Jamie A. Seabrook

State of the Art in Geriatric Rehabilitation. Part I: Review of Frailty and Comprehensive Geriatric Assessment

OBJECTIVES To increase recognition of geriatric rehabilitation and to provide recommendations for practice and future research. DATA SOURCES A CINAHL and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search used the Cochrane database. STUDY SELECTION One author reviewed the reference for relevance and another for quality. A total of 336 articles were selected. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports. DATA EXTRACTION The following major geriatric rehabilitation subtopics were identified: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. Part I describes the first 5 subtopics on concepts and processes in geriatric rehabilitation. Part II focuses on the latter 5 subtopics of common clinical problems in frail older persons. A level-of-evidence framework was used to review the literature. Level 1 evidence was a randomized controlled trial (RCT) or a meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts or descriptive studies. DATA SYNTHESIS Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic. In cases in which several articles were written on the same topic and drew similar conclusions, the authors chose those articles with the strongest level of evidence, reducing the total number of references. CONCLUSIONS Frail elderly patients should be screened for rehabilitation potential. Standardized tools are recommended to aid diagnosis, assessment, and outcome measurement. The team approach to geriatric rehabilitation should be interdisciplinary and use a comprehensive geriatric assessment. Medication reviews and self-medication programs may be beneficial. Future research should address cost effectiveness, consensus on outcome measures, which components of geriatric rehabilitation are most effective, screening, and what outcomes are sustainable.

State of the art in geriatric rehabilitation. Part II: Clinical challenges

OBJECTIVES To examine common clinical problems in geriatric rehabilitation and to make recommendations for current practice based on evidence from the literature. DATA SOURCES A CINAHL database and 2 MEDLINE searches were conducted for 1980 to 2001. A fourth search was completed by using the Cochrane database. STUDY SELECTION One author reviewed the references for relevance and another for quality. A total of 336 articles were considered relevant. Excluded articles were unrelated to geriatric rehabilitation or were anecdotal or descriptive reports on a small number of patients. DATA EXTRACTION The following areas were the major geriatric rehabilitation subtopics identified in the search: frailty, comprehensive geriatric assessment, admission screening, assessment tools, interdisciplinary teams, hip fracture, stroke, nutrition, dementia, and depression. This article focuses on the latter 5 subtopics. The literature was reviewed by using a level-of-evidence framework. Level 1 evidence was a randomized controlled trial (RCT) or meta-analysis or systematic review of RCTs. Level 2 evidence included controlled trials without randomization, cohort, or case-control studies. Level 3 evidence involved consensus statements from experts, descriptive studies, or reports of expert committees. DATA SYNTHESIS Of the 336 articles evaluated, 108 were level 1, 39 were level 2, and 189 were level 3. Recommendations were made for each subtopic according to the level of evidence in the specific area. In cases in which several articles were written on a topic with similar conclusions, we selected the articles with the strongest level of evidence, thereby reducing the total number of references. CONCLUSIONS Frail older patients with hip fracture should receive geriatric rehabilitation. They should also be screened for nutrition, cognition, and depression. Older persons should receive nutritional supplementation when malnourished. If severe dysphagia occurs in stroke patients, gastrostomy tube feeding is superior to nasogastric tube feeding.

External ventricular drains in pediatric patients.

Objective: To determine the indications and complications of external ventricular drain (EVD) placement in pediatric patients. Design: Retrospective chart review. Setting: University associated, tertiary–level Children’s Hospital. Patients: Sixty-six [median age, 10.1 years (interquartile range, 5.9)] patients between 1994 and 2006 with 96 EVDs. Measurements and Results: Clinical indications for EVD insertion include traumatic brain injury (TBI; 36%), acute hydrocephalus (35%), and ventriculoperitoneal shunt failure (29%). Of the 96 EVDs, 65% were inserted at the bedside in the pediatric critical care unit (PCCU) and 33% in the operating room (OR). Median duration of EVD insertion was 7.0 days (interquartile range, 8.8). Complications occurred with 26% of EVD insertions and included infection (9.4%), misplacement (6.3%), hemorrhage (4.2%), obstruction (3.1%), and malfunction (3.1%). The primary infectious etiology was coagulase-negative Staphylococcus (67% of infections). Despite patients with TBI having significantly smaller lateral ventricles than hydrocephalus patients (p < 0.05), EVD complications were similar (risk ratios 1.41; 95% confidence interval 0.68–2.72). Furthermore, the complication rate was the same for EVDs inserted in either the PCCU or OR (risk ratios 1.10; 95% confidence interval 0.55–2.29). Conclusion: EVDs were placed for TBI, ventriculoperitoneal shunt failure and new-onset hydrocephalus. The overall complication rate was 26%. Complication rates were similar in TBI and hydrocephalus patients, and with EVDs inserted in either the PCCU or OR. Prophylactic antibiotics or antimicrobial-impregnated catheters directed against coagulase-negative Staphylococcus may reduce EVD infections.

Survey of Atypical Antipsychotic Prescribing by Canadian Child Psychiatrists and Developmental Pediatricians for Patients Aged Under 18 Years

Objective: To describe self-reported patterns of prescribing atypical antipsychotics (ATAs) and monitoring practices of child psychiatrists and developmental pediatricians in Canada. Method: We surveyed members of the Canadian Academy of Child and Adolescent Psychiatry and members of the Developmental Paediatrics Section of the Canadian Paediatric Society regarding the types and frequencies of ATAs they prescribed, the ages and diagnoses of patients for whom they prescribed these medications, and the types and frequencies of monitoring used. Results: Ninety-four percent of the child psychiatrists (95%CI, 90% to 97%) and 89% of the developmental pediatricians (95%CI, 75% to 96%) prescribed ATAs, most commonly risperidone (69%). Diagnoses included psychotic, mood, anxiety, externalizing, and pervasive developmental disorders. Prescribing for symptoms such as aggression, low frustration tolerance, and affect dysregulation was also common. Twelve percent of all prescriptions were for children under age 9 years. Most clinicians monitored patients, but there were wide variations in the type and frequency of tests performed. Conclusions: Despite the lack of formal indications, ATAs were prescribed by this group of clinicians for many off-label indications in youth under age 18 years, including very young children. Neither evidence-based guidelines nor a consensus on monitoring exist for this age group.

Have changes in ventilation practice improved outcome in children with acute lung injury

Objectives: To describe the changes that have occurred in mechanical ventilation in children with acute lung injury in our institution over the last 10–15 yrs and to examine the impact of these changes, in particular of the delivered tidal volume on mortality. Design: Retrospective study. Setting: University-affiliated childrens hospital. Patients: The management of mechanical ventilation between 1988 and 1992 (past group, n = 79) was compared with the management between 2000 and 2004 (recent group, n = 85). Interventions: None. Measurements and Main Results: The past group patients were ventilated with a significantly higher mean tidal volume (10.2 ± 1.7 vs. 8.1 ± 1.4 mL·kg−1 actual body weight, p < .001), lower levels of positive end-expiratory pressure (6.1 ± 2.7 vs. 7.1 ± 2.4 cm H2O, p = .007), and higher mean peak inspiratory pressure (31.5 ± 7.3 vs. 27.8 ± 4.2 cm H2O, p < .001) than the recent group patients. The recent group had a lower mortality (21% vs. 35%, p = .04) and a greater number of ventilator-free days (16.0 ± 9.0 vs. 12.6 ± 9.9 days, p = .03) than the past group. A higher tidal volume was independently associated with increased mortality (odds ratio 1.59; 95% confidence interval 1.20, 2.10, p < .001) and reduction in ventilation-free days (95% confidence interval −1.24, −0.77, p < .001). Conclusions: The changes in the clinical practice of mechanical ventilation in children in our institution reflect those reported for adults. In our experience, mortality among children with acute lung injury was reduced by 40%, and tidal volume was independently associated with reduced mortality and an increase in ventilation-free days.

Cortisol and Testosterone in Hair as Biological Markers of Systolic Heart Failure

BACKGROUND Congestive heart failure (CHF) is associated with increased stress and alterations in metabolism, favoring catabolism over anabolism. Hormonal profiles of patients with heart failure have been assessed using serum and saliva as matrices, which are only point measurements and do not provide long-term information. Scalp hair is a novel matrix that allows for measurement of hormones over a period of several months. PATIENTS AND METHODS We aimed to evaluate whether levels of cortisol and testosterone and their ratio (C/T) in hair correlate with severity of heart failure. We conducted a prospective study in ambulatory male patients with a left ventricular ejection fraction (LVEF)≤40%. Hormone levels were measured using immunoassays in the proximal 2 cm of hair (representing approximately two months of systemic hormone exposure). Primary endpoints included the correlation of hair cortisol, testosterone, and C/T levels with the New York Heart Association (NYHA) class, LVEF, exercise capacity and NT-proBNP. RESULTS The 44 CHF patients had a median hair level (range) of cortisol of 207 (117.7-1277.3)ng/g. Hair cortisol levels correlated positively with NYHA class (r=0.48, p=0.001) and negatively with treadmill stress test performance, (r=-0.37, p<0.05). The hair testosterone was 5.17 (2.39-24.64)ng/g and the C/T ratio was 39.89 (12.98-173.73). No associations were found between hair testosterone and C/T ratio and heart failure severity; however, the C/T ratio was higher in patients who required a CHF-related hospitalization than in patients who did not require this in the year following the inclusion in the study. CONCLUSIONS Hair cortisol levels correlate with heart failure severity as assessed by the NYHA class and exercise capacity, while hair testosterone and C/T levels do not correlate with heart failure severity.

Genotype–environment interaction and sociology: Contributions and complexities

Genotype-environment interaction (G x E) refers to situations in which genetic effects connected to a phenotype are dependent upon variability in the environment, or when genes modify an organisms sensitivity to particular environmental features. Using a typology suggested in the G x E literature, we provide an overview of recent papers that show how social context can trigger a genetic vulnerability, compensate for a genetic vulnerability, control behaviors for which a genetic vulnerability exists, and improve adaptation via proximal causes. We argue that to improve their understanding of social structure, sociologists can take advantage of research in behavior genetics by assessing the impact of within-group variance of various health outcomes and complex human behaviors that are explainable by genotype, environment and their interaction. Insights from life course sociology can aid in ensuring that the dynamic nature of the environment in G x E has been accounted for. Identification of an appropriate entry point for sociologists interested in G x E research could begin with the choice of an environmental feature of interest, a genetic factor of interest, and/or behavior of interest. Optimizing measurement in order to capture the complexity of G x E is critical. Examining the interaction between poorly measured environmental factors and well measured genetic variables will overestimate the effects of genetic variables while underestimating the effect of environmental influences, thereby distorting the interaction between genotype and environment. Although the expense of collecting environmental data is very high, reliable and precise measurement of an environmental pathogen enhances a studys statistical power.

The Effect of Two Different Domperidone Doses on Maternal Milk Production

Background: The benefits of breast milk to the newborn infant are well established. The Canadian Paediatric Society recommends exclusive breastfeeding for the first 6 months of life for healthy, term infants. Mothers of premature newborns, however, may have difficulty providing an adequate supply of breast milk. Domperidone is officially used as a prokinetic agent. However, it is used widely around the world as a galactogogue. Despite its widespread use as a galactogogue, only a small number of investigators have studied domperidone for this indication. Aims: The purpose of this study was to determine an optimal dosage of domperidone as a galactogogue. Methods: Eligible subjects were randomized to receive domperidone 10 mg 3 times daily or domperidone 20 mg 3 times daily for 4 weeks. At week 5, the frequency was decreased to twice daily in both groups, and finally once daily for week 6. Results: Over the entire first 4-week period, there was a significant increase in daily milk volumes within each group (P < .01). The between-group difference over this period, although not statistically significant, was clinically significant. Additionally, there was no significant within- or between-group difference during weeks 5 and 6. Conclusion: A dose of domperidone of 20 mg, 3 times daily instead of 10 mg, 3 times daily was associated with a clinical, but not statistically significant, increase in milk production.

Additive value of nuclear medicine shuntograms to computed tomography for suspected cerebrospinal fluid shunt obstruction in the pediatric emergency department.

Objective: To measure the predictive value of nuclear medicine studies (cerebrospinal fluid [CSF] shuntograms) and radiographic studies (computed tomographic [CT] scans) in a cohort of children undergoing evaluation for suspected shunt obstruction in a tertiary care pediatric emergency department (ED). Methods: A retrospective chart review was conducted on patients younger than 18 years who presented to the pediatric ED of the Childrens Hospital of Western Ontario and had both CT of the head and a CSF shuntogram ordered by the attending pediatric emergency medicine physician between December 1998 and April 2003 because of suspected shunt obstruction. Results: A total of 69 patients were evaluated for suspected shunt obstruction in the ED during this period with both a CT and a CSF shuntogram. Twenty-seven patients (39.1%) subsequently required corrective surgery for suspected shunt obstruction that was confirmed intraoperatively. The CT scans showed abnormalities suggestive of CSF shunt obstruction in 21 of the patients who required surgery (sensitivity, 77.8%; negative predictive value, 82.4%), whereas the CSF shuntograms showed abnormalities suggestive of CSF obstruction in 25 of the patients who required surgery (sensitivity, 92.6%; negative predictive value, 92.6%). The CT scans and the shuntograms combined revealed abnormalities suggestive of CSF shunt obstruction in 26 of the 27 patients who required surgery (sensitivity, 96.3%; negative predictive value, 97.4%). Conclusions: Over one third of pediatric ED patients evaluated with CT and CSF shuntograms required surgical management. Sensitivity was increased with CT and CSF shuntogram compared with CT alone. Prospective studies are required to assess the use of radiographic and nuclear medicine tests for the shunt evaluation in conjunction with the development of a clinical prediction rule for the pediatric emergency physician.

Dehydration in children with diabetic ketoacidosis: a prospective study

Objectives To investigate the association between the degree of patient dehydration on presentation with diabetic ketoacidosis (DKA) and clinical and laboratory parameters obtained on admission. Design Prospective descriptive study. Setting A tertiary care childrens hospital. Patients Thirty-nine paediatric patients (1 month–16 years) presenting with 42 episodes of DKA. Intervention Clinical and biochemical variables were collected on admission. Dehydration was calculated by measuring acute changes in body weight during the period of illness. All patients were treated according to a previously established protocol. Main outcome measures Magnitude of dehydration, defined as % loss of body weight (LBW), was determined by the difference in body weight obtained at presentation and at discharge. The relationship between the magnitude of dehydration and the clinical assessment and biochemical parameters was examined. Results The median (25th–75th centiles) magnitude of dehydration at presentation was 5.7% (3.8–8.3%) (mean±SD 6.8±5%). Neither the initial clinical assessment nor the comprehensive biochemical profile at admission correlated with the magnitude of dehydration. Despite considerable variation in the degree of dehydration and biochemical disequilibrium, all patients recovered from DKA within 24 h with a standardised therapeutic approach. Furthermore, the rapidity of patient recovery did not correlate with the magnitude of dehydration on presentation or the amount of fluid administered (median (25th–75th centiles) 48.8 ml/kg (38.5–60.3)) in the first 12 h. Conclusion The magnitude of dehydration in DKA is not reflected by either clinical or biochemical parameters. These findings need confirmation in larger studies.