Impact of HAART on causes of death of persons with late-stage AIDS.

CONTEXT: The increasing use of highly active antiretroviral therapies (HAARTs) has changed the course of AIDS-related illnesses and enhanced the quality of life of patients infected with human immunodeficiency virus (HIV) and may have changed the causes of deaths in patients with acquired immunodeficiency syndrome (AIDS). OBJECTIVE: The aim of the present study was to investigate causes of deaths in long-term care hospital patients with late-stage AIDS who expired at the Coler-Goldwater Memorial Hospital in New York City in 1995, and in 1998 and 1999, that is, immediately before and the two most recent years after the advent of HAART. METHODS: Analysis of causes of deaths as recorded on the death certificates of 232 AIDS patients. RESULTS: The overall mortality rate declined from 75.6 deaths per 100 person-years in 1995 to 33.2 deaths per 100 person-years in 1998-1999 (P < .001). The number of AIDS patients who expired because of sepsis and opportunistic infections, which included Pneumocystis carinii pneumonia (PCP), decreased significantly from 30 (26.1%) and 24 (20.9%) in 1995 to 15 (12.8%) and 10 (8.5%) in 1998-1999, respectively (P < .05). In contrast, deaths from hepatic failure increased from 0 (0%) in 1995 to 7 (6%) in 1998-1999 (P < .05). Increases, although not significant statistically, were associated with pneumonias excluding PCP, end-stage AIDS, renal failure, and malignancies. Analysis of cause-specific mortality by gender between 1995 and 1998-1999 revealed very little difference between men and women. This analysis showed, however, that the infectious processes taken together (pneumonias excluding PCP, sepsis, and opportunistic infections including PCP) were significantly less frequent causes of death in 1998-1999 than in 1995 (P < .01). CONCLUSION: These findings indicate that HAART affected the causes of deaths in patients with AIDS, with "traditional" opportunistic infections diminishing in importance relative to chronic medical conditions and malignancies.

Physical restraints in the acute care setting: issues and future direction.

The pattern and prevalence of physical restraint in hospital settings have changed over the past decade. The challenge to health professionals who wish to reduce or eliminate the use of restraints includes clinical, ethical, and legal concerns. Factors that influence health care providers' decisions regarding whether to use physical restraints include organizational characteristics and systems of care, environmental characteristics, and specific clinical guidelines or protocols, as well as individual patient characteristics. To reduce the incidence of physical restraint, hospital professionals need to develop and test feasible alternative practices using an interdisciplinary approach that addresses organizational, environmental, and patient-specific factors.

Adverse drug reactions in an elderly outpatient population.

The prevalence of adverse drug reactions (ADRs) in elderly outpatients was investigated, along with factors that might be associated with their occurrence. The medical records of elderly patients attending an interdisciplinary geriatric clinic and a general medical clinic during 1988 were audited to collect a variety of demographic and treatment data and to detect documentation of first-time ADRs. Subjects were classified as having had an ADR if a physician documented this or if a relevant symptom was noted in the record and a score of 1 or above was obtained on the Adverse Drug Reaction Probability Scale. The presence of potential drug interactions was also assessed. The sample size was 463 patients, of whom 332 attended the medical clinic and 131 attended the geriatric clinic. Potential drug interactions were identified in the records of 143 subjects (31%). There were 107 documented ADRs in 97 patients (21%). Of these patients, 86 were noted by the physicians as having had an ADR. Twelve patients were hospitalized as a direct result of an ADR. Significant risk factors for ADRs were attendance in the geriatric clinic, the use of potentially harmful drug combinations, and the use of drugs that require therapeutic monitoring. Patient age and the number of drugs had no association with ADRs. In the elderly population studied, patients with frailty arising from multiple pathologies were more likely to have ADRs than the more robust elderly, even when their therapeutic regimens were simplified.

A further exploration of the use of physical restraints in hospitalized patients.

Four hundred twenty-one consecutive patients admitted to an acute general medical ward and two acute rehabilitation medical wards were studied to compare the characteristics and outcomes of physically restrained patients and unrestrained patients. Restraints were used in 35 (13%) of the general medical patients and in 49 (34%) of the rehabilitation patients. The restrained general medical patients had higher mortality and morbidity rates than their unrestrained counterparts. Restrained patients had a higher prevalence of a psychiatric diagnosis, and major tranquilizers were used more than in their unrestrained counterparts in both settings. The general medical patients tended to have more than one type of restraint at a time, whereas the rehabilitation patients were restrained for longer proportions of their hospital stay. Thirty-three percent of the restrained patients whom we were able to interview expressed negative perceptions about the presence of the physical restraints. Moreover, it was found that the presence of cognitive and physical impairments were highly predictive of restraint use in both populations.

Severe illness in older patients: the association between depressive disorders and functional dependency during the recovery phase.

An association between depression and physical dependency arising from a recent illness has been generally accepted. To clarify this relationship over time, 30 medical rehabilitation patients aged 54 to 94 years were assessed 1 week after admission and at discharge to quantify symptoms of depression, physical dependency, and cognitive functioning using the Hamilton Depression Scale (HAM-D), the Geriatric Depression Scale (GDS), the Barthel Index for physical function, and the Mini-Mental State Examination (MMSE). Significant depressive symptomatology was found by HAM-D in 25 patients on admission and 14 on discharge. No significant associations were present between either admission or discharge depression scores and all other variables. The HAM-D change score was significantly correlated with the Barthel change score (r = 0.57, P less than 0.001) and with the MMSE change score (r = 0.48, P = 0.01). All patients whose mood improved also improved in physical functioning, whereas 75% of those whose mood did not improve failed to make headway in physical functioning. This implies that it is not the degree of physical incapacity but rather the failure to regain prior abilities which is strongly associated with persisting depression following a catastrophic illness. Furthermore, characteristics found commonly in the group whose mood did not improve included physicians' failure to diagnose and treat depression or a setback from a significant medical or surgical complication.

Incidence of physical restraints on acute general medical wards.

On four acute medical wards 1292 patients were observed over 15 weeks to determine how frequently physical restraints were used. Patients were divided into age groups of less than 40 years, 40 to 55 years, 56 to 69 years, and 70 years and older. Ninety-five patients were found to be restrained giving an overall incidence of 7.4%. As expected, patients 70 years of age and older were restrained more frequently (20.3%) than younger patients, with the lowest incidence (2.9%) occurring in those 40 to 55 years of age. In each age group the patients who were restrained had a length of stay more than twice as long as their unrestrained counterparts. Twelve percent of the restrained patients died, which was nearly one-half of all the patients who died during the period of the study. The findings suggest a probable relationship between the severity of an illness and the use of physical restraints.

Effective low dose tricyclic antidepressant treatment for depressed geriatric rehabilitation patients. A double-blind study.

The efficacy of low doses (10 to 20 mg daily) of doxepin in the treatment of depressive disorders in elderly inpatients was assessed by a double-blind study in 24 patients. The patients were treated for a three-week period to test for an early response. The Hamilton Depression Scale and the Geriatric Depression Scale were used to quantify symptoms of depression. The patients treated with doxepin had a significantly greater reduction in depressive symptoms than did those who received a placebo. No side effects were found and there were no major differences in the degree of physical dependency between the doxepin and placebo groups. A depressive disorder is a common occurrence among elderly inpatients and the effectiveness of low dose doxepin therapy without demonstrable side effects argues for the active treatment for this condition.

Success with an inpatient geriatric unit: a controlled study of outcome and follow-up.

To assess the worth of a newly established geriatric unit, outcomes for 50 subject patients cared for on this unit were compared with outcomes for 50 control patients. Both groups of patients were hospitalized in Highland View Hospital, the chronic illness and rehabilitation section of a major teaching hospital in Cleveland, Ohio. Analysis of admission data showed the two groups to be closely comparable. All patients were managed by multidisciplinary teams, and the length of stay of both groups was comparable. The discharge data showed that the subject patients were more independent, with significantly greater numbers improving in ambulation and significantly more subject patients being discharged to a home setting. Although the patients in the control group were discharged at lower levels of function, they showed improvement at follow-up. Follow-up data also showed that both groups largely remained in their discharge environments. Explanations for these findings are discussed. The results of this study support the establishment of geriatric inpatient units.

Herpes zoster: a challenge in management.

Although herpes zoster is not a fatal disease, its legacy of postherpetic neuralgia gives rise to a great deal of misery and distress, especially in elderly patients. Furthermore, in the immunocompromised patient herpes zoster is an important complication. The management of the sequelae of herpes zoster continues to be extremely difficult. Although work on agents to control viral replication holds promise for the future, at present meticulous management of the pain and depression in the early phases and much patience and understanding in the later phases of the condition are necessary.

A 'firm' system for graduate training in general internal medicine.

The faculty of the Department of Medicine at Cleveland Metropolitan General Hospital has responded to the challenge of fostering general internal medicine in a graduate training program by organizing a "firm" system of medical care which has appealed to academic internists with broad interests in clinical medicine. This firm system consists of four medical teams which care for distinct patient populations, closely integrating their outpatient and inpatient care. The firms are made up of all the house staff in training in internal medicine together with senior and junior faculty members who are directors for the firms. Medical students in general medicine are also assigned to firms. This firm system is relatively simple to understand and establish and is readily applicable to other academic departments with general medical responsibilities.