet no consensus regarding specific treatment guidelines. Several experienced clinicians have published suggested treatment algorithms, but they are based on anecdotal experience. With regard to the prevention of RCDI, the literature is scarce, and currently, the only effective strategies remain judicious use of perioperative antibiotics and appropriate implementation of infection control procedures. There are several vaccination medications that are currently being studied but are not yet ready for clinical use. We agree with the approach to management of RCDI that has been proposed in several articles, that is, on confirmation of a first recurrence of CDI by a stool toxin assay and clinical symptoms, a 14-day course of metronidazole or vancomycin; for a second recurrence, a tapered-pulsed course of vancomycin; and, for 3 or more recurrences, a repeat course of the tapered-pulsed vancomycin and adjunctive Saccharomyces boulardii or cholestyramine.

Objectives: To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care., Design: Survey questionnaire of participants in a prospective nonrandomized clinical trial., Setting: Three Medicare managed care health systems and a Veterans Affairs Medical Center., Participants: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbations of chronic heart failure or chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in HaH and 130 in an acute care hospital., Intervention: Treatment in a HaH care model that substitutes for care provided in the traditional acute care hospital., Measurements: Change in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores from 1 month before admission to 2 weeks post admission to HaH or acute hospital and the proportion of groups that experienced improvement, no change, or decline in ADL and IADL scores., Results: Patients treated in HaH experienced modest improvements in performance scores, whereas those treated in the acute care hospital declined (ADL, 0.39 vs -0.60, P=.10, range -12.0 to 7.0; IADL 0.74 vs -0.70, P=.007, range -5.0 to 10.0); a greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P=.10) or IADLs (46% vs 17%, P=.04)., Conclusion: HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.

Objective: To compare the cost of substitutive Hospital at Home care versus traditional inpatient care for older patients with community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, exacerbation of congestive heart failure, or cellulitis., Study Design: Prospective nonrandomized clinical trial involving 455 community-dwelling older patients in 3 Medicare managed care health systems and at a Department of Veterans Affairs medical center., Methods: Costs were analyzed across all patients, within each of the separate health systems, and by condition. Generalized linear models controlling for confounders and using a log link and gamma family specification were used to make inferences about the statistical significance of cost differences. t Tests were used to make inferences regarding differences in follow-up utilization., Results: The costs of the Hospital at Home intervention were significantly lower than those of usual acute hospital care (mean [SD], $5081 [$4427] vs $7480 [$8113]; P <.001). Laboratory and procedure expenditures were lower across all study sites and at each site individually. There were minimal significant differences in health service utilization between the study groups during the 8 weeks after the index hospitalization. As-treated analysis results were consistent with Hospital at Home costs being lower., Conclusions: Total costs seem to be lower when substitutive Hospital at Home care is available for patients with congestive heart failure or chronic obstructive pulmonary disease. This result may be related to the study-based requirement for continuous nursing input. Savings may be possible, particularly for care of conditions that typically use substantial laboratory tests and procedures in traditional acute settings.

Objectives: To compare differences in the stress experienced by family members of patients cared for in a physician-led substitutive Hospital at Home (HaH) and those receiving traditional acute hospital care., Design: Survey questionnaire completed as a component of a prospective, nonrandomized clinical trial of a substitutive HaH care model., Setting: Three Medicare managed care health systems and a Veterans Affairs Medical Center., Participants: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis., Intervention: Treatment in a substitutive HaH model., Measurements: Fifteen-question survey questionnaire asking family members whether they experienced a potentially stressful situation and, if so, whether stress was associated with the situation while the patient received care., Results: The mean and median number of experiences, of a possible 15, that caused stress for family members of HaH patients was significantly lower than for family members of acute care hospital patients (mean +/- standard deviation 1.7 +/- 1.8 vs 4.3 +/- 3.1, P<.001; median 1 vs 4, P<.001). HaH care was associated with lower odds of developing mean levels of family member stress (adjusted odds ratio=0.12, 95% confidence interval=0.05-0.30)., Conclusion: HaH is associated with lower levels of family member stress than traditional acute hospital care and does not appear to shift the burden of care from hospital staff to family members.

Objectives: To examine differences in satisfaction with acute care between patients who received treatment in a physician-led substitutive Hospital at Home program and those who received usual acute hospital care., Design: Survey questionnaire of participants in prospective, nonrandomized clinical trial., Setting: Three Medicare-managed care health systems and a Department of Veterans Affairs Medical Center., Participants: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in Hospital at Home and 130 in the acute care hospital., Intervention: Treatment in a Hospital at Home model of care that substitutes for treatment in an acute care hospital., Measurements: A 40-question survey measuring nine domains of care for patients and a 37-question survey measuring eight domains of care for family members., Results: A higher proportion of patients were satisfied with treatment in Hospital at Home than with the acute care hospital in eight of nine domains, and this difference was statistically different in four domains. Hospital at Home patients were more likely than acute hospital patients to be satisfied with their physician (adjusted odds ratio (AOR) = 3.84, 95% confidence interval (CI) = 1.32-11.19), comfort and convenience of care (AOR = 6.52, 95% CI = 1.97-21.56), admission processes (AOR = 5.90, 95% CI = 2.21-5.76), and the overall care experience (AOR = 2.98, 95% CI = 1.08-8.21). Family members of patients treated in Hospital at Home were also more likely to be satisfied with multiple domains of care., Conclusion: Hospital at Home care was associated with greater satisfaction than acute hospital inpatient care for patients and their family members. These findings support further dissemination of the Hospital at Home care model.

Objectives: To describe the incidence and prevalence of Clostridium difficile-associated diarrhea (CDAD) in a long-term care facility (LTCF)., Design: Retrospective review of CDAD cases between July 2001 and December 2003., Setting: Two hundred two-bed LTCF affiliated with an academic medical center in Baltimore, Maryland., Participants: All residents of the facility during July 2001 to December 2003., Measurements: Clinical and laboratory-confirmed cases of CDAD., Results: Incidence of CDAD ranged from 0 to 2.62 cases per 1,000 resident days. The highest rates were observed in residents of subacute units, whereas incidence was much lower on traditional nursing home units. Prevalence of CDAD at admission was greater on units (subacute and rehabilitative) where the majority of patients were admitted from hospital settings than on those where the majority of patients were admitted from the community (nursing home units). Recurrent disease occurred in 21.7% of patients with CDAD., Conclusion: CDAD remains a problem in the long-term care setting, and importation from the acute care setting accounts for a large proportion of the C. difficile seen LTCFs. As the population continues to age, issues of disease and infection in long-term care are expected to increase. New prevention and control strategies are needed to control the spread of CDAD in LTCFs.

Thomas Campbell Butler, at 63 years of age, is completing the first year of a 2-year sentence in federal prison, following an investigation and trial that was initiated after he voluntarily reported that he believed vials containing Yersinia pestis were missing from his laboratory at Texas Tech University. We take this opportunity to remind the infectious diseases community of the plight of our esteemed colleague, whose career and family have, as a result of his efforts to protect us from infection by this organism, paid a price from which they will never recover.

The recent history of research on cholera illustrates the importance of establishing research and care facilities equipped with advanced technologies at locations where specific health problems exist. It is in such settings, where scientific research is often considered difficult due to poverty and the lack of essential infrastructure, that investigators from many countries are able to make important advances. On this, the 25th anniversary of the founding of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), this article seeks to recount the Centre's demonstration of how high-quality research on important global health issues, including cholera, can be accomplished in conditions that may be considered by many as unsuitable for scientific research.

Withdrawal of medical interventions has become common in the hospital for patients with terminal disease. Despite the widespread feeling that medical interventions may be futile in certain patients, many patients, families, and medical staff find withdrawal of care difficult and withdrawal of mechanical ventilation to be the most disturbing secondary to the close proximity of withdrawal and death. Presented is a 6-year retrospective review of elective withdrawal of life-sustaining mechanical ventilation on a chronic ventilator unit (CVU) in an academic nursing home. Of the 98 patients admitted to the 19-bed CVU during this period, only 13 underwent terminal weaning (TW). Statistically, these 13 patients did not differ significantly in age, gender, race, route of nutrition, decisional capacity, or length of stay on the unit compared with the 85 patients who were not terminally weaned (t-test P > .05). Stepwise logistic regression found that patients who were more alert at admission were more likely to have participated in TW (chi2 = 5.22, coefficient for alertness P < .036). The decision to terminate mechanical ventilation was made by patients in eight cases and by family in five cases. The first step in the process leading to TW was a discussion with the patient and family about plan of care, including the patient's desires for attempted resuscitation, rehospitalization, advance directives, and family contacts. Plan of care was reviewed informally in a weekly multidisciplinary round and formally, to address each patient's care plan, in a multidisciplinary family meeting on a regular basis. The second step was to address TW when brought up by the patient, family, or medical staff. A request for TW by a patient or surrogate was referred to the medical staff, who screened the patient for depression or other remediable symptoms. The third step was to refer the patient and family to another formal meeting to discuss the request for TW and, if needed, in the case of multiple family members, to allow questions to be answered and consensus to be formed. Additional meetings were scheduled as needed. The next step occurred once a consensus was reached to proceed with TW; a date and time was set to reconvene the patient, family, and anyone else who wanted to be present at the TW. The TW process began when a peripheral intravenous catheter was placed and the patient was premedicated with low doses of morphine sulfate and a benzodiazepine. After premedication, the patient was removed from the ventilator. The physician, nurse, family, and physician assistant remained at the bedside and additional morphine or benzodiazepine was given, as needed, for symptom management. Death from TW occurred in all patients, at times ranging from 2 minutes to 10.5 hours (average 6.2 hours). A mean total dose of 115 mg morphine and 14 mg diazepam was given for symptom control. There was no correlation between dose of these medications and duration of survival off the ventilator.

Objective: To evaluate the basic safety and feasibility of hospital care at home (Home Hospital (HH)) for treating acutely ill older persons requiring hospitalization., Design: Prospective case series, Settings and Participants: Community-dwelling persons aged 65 and older requiring acute hospital admission for community-acquired pneumonia, chronic heart failure, chronic obstructive airways disease, or cellulitis., Results: Seventeen subjects were treated in HH. One hundred twenty-two could not be enrolled because they presented for admission at times when HH was not operational. Six patients refused to enroll in HH. Subjects treated in HH had comparable clinical outcomes to those treated in the acute hospital and were highly satisfied with HH. Charges for HH care were 60% of those for the acute hospital care., Conclusions: In this pilot study, HH was safe, feasible, highly satisfactory, and cost-effective for certain acutely ill older persons who required acute hospitalization.

Objective: To examine the acceptability to older patients of receiving care in the home for acute medical conditions that require hospital level care by current standards., Design: Interviews with patients during hospitalization regarding their views of a hypothetical "home hospital.", Participants: Patients (n = 87) admitted to a community-based academic medical center with a primary diagnosis of pneumonia, congestive heart failure, or chronic obstructive airway disease, their nurses (n = 111), and resident physicians (67)., Measurements: A questionnaire was developed to measure several domains of acceptability and expectations for care., Results: A majority of patients agreed that treatment in a home hospital would be more comfortable compared with treatment in a hospital (78.5%), would be less likely to result in an infection (62.5%), and would not be a burden to their family (71.8%). There was less certainty that medical care at home can be as good as in the hospital (56.9%). Nearly three-quarters (72.3%) of patients would choose home hospital if it were available., Conclusion: Patients may be ready to accept home hospital as an alternative for acute care. The acceptability of home hospital to acutely ill older patients is a critical factor in the development of this alternative for care and has the potential for improving satisfaction with care, reducing complications, hastening return to function, and, possibly, of lowering costs of care.

Objective: To determine whether low airloss hydrotherapy reduces the incidence of new skin lesions associated with incontinence in hospitalized patients and results in more rapid healing of existing pressure sores compared with standard care. To assess subjectively patient and nursing satisfaction related to using low airloss hydrotherapy beds., Design: Randomized, prospective, unblinded study., Setting: Acute and chronic hospital wards., Participants: A total of 116 newly admitted, incontinent, hospitalized patients with and without existing pressure sores., Intervention: Low airloss hydrotherapy compared with treatment on hospital beds and mattresses ordered by the patient's attending physician., Measurements: Incidence rates of new skin lesion development, e.g., pressure sores, candidiasis, and chemical irritation; improvement in existing pressure sore size, volume, and status; subjective assessment of patient and nursing satisfaction., Results: Possible hypothermia was identified in two patients during the first week of the study, and patient and nursing dissatisfaction with low airloss hydrotherapy remained high throughout the first months of the study. Therefore, two major modifications in the initial protocol were made: (1) increased patient temperature monitoring for hypothermia was initiated in Week 2 of the study and (2) increased staff resources for in-service training on bed use began in Week 18 of the study. After the latter change, 58 subjects were randomized to low airloss hydrotherapy and 58 to standard care. Subjects were old (median age > or = 80 years), and almost all were bedbound or nonambulatory. The median (range) length of follow-up for subjects in the treatment group was significantly shorter than for those in the control group (4 (1-60) days versus 6 (1-62) days, respectively, P = .017) because there were more dropouts from the treatment group (24 (36%) of 58 versus 2 (3%) of 58, P = .0001). The major reasons dropout occurred were patient or family dissatisfaction (12 (21%)), new or worsened skin lesions thought to be related to bed use (4 (7%)), and hypothermia < 97 degrees F (4 (7%)). The total cumulative incidence of new truncal skin lesions within 9 days of enrollment was greater in the treatment than in the control group (48% versus 14%, respectively, P < 0.01). Too few patients with existing pressure sores were treated for too short a period of time to assess the effect of low airloss hydrotherapy on pressure sore healing. Because only 10 patients treated on low airloss hydrotherapy beds were able to complete satisfaction surveys meaningfully, interpretation of these data is difficult. Only nine (21%) of 44 nurses subjectively reported overall satisfaction using the low airloss hydrotherapy bed., Conclusions: This study shows the value of a rigorously designed clinically based evaluation of a new product developed for older patients. The results of the study led to re-engineering of the prototype low airloss hydrotherapy bed as well as a change in marketing strategy. Studies of products targeted to the prevention and treatment of pressure sores in older patients should be undertaken before generalized marketing begins.

Objective: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital., Design: Prospective record review., Setting and Participants: Patients aged 65 and older admitted to the general medical service of a community-based university hospital., Measurements: We developed illness-specific selection criteria to identify older persons with certain acute medical conditions for treatment in a hypothetical home hospital. The selection criteria were reviewed prospectively against all community-dwelling older patients admitted to the general medical service of a community-based university hospital over a 2-month period. We determined eligibility for home hospital admission based on information available at the time of admission and then tracked the patient's hospital course., Results: One hundred fifty-seven admissions of 143 patients were reviewed. The selection criteria identified 33% of patients admitted to the acute hospital with one of the three target diagnoses as eligible for a home hospital model of care had it been available. Eligible patients experienced shorter lengths of stay (3.7 vs 5.4 days, P = .012), fewer mean number of procedures performed (0.98 vs 1.70, P = .001), fewer mean number of complications (0.17 vs 0.56, P = .010), and fewer events that could be handled only in the acute hospital setting (P = .036). In addition, in logistic regression analysis, three criteria for home hospital ineligibility, pulmonary congestion associated with ischemic chest pain (odds ratio 6.85, 95% CI 2.64, 17.81), the presence of an acute coexisting illness requiring hospitalization independent of the target conditions (odds ratio 2.66, 95% CI 1.11, 6.41), and significant pulmonary congestion after initial treatment (odds ratio 14.4, 95% CI 1.77, 117.41) were significantly associated with items difficult to accomplish at home., Conclusions: Criteria can be delineated that identify older persons with acute medical illnesses who may be suitable for treatment in a home hospital.

Hand washing with soap and water can prevent the spread of diarrhoeal diseases in areas where comparatively costly interventions, such as supply of safe water and improved sanitation, are not possible. In this study, the practice of hand washing with soap and water was instituted in a periurban slum of Dhaka city, and the surveillance for diarrhoea sustained for a one-year period. Rates of primary and secondary attacks were compared to those of a non-intervention area similar in age structure, economic status, education, and other relevant variables. Rectal swabs of cases and contacts established aetiologies. There was a large (2.6 fold) reduction in diarrhoeal episodes in the intervention area during the observation period. Rates of bacterial pathogens were also lower in the intervention area. Significant reduction in diarrhoeal incidences was observed in all age groups for all pathogens except for rotavirus. These observations if implemented as health policy could reduce the spread of diarrhoeal diseases at low cost in high risk areas.

To define ranges of plasma specific gravity useful for identifying volume depletion in older adults, plasma specific gravity was measured in 170 young adults (mean age 28 years) and 100 retirees (mean age 81 years), and ranges of values likely to be associated with volume depletion were defined. Subsequently, measurements of plasma specific gravity were made in 68 older emergency room (ER) patients (mean age 74 years), a few of whom had obvious reasons for being hypovolaemic, e.g. dehydrating diarrhoea, and these results were compared to those for the control groups. Ranges for plasma specific gravity useful for identifying volume depletion were designated as possible hypovolaemia (1.0265-1.0279), probable hypovolaemia (1.0280-1.0294), and hypovolaemia (> or = 1.0295). Using these definitions, there were more older ER patients compared to both young and old control group subjects, respectively, with probable hypovolaemia (21% vs. 5% and 8%; p < 0.03) and hypovolaemia (16% vs. 0% and 0%; p < 0.03). This study establishes ranges for plasma specific gravity for young and old adults likely to be associated with hypovolaemia, and shows that based upon measurement of plasma specific gravity, older ER patients may often be hypovolemic even in the absence of obvious fluid-wasting illnesses. Future studies are needed to identify the risk factors for hypovolaemia in ER patients, and more vigorously substantiate the findings of this study.

Body temperature is a convenient and objective indicator of the body's physiologic state. Typical and atypical febrile responses are discussed and their sources reviewed. Diagnosis, treatment, and prevention of fever in nursing home patients are highlighted.