Determinants of home health visit length: results of a multisite prospective study.

OBJECTIVES: The authors (1) compare visit length across four categories of skilled nursing home health visits which reflect recent changes in home health casemix-AIDS-related, hospice/terminal (HT), intravenous (IV) therapy, and maternal and child health (MCH)-with general adult medical/surgical (MS) visits and (2) identify factors influencing visit length. METHODS: The study sites were 12 nonproprietary Massachusetts home health agencies (HHAs). Staff nurses collected data concurrently on a sample of visits they provided between December 1, 1992 and November 30, 1993. The visits were stratified by agency, time of year, and visit category. The authors used analysis of variance to test for significant differences across visit categories in Home Length of Visit (the number of minutes between when the nurse entered and left the home) (HLOV). The authors used multivariate regression analysis to develop models identifying determinants of HLOV and adjusted R2 to measure the explanatory power of partial models. RESULTS: In univariate analysis, the categories differed significantly from each other in length (P < 0.0001). HT visits were the longest (median visit length = 60, 80, and 59 minutes for HT Only visits, visits in both the HT and AIDS categories (HT/AIDS), and HT/IV visits, respectively). MS visits were the shortest (median = 30 minutes). The remaining categories were intermediate in length (medians = 37 to 50 minutes). Almost half the variability in HLOV was explained by the full multivariate regression model, which includes all independent variables (adjusted R2 = .4486; P < 0.0001). Visit characteristics alone in a partial model explained 18% of the variability in HLOV. Three other variable sub-groups-agency, client characteristics, and nursing workload-each explained about 15% of the variability in HLOV. Nursing activities performed during the visit explained 11%; several of these related to teaching, education, or assessment. CONCLUSIONS: Accurate reimbursement reflecting casemix differences is important to protect the teaching, education, and assessment functions of nurses; measure nurse productivity and allocate caseloads; maintain access to services for clients with greater needs; and avoid creating economic disincentives to the agencies that serve them. Payers formulating prospective payment systems can adjust per visit reimbursement rates to reflect differences in visit length by category and incorporate functional limitations, clinical instability, and case coordination as classification variables. Developers of home health casemix systems can use factor analysis to improve the robustness of multivariate models and include nursing workload in predicting visit length. Home health agencies measuring productivity and caseload across complex client populations can classify visits into three groups-MS; HT; and AIDS, IV, and MCH-or use the regression results to develop more refined predictors of visit length and nursing caseload.

Iliac artery stenosis measurements: comparison of two-dimensional time-of-flight and three-dimensional dynamic gadolinium-enhanced MR angiography.

OBJECTIVE: We compared our ability to make iliac artery measurements on two-dimensional (2D) time-of-flight (TOF) and three-dimensional dynamic gadolinium-enhanced MR angiography with conventional angiography. SUBJECTS AND METHODS: Fifteen patients with lower extremity vascular disease underwent pelvic MR angiography. Parameters of the cardiac-gated axial 2D TOF sequence included a TR/TE of 24/7 msec and a 50 degrees flip angle. Parameters for the three-dimensional MR angiography sequence, in which we obtained 32 coronal 3-mm slices with fat suppression, included a TR/TE of 32/5 msec and a 40 degrees flip angle during infusion of 40 ml of gadolinium-chelated contrast material. Patients then underwent conventional angiography of the iliac arteries. Maximum stenosis in the common iliac, external iliac, and common femoral arteries was then measured. Measurements of stenosis were compared by repeated measures of analysis of variance. Sensitivity and specificity were calculated for identification of greater than or equal to 50% stenosis and less than 50% stenosis. RESULTS: For all vessels studied, we found no significant difference in measurements obtained from the gadolinium-enhanced MR angiography technique and those obtained from conventional angiography (p > .05). However, significantly different stenotic measurements were obtained from the 2D TOF MR angiography sequence and conventional angiography. In the external iliac arteries, 2D TOF MR angiography exaggerated stenoses most substantially. Gadolinium-enhanced MR angiography achieved 100% sensitivity and specificity. CONCLUSION: Dynamic gadolinium-enhanced MR angiography was more accurate than 2D TOF MR angiography when measuring degree of stenosis in the iliac arteries.

Developing psychodynamic group treatment methods for aggressive male inpatients.

Group psychotherapy is one intervention that can be used for aggressive male inpatients. This paper reports relevant literature and clinical applications for conducting a psychodynamic psychotherapy group designed to help patients (a) identify, understand, and deal with underlying problems resulting in aggressive behavior; (b) improve interpersonal relationships; and (c) find more appropriate ways of expressing feelings, particularly those associated with aggressive behavior. The review of literature focuses on therapeutic approaches for dealing with aggressive feelings in group therapy; men's issues in group psychotherapy, including stages of group development for men and the expression of aggression; and the outcome of aggressive behavior in response to group therapy. Clinical applications discussed are preparation for the group; the group contract, including the "group as a whole" approach; patient selection; modeling authority; and countertransference and projective identification.

The relationship of behavioral cues to assaultive behavior.

The purpose of this 2-year, case control study was to determine whether differentiation between assaultive and nonassaultive patients can be made based on behavioral assessments and/or sociodemographic variables. For each assault incident, the chart of the patient who assaulted and a randomly chosen patient who did not assault on that day were reviewed (N = 72 subjects or 26 pairs). Various scales were used to evaluate the subjects retrospectively (the day prior to the assault), and patients who assaulted staff were interviewed when possible. An analysis found no differences between patients who assaulted and controls on sociodemographic variables. Those who assaulted had significantly more prior assaults (p = .04) and more difficulty verbalizing angry feelings appropriately on their units (p < .01). Prior to the assault, assaultive patients were more verbally hostile (p = .037) and showed more increased motor activity (p = .001) than controls.

A metaanalysis of home uterine activity monitoring.

OBJECTIVE: Our purpose was to assess by metaanalysis the evidence from randomized clinical trials regarding home uterine activity monitoring. STUDY DESIGN: Six randomized controlled trials of home uterine activity monitoring, the same six trials reviewed by the U.S. Preventive Services Task Force on home uterine activity monitoring, were studied. Data were extracted from published reports of the six trials. In addition, unpublished data were obtained by personal communication from the trials' principal investigators. Insofar as possible, the principle of intention-to-treat was maintained. Data regarding twins were handled by use of numbers of pregnancies rather than numbers of infants as sample sizes. Stratified metaanalyses were conducted according to whether the trial did or did not control in study design for the nursing contact factor that accompanies home uterine activity monitoring. In addition, stratified metaanalyses were conducted for singleton and twin pregnancies. The four outcomes investigated were incidence of preterm birth, incidence of preterm labor combined with cervical dilatation > 2 cm, infant referral to the intensive care unit, and mean birth weight. RESULTS: Overall, for all pregnancies home uterine activity monitoring was associated with a statistically significant reduction of 52% in risk of preterm labor combined with cervical dilatation > 2 cm (relative risk = 0.48, p = 0.001) and a statistically significant increase of 86 gm in mean birth weight (p = 0.038). When stratified by singleton or twin pregnancy, the pooled results generally differed by strata. Among singleton pregnancies, home uterine activity monitoring was associated with a statistically significant reduction of 24% in risk of preterm birth (relative risk 0.76, p = 0.037) and a statistically significant increase of 126 gm in mean birth weight (p = 0.009). Among twin pregnancies, there was a statistically significant effect of home uterine activity monitoring with a reduction of 56% in risk of preterm labor combined with cervical dilatation > 2 cm (relative risk 0.44, p = 0.005). There were no statistically significant effects found overall and in any stratum with regard to infant referral to the intensive care unit. Metaanalyses of studies that controlled in design for the nursing contact factor that accompanies home uterine activity monitoring showed either no difference or stronger pooled effects compared with metaanalyses of those studies that did not control for nursing contact. This suggests that the potential bias attributed to the nursing contact feature that accompanies home uterine activity monitoring is not as appreciable as home uterine activity monitoring critics have suggested. CONCLUSIONS: Metaanalysis of existing clinical trial evidence regarding home uterine activity monitoring reveals statistically significant benefits of home uterine activity monitoring. Of the outcomes investigated, home uterine activity monitoring is associated with reductions in risks of preterm birth (in singleton pregnancies only) and preterm labor combined with cervical dilatation > 2 cm, as well as with increased mean birth weight (in singleton pregnancies only).

Improved mortality and rehabilitation of transplant candidates treated with a long-term implantable left ventricular assist system.

OBJECTIVE: This nonrandomized study using concurrent controls was performed to determine whether the HeartMate implantable pneumatic (IP) left ventricular assist system (LVAS) could provide sufficient hemodynamic support to allow rehabilitation of severely debilitated transplant candidates and to evaluate whether such support reduced mortality before and after transplantation. METHODS: Outcomes of 75 LVAS patients were compared with outcomes of 33 control patients (not treated with an LVAS) at 17 centers in the United States. All patients were transplant candidates who met the following hemodynamic criteria: pulmonary capillary wedge pressure > or = 20 mm Hg with a systolic blood pressure < or = 80 mm Hg or a cardiac index < or = 2.0 L/minute/m2. In addition, none of the patients met predetermined exclusion criteria. RESULTS: More LVAS patients than control patients survived to transplantation: 53 (71%) versus 12 (36%) (p = 0.001); and more LVAS patients were alive at 1 year: 48 (91%) versus 8 (67%) (p = 0.0001). The time to transplantation was longer in the group supported with the LVAS (average, 76 days; range, < 1-344 days) than in the control group (average, 12 days; range, 1-72 days). In the LVAS group, the average pump index (2.77 L/minute/m2) throughout support was 50% greater than the corresponding cardiac index (1.86 L/minute/m2) at implantation (p = 0.0001). In addition, 58% of LVAS patients with renal dysfunction survived, compared with 16% of the control patients (p < 0.001). CONCLUSIONS: The LVAS provided adequate hemodynamic support and was effective in rehabilitating patients based on improved renal, hepatic, and physical capacity assessments over time. In the LVAS group, pretransplant mortality decreased by 55%, and the probability of surviving 1 year after transplant was significantly greater than in the control group (90% vs. 67%, p = 0.03). Thus, the HeartMate IP LVAS proved safe and effective as a bridge to transplant and decreased the risk of death for patients waiting for transplantation.

Newborn acoustic cry characteristics of infants subsequently dying of sudden infant death syndrome.

OBJECTIVE: To test the hypothesis that the occurrence of a neonatal cry exhibiting a high first formant is a risk factor for sudden infant death syndrome (SIDS) and to evaluate the association between SIDS and other acoustic cry variables. METHOD: We recorded cries and obtained medical and demographic data for 21,880 apparently healthy term newborns. Two cries were recorded between days 2 and 7 of life, after a painful stimulus at the time of routine blood drawing. Acoustic variables were measured with an automated computer-based analysis system. Twelve infants died of SIDS. Age at death ranged from 19 days to 6.5 months. Autopsies were performed in all cases. At least one cry was analyzed for all 12 infants who died of SIDS and 20,167 infants without SIDS. Two cries were analyzed for 9 infants who died of SIDS and 14,235 infants without SIDS. RESULTS: Newborns whose first cries exhibited a high first formant were more likely to die of SIDS than infants whose first cries did not have this characteristic (relative risk, 3.5; 95% confidence interval [CI], 1.1 to 12). The relative risk for SIDS increased to 8.8 (95% CI, 2.2 to 35) for newborns whose second cries showed that this characteristic persisted. Newborns with the combination of both a high first formant and a high number of mode changes on both of two cries had a relative risk of 32 (95% CI, 8.7 to 120). CONCLUSIONS: We have shown an association between alterations in neonatal cry acoustics and SIDS. Cry analysis represents a potentially important research tool that, when studied in relation to other physiologic measures, may lead to an improved understanding of SIDS.

Patient assault: a comparison of patient and staff perceptions.

The purpose of this study was to compare the perceptions of assaultive patients and staff victims regarding assault incidents. The hypotheses were as follows: (1) There will be congruence between patients' and victims' reports of objective or factual information regarding the assaults and (2) there will not be congruence between patients' and victims' reports of subjective information about the assaults. Monahan's (1981) framework was used for assessing violence on the assaultive patient and the assaulted staff member. Patients who assaulted a nursing staff member and nursing staff members who were assaulted were interviewed, and the congruence of responses between each pair (patient and staff member) on each question was assessed. For 10 items designated as objective, there was agreement between patients and victims in 6 cases and disagreement in 4 cases. For 8 subjective items, in all cases patients and victims gave different perceptions.

Predicting violence: nursing diagnosis versus psychiatric diagnosis.

Predicting violent behavior is a major concern for nurses as well as other mental health professionals. Two diagnostic assessment systems (Nursing Diagnosis-NANDA and Psychiatric Diagnosis-DSM III-R) were compared in their ability to predict assaultive behavior. The nursing diagnosis potential for violence suggested a difference (p = .07) between the assaultive and control subjects. No differences were found between assaultive and control subjects on psychiatric diagnoses. Nursing diagnosis is based upon measurable behaviors and is time specific. Clinical implications and further research endeavors in this area are suggested.

Environmental characteristics related to patient assault.

Environmental factors related to physical assault by patients were examined to identify clinical implications warranting further investigation and to test methodology. The concepts of ward conditions (degree of patients' illness, numbers of patients and staff) and ward climate were the focus of the study. Participants were patients and nursing staff on two acute and four long-term psychiatric units in a large neuropsychiatric hospital. Patients and staff were asked to complete the Ward Atmosphere Scale to assess ward mood and climate. Each assault incident was identified from the daily nursing ward report. With each assault occurrence, the nurse manager was asked to complete a questionnaire about environmental conditions at the time of the assault. Most assaults occurred during meal times and afternoons. The most frequent locations were ward corridors and dayrooms. There appeared to be an inverse relationship between assault frequency and number of staff. Crowding rather than total number of patients per ward was suggested as a factor related to assault. Degree of patient acuity seemed to be inversely related to assault frequency. There were suggested trends between assault frequency and a low score on autonomy and a high score on staff control. Clinical implications, ideas for further research, and improved design measures are suggested. The challenge to understand and control this complex phenomenon remains a critical issue for inpatient nursing care.

Polysymptomatic syndromes and autonomic reactivity to nonfood stressors in individuals with self-reported adverse food reactions.

This study compared symptom reports and cardiovascular reactivity of a group of 24 individuals recruited from the community who reported a cognitive or emotional symptom caused by at least one food (food-sensitivity reporters, FSR) vs those of 15 controls (C) without a history of food, chemical, drug, or inhalant sensitivities. The main findings were: 1) FSR indicated sensitivities not only to foods, but also to environmental chemicals, drugs, and natural inhalants, as well as significantly more symptoms than C in multiple systems; 2) more FSR than C noted recent state depression and anxiety, as well as higher trait anxiety on the Bendig form of the Taylor Manifest Anxiety Scale; 3) however, on multiple regression analysis, not only depression, but also the number of sensitivities (foods, chemicals, drugs, inhalants), accounted for part of the variance in total number of symptoms (38 and 17%, respectively), whereas none of the affective measures accounted for any of the variance in total number of sensitivities over all subjects; 4) after controlling for depression and anxiety, FSR still showed a trend toward poorer performance on a timed mental arithmetic task (p = 0.16); and 5) FSR and C showed opposite patterns of heart rate change to two different stressful tasks (mental arithmetic and isometric exercise) (group by task interaction, p < 0.05). The data are discussed in terms of a time-dependent sensitization (TDS) process that predicts a cross-sensitizing and cross-reactive role for xenobiotic agents (e.g., foods, chemicals, drugs, and inhalants) and for salient psychological stress in the expression of psychophysiological dysfunctions of FSR. As in other chronically ill populations, negative affect in food-sensitive individuals may explain greater symptom reporting, but not necessarily account for the illness itself. For either a food or a psychological stimulus to begin to elicit sensitized responses, e.g., marked physiological differences from C, FSR may require multiple, intermittent exposures spaced over 5-28 days rather than on only 1 day.

Plasma homocysteine in vascular disease and in nonvascular dementia of depressed elderly people.

Depression among elderly people with reversible cognitive loss often manifests with concomitant vascular disease and can also precede the development of nonvascular degenerative dementia. Little is known about etiological factors for reversible or irreversible dementias in older depressed people. The amino acid homocysteine (HC), which is both a vascular disease risk factor and a precursor of the excitotoxic amino acids cysteine and homocysteic acid, could play a role in the pathophysiology of such individuals. Twenty-seven depressed elderly acute inpatients by DSM-III-R criteria had significantly higher plasma homocysteine levels and lower cognitive screening test scores than did 15 depressed young adult inpatients. HC was highest in the older patients who had concomitant vascular diseases (n = 14). HC was lowest in the older depressives who had neither vascular illnesses nor dementia (n = 8), comparable to the young adult depressives. Higher HC correlated significantly with poorer cognition only in the nonvascular geriatric patients (rs = -0.53). The findings extend earlier work showing higher HC in vascular patients from general medical populations, and also suggest a possible metabolic factor in certain dementias associated with late-life depression.

Effects of in utero cocaine exposure on newborn acoustical cry characteristics.

As part of a large, multicenter study of newborn cry analysis and Sudden Infant Death Syndrome, we examined the effects of in utero cocaine exposure on ten acoustical cry characteristics. Newborn cry recording and medical record review was performed for 23,948 newborns. Cocaine use during pregnancy (determined by record review) was identified in 438 (1.8%) women (310 by self-report only; 128 newborns also had positive urine assay). A demographically similar group of 373 newborns, selected from the 23,510 newborns without known cocaine exposure, made up the comparison group. Cry analysis was technically possible for 768 recordings: 404 cocaine-exposed and 364 non-exposed controls. Comparison of cocaine-exposed vs control newborns, after adjustment for potential confounding variables, found significant differences including: fewer cry utterances (P = .001), more short cries (P = .02), and less crying in the hyperphonation mode (P = .01), for the cocaine-exposed neonates. As reported in other studies, cocaine-exposed newborns also were significantly lower in birth weight, length, and head circumference. Newborns who had positive urine tests for cocaine suffered the greatest effects on both cry and growth parameters. These findings suggest a pattern of underaroused neurobehavioral function and are consistent with the emerging picture of the adverse neurobehavioral effects of cocaine. Developmental outcome studies are in progress to determine if acoustical analysis of the newborn cry can be used to identify cocaine-exposed newborns who are at highest risk for poor outcome.

Brief communication. Vitamin B1, B2, and B6 augmentation of tricyclic antidepressant treatment in geriatric depression with cognitive dysfunction.

This was a 4-week randomized placebo-controlled double-blind study to assess augmentation of open tricyclic antidepressant treatment with 10 mg each of vitamins B1, B2, and B6 in 14 geriatric inpatients with depression. The active vitamin group demonstrated significantly better B2 and B6 status on enzyme activity coefficients and trends toward greater improvement in scores on ratings of depression and congnitive function, as well as in serum nortriptyline levels compared with placebo-treated subjects (Ss). Without specific supplementation, B12 levels increased in Ss receiving B1/B2/B6 and decreased in placebo Ss. These findings offer preliminary support for further investigation of B complex vitamin augmentation in the treatment of geriatric depression.

Abnormalities in color vision and contrast sensitivity in Parkinson's disease.

Dopamine is a neurotransmitter found in the retina. Delays in the visual evoked responses and abnormalities in contrast sensitivity occur in patients with Parkinson's disease. Improvement in the P100 has followed L-dopa therapy. Suspected abnormalities at the retinal level in Parkinson's disease are observed in reductions in photopic, scotopic, and pattern-derived electroretinograms. We studied 35 patients with Parkinson's disease and 26 controls of comparable age and visual acuities using visual evoked responses, color vision, and contrast sensitivity testing. Contrast sensitivity thresholds were significantly different at most frequencies tested, using both stationary and temporally modulated sinusoidal gratings. The total error score of the Farnsworth-Munsell 100 Hue Test revealed significant differences between the patients and controls. The contrast thresholds derived from certain spatial frequencies and the total error in color score were significantly related to the duration of disease. A stepwise discriminant analysis correctly identified 94% of the patients and 94% of the controls. The significant error in chromatic discrimination observed in Parkinson's disease patients may be due to altered intraretinal dopaminergic synaptic activity in these patients.

Multicenter randomized clinical trial of home uterine activity monitoring for detection of preterm labor.

Home uterine activity monitoring has been described as an effective means of detecting uterine contractions, but controversy exists whether it is home uterine activity monitoring or increased nursing support in conjunction with it that contributes to earlier detection of preterm labor. In this study 377 women at risk for preterm labor from three centers were prospectively, randomly assigned to high-risk prenatal care alone (not monitored) or to the same care with twice-daily home uterine activity monitoring without increased nursing support (monitored). The two groups were medically and demographically similar at entry into the study. Routine visits, nonroutine visits, and gestational age at diagnosis of preterm labor were similar in both groups. Preterm labor occurred in 41 of 198 monitored and 39 of 179 not monitored patients. Mean cervical dilatation was 1.4 cm in 41 monitored compared with 2.5 cm for 37 not monitored (p = 0.0006); 73.1% of monitored and 27.5% of not monitored had preterm labor detected before 2 cm dilatation (p = 0.00009). Neonatal outcome of singleton pregnancies showed greater birth weight, fewer days in the neonatal intensive care unit, and fewer babies requiring oxygen therapy and mechanical ventilation in the monitored group. The better outcomes are probably due to the increased likelihood of diagnosis of preterm labor before advanced cervical dilatation with home uterine activity monitoring, thus providing the clinician with a better chance to initiate tocolytic therapy directed at improving pregnancy outcome.

Nursing staff characteristics related to patient assault.

There is an underlying belief that there is something special about the victims of patient assault, that they possess certain characteristics or behave in a different way from those staff who are not assaulted. Is this a case of blaming the victims, or are there some actual differences between those staff members who are assaulted and those who are not? This study undertook this question. Its specific purpose was to (1) characterize staff victims and compare them to nonassaulted staff and (2) document outcomes on staff who were assaulted. The design included a prospective and retrospective phase. Nursing staff on two acute and four long-term psychiatric units were asked sociodemographic and job-related information at the beginning of the study. The frequency with which each staff member was assaulted was recorded. At the end of 1 year, staff who had been assaulted were compared with staff who had not been assaulted. Any staff members who were assaulated were interviewed to assess the physical and emotional effect of the assault on the victim. Findings indicated no difference between assaulted versus nonassaulted staff on sociodemographic factors, with the exception of marital status. Assessment of job-related factors suggested differences on position in the administrative hierarchy, type of activities involved in direct patient care such as medication administration, and education about handling the aggressive patient. Victim outcomes supported the existing literature. The most frequent site of injury was the head. Staff either did not take leave time or returned to work before they recovered, and many reported emotional stress.

B complex vitamin patterns in geriatric and young adult inpatients with major depression.

This study compared the B complex vitamin status at time of admission of 20 geriatric and 16 young adult non-alcoholic inpatients with major depression. Twenty-eight percent of all subjects were deficient in B2 (riboflavin), B6 (pyridoxine), and/or B12 (cobalamin), but none in B1 (thiamine) or folate. The geriatric sample had significantly higher serum folate levels. Psychotic depressives had lower B12 than did non-psychotic depressives. Poorer blood vitamin status was not associated with higher scores on the Hamilton Depression Rating Scale or lower scores on the Mini-Mental State Examination in either age group. The data support the hypothesis that poorer status in certain B vitamins is present in major depression, but blood measures may not reflect central nervous system vitamin function or severity of affective syndromes as measured by the assays and scales in the present study.

Relationship of normal serum vitamin B12 and folate levels to cognitive test performance in subtypes of geriatric major depression.

This retrospective study evaluated the relationships between normal serum vitamin B12 and folate levels and neuropsychologic measures in a sample of 60 geriatric inpatients with psychotic depression, nonpsychotic depression, bipolar disorder, and dementia--all consecutively referred for cognitive testing. The psychotic depression subgroup demonstrated numerous significant positive correlations between B12 and cognitive subtests not seen in other diagnostic subgroups, especially those of IQ, and verbal and visual memory. Metabolic factors including vitamin B12 may play specific roles in the cognitive dysfunctions of different geropsychiatric disorders.

School Breakfast Program and school performance.

To test the hypothesis that participation in the School Breakfast Program by low-income children is associated with improvements in standardized achievement test scores and in rates of absence and tardiness, children in grades 3 through 6 were studied in the Lawrence, Mass, public schools, where the School Breakfast Program was begun at the start of the second semester 1986-1987 school year. The changes in scores on a standardized achievement test and in rates of absence and tardiness before and after the implementation of the School Breakfast Program for children participating in the program were compared with those of children who also qualified but did not participate. Controlling for other factors, participation in the School Breakfast Program contributed positively to the 1987 Comprehensive Tests of Basic Skills battery total scale score and negatively to 1987 tardiness and absence rates. These findings suggest that participation in the School Breakfast Program is associated with significant improvements in academic functioning among low-income elementary school children.