Robert C. Walls

Protein‐Energy Undernutrition and the Risk of Mortality Within One Year of Hospital Discharge: A Follow‐Up Study

OBJECTIVE: The primary objective of this study was to confirm the results of a previous study that demonstrated a strong independent correlation between the severity of protein‐energy undernutrition and the risk of 1‐year postdischarge mortality in a population of older rehabilitation patients.

Impact of nutritional status on morbidity in a population of geriatric rehabilitation patients.

Objective: The primary objective was to confirm the results of a prior study that demonstrated a strong independent correlation between the severity of protein‐energy undernutrition and the risk of subsequent morbidity in a population of elderly rehabilitation patients. A second objective was to determine whether inadequate in‐hospital nutrient intake is a co‐contributor to the risk of subsequent morbidity.

Improving Dressing Behavior in Cognitively Impaired Nursing Home Residents

This study tested the extent to which a behavioral intervention, Strategies to Promote Independence in Dressing (SPID), improved dressing independence among 90 cognitively impaired nursing home residents (average score on Mini Mental Status Exam = 7.35 +/- .69). The effect of SPID on caregiving efficiency, the time required for nursing assistants to use the strategies, was also examined. The results showed improved independence (decrease in assistance) from 6.08 +/- .12 at baseline to 4.93 +/- .19 following 6 intervention weeks. This significant improvement in dressing independence occurred without a clinically relevant increase in caregiver time (less than 1 min). Seventy-five percent of the subjects improved one or more levels of dressing independence, and more than 20% achieved their maximum intervention effect during the first week of treatment.

Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial.

OBJECTIVE This non-blinded randomized controlled trial was the first phase of a planned series of investigations designed to test the efficacy of aggressive post-operative enteral nutrition support to decrease the rate of post-operative complications or improve long-term outcomes in specifically defined subgroups of elderly patients who have sustained a hip fracture requiring surgery. METHODS Eighteen patients (17 males) were randomized to the treatment (eight male subjects) or control groups. The control group (mean age 76.5+/-6.1 years) received standard post-operative care. Subjects in the treatment group (mean age 74.5+/-2.1 years) received 125 cc/hour of nasoenteral tube feedings over 11 hours each night in addition to standard post-operative nutritional care. RESULTS Both the treatment and control groups had reduced volitional nutrient intakes for the first 7 post-operative days (3,966+/-2,238 vs. 4,263+/-2,916 kJ/day [948+/-535 vs. 1019+/-697 kcal/day], p=0.815), but the treatment subjects had a greater total nutrient intake (7,719+/-2,109 vs. 4,301+/-2,858 kJ/day [1845+/-504 vs. 1028+/-683 kcal], p=0.012). On average, treatment subjects were tube fed for 15.8+/-16.4 days. There was no difference between the groups (treatment vs. controls) in the rate of post-operative life-threatening complications (25 vs. 30%, p=1.00) or in-hospital mortality (0 vs. 30%, p=0.216). Mortality within 6 months subsequent to surgery was lower in the treatment group compared to the controls (0 vs. 50%, p=0.036). DISCUSSION We conclude that nightly enteral feedings are a safe and effective means of supplementing nutrient intake. The greatest impact of nutrition support may be to reduce mortality.

Toxicity of methylenedioxymethamphetamine (MDMA) in the dog and the rat

Methylenedioxymethamphetamine (MDMA) was administered to dogs and rats orally once a day for a 28-day period to evaluate the morphological and neuropathological effects. Major clinical signs associated with the administration of MDMA in the dog included circling, depression, dilated pupils, hyperactivity, rapid breathing, and salivation. Major clinical signs in the rat included hyperactivity, excitability, piloerection, exophthalmos, and salivation. Gross observations at necropsy in the dog possibly related to administration of the test article included reduced testicular size (one high and one medium dose) and prostatic enlargement in two high-dose animals. No gross lesions were seen in the rats at necropsy. The medium- and the high-dose groups in both sexes in both the rats and the dogs gained significantly less weight than the control and low-dose groups. Food consumption decreased the first week for the high- and medium-dose groups, but a significant reversal toward more normal consumption was noted in the following weeks in both the rats and the dogs. Hematologic, clinical chemistry, and urinalysis values did not appear to be affected by the administration of the test article in the dog. In the rat clinical pathology variables showing a trend to decrease with dose included urinary pH, blood urea nitrogen, glucose, creatinine (females), lactate dehydrogenase (LDH) (females), and chloride. Clinical pathology variables showing a trend to increase with dose included total white blood cell count and phosphorus. Microscopically, testicular atrophy was present in one medium-dose and two high-dose male dogs. Prostatic hyperplasia was present in two high-dose male dogs. No test article-related lesions were seen in the brains of either species.

Psychological correlates of loneliness in the older adult

Loneliness is the emotional response to the discrepancy between desired and available relationships. As people grow old, the likelihood of experiencing age-related losses increases. Such losses may impede the maintenance or acquisition of desired relationships, resulting in a higher incidence of loneliness. This pilot study examines how loneliness relates to age-related losses, hopelessness, self-transcendence, and spiritual well-being in a convenience sample of 107 adults aged 65 years or older. The collective utility of the independent variables in predicting loneliness was investigated by means of a regression decision tree with an automatic random subset crossvalidation procedure. This procedure explained 46% of the variance. Higher scores for age-related losses and hopelessness were associated with higher loneliness scores. Higher scores for self-transcendence and existential spiritual well-being were associated with lower loneliness scores.

Case mix groups for va hospital based home care

The purpose of this study is to group hospital-based home care (HBHC) patients homogeneously by their characteristics with respect to cost of care to develop alternative case mix methods for management and reimbursement (allocation) purposes. Six Veterans Affairs (VA) HBHC programs in Fiscal Year (FY) 1986 that maximized patient, program, and regional variation were selected, all of which agreed to participate. All HBHC patients active in each program on October 1,1987, in addition to all new admissions through September 30,1988 (FY88), comprised the sample of 874 unique patients. Statistical methods include the use of classification and regression trees (CART software: Statistical Software; Lafayette, CA), analysis of variance, and multiple linear regression techniques. The resulting algorithm is a three-factor model that explains 20% of the cost variance (R2 = 20%, with a cross validation R2 of 12%). Similar classifications such as the RUG-II, which is utilized for VA nursing home and intermediate care, the VA outpatient resource allocation model, and the RUG-HHC, utilized in some states for reimbursing home health care in the private sector, explained less of the cost variance and, therefore, are less adequate for VA home care resource allocation.

The effect of in utero exposure to hexachlorobenzene on the developing immune response of BALB/c mice.

BALB/c mice were exposed to 0.0, 0.5 and 5.0 mg/kg maternal body weight hexachlorobenzene (HCB) throughout gestation by daily per os dosing of the females. At 45 days of age selected immune functions of the offspring were assessed. The delayed-type hypersensitivity (DTH) response to oxazolone was severely depressed in animals exposed to either 0.5 or 5.0 mg/kg HCB, however, only those animals exposed to 5.0 mg/kg HCB showed a significant decrease in their mixed lymphocyte response (MLR) levels. The ability of isolated spleen cells to undergo a blastogenic response to concanavalin A (ConA), phytohemagglutinin (PHA) and lipopolysaccharide (LPS) showed no significant changes due to HCB exposure. Similarly, no significant difference in the induction of direct hemolytic plaque-forming cells was seen. A significant increase in the relative distribution of splenic T cells and a significant decrease in splenic B cells was measured in the offspring of HCB-treated females. These results suggest that HCB is capable of affecting the development or maturation of the immune response in mice, perhaps at the T cell level.

Prevalence of palpebral fissure asymmetry in white persons

PURPOSE Because palpebral fissure asymmetry in horizontal gaze is reportedly common in otherwise normal persons, we determined the prevalence of physiologic palpebral fissure asymmetry for primary and horizontal gazes. METHODS We measured the palpebral fissure height of both eyes of 88 healthy white subjects. Measurements were obtained with high-resolution videography, with the eyes in primary position, in 45-degree right gaze, and in 45-degree left gaze. RESULTS Of the 88 subjects, 36 (41%) were male and 52 (59%) were female. The ages ranged from 12 to 50 years, with a mean of 32.5 +/- 9.0 years. When a criterion of equal to or greater than 1 mm was used, the prevalence of physiologic palpebral fissure asymmetry was 5.7% (five of 88) in primary gaze, 18.2% (16 of 88) in right gaze, and 14.8% (13 of 88) in left gaze. The largest observed palpebral fissure asymmetry was 2.1 mm. After correcting for any existing fissure asymmetry in primary gaze, two-tailed trivariate analysis of variance showed that the fissure of the adducting eye tended to be wider. The mean increase in the palpebral fissure of the adducting eye was 0.12 mm for right gaze (P = .052) and 0.13 mm for left gaze (P = .034). Additionally, a chi 2 test indicated that the occurrence of wider adducting eye in both right and left gazes was highly significant (P = .0023). CONCLUSIONS In this sample of white subjects, palpebral fissure height asymmetry increased in horizontal gaze to the right and to the left, which is in part because of a tendency of the adducting eye to widen slightly. In contrast to previous reports, the prevalence of palpebral fissure asymmetry was low, and the abducting eye did not widen significantly.

Effect of Light on the Prevalence of Simple Anisocoria

PURPOSE Because simple anisocoria is believed to decrease in bright light, the authors determined the prevalence of simple anisocoria under different lighting conditions. METHODS The authors measured the pupil size of 104 healthy subjects with infrared videography at four clinically accessible light levels: darkness; darkness with a hand-held light shining from below; room light; and room light with the hand light shining from below. RESULTS Of the 104 subjects, 40 (38%) were men and 64 (62%) were women. The ages ranged from 12 to 71 years (mean, 36.3 +/- 12.5 years). The mean decrease in pupillary diameter from darkness to the brightest condition was 1.89 mm. Based on the traditional definition of a pupillary diameter difference of 0.4 mm or greater, the prevalence of simple anisocoria decreased from 18% in darkness to 8% in room light with the hand-held light shining from below. The prevalence of anisocoria varied considerably when other definitions were used. Repeated measures analysis of variance showed that pupillary area difference decreased with brighter conditions (P = 0.026). However, the ratio of the pupillary areas did not change with brighter conditions (P = 0.666). CONCLUSIONS The prevalence of simple anisocoria decreases with brighter conditions based on pupillary diameter difference. However, this decrease is not apparent when anisocoria is expressed as pupillary area ratio. Those clinicians who measure pupils will find that simple anisocoria decreases in bright light. However, with gross observation where perception of an anisocoria may be related more to the ratio of the pupillary areas, simple anisocoria may not seem to change much with brighter conditions.