Economic evaluation is essential in healthcare for the elderly. A viewpoint.

The aging population is considered to be one of the major factors driving the cost of healthcare upward in industrialised countries. However, several analyses show that expenditure has increased mainly because of other factors. Expenditure is expected to increase when an aging population is combined with technical progress. In addition, the growing proportion of the population who are elderly means that there is an increasing proportion of people who do not work, creating further problems in the financing of healthcare. These problems make it imperative to provide medical care to the elderly in an efficient way. Economic evaluation studies should render information about the cost-effectiveness of medical treatments as well as the preferences of patients. A MEDLINE-based review of the literature reveals that few studies specifically assess the cost-effectiveness of medical care for the elderly. Since age can influence the costs and effects of patient treatment, study results from younger patient samples may not adequately reflect the results to be expected for elderly patients. A significant information gap concerning the efficiency of care for the elderly thus exists, including information on the efficiency of drug treatment. There is also a need to test and, eventually, specify evaluation methodology (such as the appropriateness of quality of life measurement) for elderly patients. Since the elderly have a shorter life expectancy, they may be at a disadvantage when cost-effectiveness measures are compared across age groups. Depending on the normative position, such comparisons can be accepted from a utilitarian, population-oriented perspective, or rejected from a libertarian, individualistic perspective. The normative position needs to be discussed when making use of evaluation results. Avoiding this discussion can bring about ethically unfavourable consequences.

The effects of research on clinical practice: the use of restraints.

The investigators have conducted a series of four descriptive, clinical studies to examine the nature of restraint use in extended care and nursing home units in a veterans' facility. Based on the findings of three of these studies, staff education and policy changes were implemented with the intent of decreasing the use of restraints. The present and fourth study in the series examines whether the use of restraints decreased from 1990 to 1993, after policy changes and staff education were initiated. Findings indicate that the frequency of restraint use decreased by almost half, from 25% to 14%. In addition, falls did not increase, but those falling were less likely to be restrained. These findings illustrate the importance of research in setting a course for positive change in clinical practice.

German rescue system--an overview.

Aim of the report is to show the structure, organisation and legal aspects of the rescue system of the Federal Republic of Germany. The laws are the basis of the rescue system in each of the sixteen federal countries. The governments of the countries delegate their tasks to the administrative districts. Several organisations like German Red Cross, the Fire Brigades; societies like Arbaite-Samariter-Bund, Johanniter-Unfall-Hilfe, Malteser-Hilfsdienst take part in the rescue system with a great number of paid professional people and volunteers with a more or less professional education. Who is Who in the rescue system? Who is responsible for medical education and what is the difference between the rescue system and the "doctor on emergency call"? Both systems exist side by side, but they are very different from one another. The "doctor on emergency call" is private organised by the board of general practitioners and is responsible for "all day" emergency cases on weekends and during the night. The task of the countries and districts is to care for the rescue services, and they should only be used for severe injuries and illness. Most of the physicians taking part in the rescue services belong to hospitals and have no financial interests in their duty.

Chronic angiotensin-converting enzyme inhibition may improve sodium excretion in cardiac transplant hypertension.

Cyclosporine-associated hypertension (CAH) may be mediated in part by sodium and volume retention. To investigate this issue, we studied the effects of a calcium antagonist, nitrendipine (NIT, 10-20 mg b.i.d.), and a converting enzyme inhibitor, lisinopril (LIS, 10-20 mg o.d.), on blood pressure (office BP, 24 hr ambulatory BP), excretion of an acute sodium load (200 mmol/2 hr i.v.), glomerular filtration rate (insulin clearance), cumulative dopamine excretion, plasma atrial natriuretic peptide (ANP), and endothelin excretion in 8 patients with CAH after cardiac transplantation in a double-blind, randomized, crossover trial for 6 weeks. Five patients received a diuretic during the trial at a constant dose. Office diastolic BP (DBP) decreased significantly with LIS from 97 +/- 6 to 87 +/- 9 mmHg and with NIT from 96 +/- 7 to 92 +/- 12 mmHg. Ambulatory 24 hr DBP decreased significantly from 96 +/- 7 mmHg to 86 +/- 10 mmHg (LIS) and to 84 +/- 11 mmHg (NIT). Ambulatory DBP during the day was lowered significantly from 98 +/- 11 mmHg to 87 +/- 10 mmHg (LIS) and to 88 +/- 9 mmHg (NIT) and during the night from 95 +/- 9 mmHg to 86 +/- 8 mmHg (LIS) and to 79 +/- 7 mmHg (NIT). Cumulative sodium excretion 6 hr after an acute sodium load increased to 52 +/- 39 mmol (placebo), 96 +/- 44 mmol (LIS, P < 0.05 vs. placebo), and 71 +/- 34 mmol (NIT). Glomerular filtration rate, cumulative dopamine excretion, ANP, and endothelin excretion did not differ between either treatment group. We conclude, that: (1) both drugs were similar in lowering office BP and during the day, but NIT tended to be more effective during the night; and (2) cumulative sodium excretion during LIS was significantly increased compared with placebo. There was a similar trend during NIT also. Therefore, it is possible that chronic angiotensin-converting enzyme inhibition and possibly calcium antagonists might improve the sodium-retaining state in CAH independent of differences in blood pressure, ANP, dopamine, or renal function.

Substrate and product binding sites of yeast fatty acid synthase. Stoichiometry and binding kinetics of wild-type and in vitro mutated enzymes.

The four known substrate binding sites of yeast fatty acid synthase (FAS), Ser819 (acetyltransferase, OHAC) and Ser5421 (malonyl/palmitoyl transferase, OHMa1) of subunit beta and Ser180 (pantetheine binding site, SHc) and Cys1305 (3-oxoacyl synthase, SHp) of subunit alpha were replaced, by targeted in vitro mutagenesis, by the non-acylatable amino acids glutamine, glycine or alanine. The four mutated FAS proteins together with two pairs of double mutants (OHAc/OHMa1 and SHc/SHp) were episomally expressed in appropriate delta fas1 or delta fas2 deletion strains. The purified enzymes isolated from these transformants were used for comparative acyl binding studies with the substrates [1-14C]acetyl-CoA and [2-14C]malonyl-CoA. Malonate was found to be transacylated to enzyme-bound pantetheine (SHc) exclusively by the Ser5421 hydroxyl group of malonyltransferase (OHMa1) while acetate could use both the acetyl (Ser819) and the malonyl (Ser5421) transferase active sites on its way to the SHc and SHp binding sites. Acylation of SHc with either substrate was unaffected by the absence of the 'peripheral' SH group (SHp) while binding of acetate to SHp was dependent on enzyme-bound pantetheine (SHc). These genetic data support a revised model regarding the intra-molecular channeling of acetate and malonate within yeast fatty acid synthase. Quantitative acyl binding studies revealed a maximum of 2-3 mol rather than the expected 12 mol of malonate and of 6-7 mol rather than 24 mol of acetate bound/mol hexameric yeast FAS. Only 20-30% of the malonyl-enzyme and 35-50% of the acetyl enzyme represented performic-acid-labile thioester bonds. The binding characteristics of both substrates, exhibiting Hill coefficients distinctly lower than 1, as well as their non-linear Lineweaver-Burk and Scatchard plots, point to a marked negative cooperativity among the 12 yeast FAS subunits. The observed sub-stoichiometric substrate binding characteristics of the enzyme are ascribed to this effect. An a priori asymmetry of the complex appears unlikely since the coenzyme-A:FAS transacylation equilibrium may be shifted towards the fully acetylated enzyme in the presence of N-ethylmaleimide. In contrast to the limited acylation capacity of the 'resting' enzyme, complete acylation of yeast FAS at all of its 12 SHc and SHp sites is observed under steady-state conditions of fatty acid biosynthesis. Under these conditions, the enzyme exhibits full-site reactivity at its SHp, SHc and OHAc sites, but a concomitant 18-fold increase in Km of the coenzyme-A:OHAc transacylation reaction keeps the acyl-O-ester content of the acylated enzyme at less than 5% of the total.(ABSTRACT TRUNCATED AT 250 WORDS)

Extended care and nursing home staff attitudes toward restraints. Moderately positive attitudes exist.

1. The average score on the Restraint Questionnaire for Staff indicated that the extended care and nursing home staff members in the study presented had moderately positive attitudes toward using restraints. 2. There were no significant differences in attitude scores based on gender, position, education, or clinical experience. 3. Collaborating with another professional, especially a physician, was related to a more positive attitude toward restraints; this effect approached statistical significance. 4. Sixty-five percent of the staff could offer no alternatives to restraining a patient; for those who could offer an alternative, increasing staff size was cited most frequently.

Patient and family perceptions of restraints.

Based on a holistic philosophy that aging persons' most primary need is that of autonomy and freedom, this qualitative descriptive study examined patients' and their family members' perceptions of the restraint procedure. Twenty-five restrained patients were interviewed, and 19 of their family members completed mailed surveys to describe their perceptions about restraints. Results indicated that the majority of patients (52%) expressed negative feelings about being restrained. Family members expressed a wide variety of feelings and were ambivalent about seeing a loved one restrained. Implications are that nursing needs to become committed to the philosophy of autonomy and freedom for elderly persons.

Institutional policy: use of restraints in extended care and nursing homes.

1. The percentage of patients restrained on these nursing home and extended care units was 32%, similar to that for other nursing home studies. 2. The archetypical restrained patient was older, new on the unit, had altered thought processes and a high potential for injury, and required extensive nursing care. Typically, the type of restraint a patient wore was a vest posey, on the day shift while in his room. 3. The most frequent rationale given by nurses for applying restraints was to prevent patient falls; however, half the time, this rationale was not charted. 4. Upon examining institutional restraint policy, nurses should be prepared to implement changes in documentation format, provide staff education regarding restraint use and alternatives available, institute a rehabilitative and restorative nursing care and fall prevention program, redesign the physical environment, and designate adequate resources for an effective diversion activity program.

Effects of nitrendipine and lisinopril on blood pressure and sodium excretion in ciclosporin-associated hypertension after heart transplantation.

Hypertension associated with ciclosporin A may be mediated by sodium and volume retention. Therefore, the effects of an antihypertensive therapy (6 weeks) with nitrendipine (10-20 mg twice daily) or lisinopril (10-20 mg once daily) on office blood pressure, 24-hour ambulatory blood pressure, and left ventricular function were evaluated in a randomised, double-blind cross-over trial in patients after heart transplantation. Nitrendipine and lisinopril were equally effective in lowering office and ambulatory systolic and diastolic blood pressures. After an acute sodium load (210 mval/2 h i.v.), sodium excretion was significantly increased during therapy with lisinopril but only slightly during nitrendipine, indicating that angiotensin-converting enzyme inhibition may improve the sodium-retaining state of heart transplant recipients associated with ciclosporin A.

[Choice of anesthesia procedure in cesarean section (general versus regional)]. / Auswahl des Anaesthesieverfahrens zur Sectio caesarea (generell versus regional).

Peripartum maternal mortality occurs in about 0.2% of patients. There are anaesthesiological causes in 5%-15%. Almost 50% of the anaesthesiologically based fatalities can be attributed to aspiration and hypoxia, frequently in combination with problems of intubation during general anaesthesia. In spite of numerous recommendations to avoid aspiration, it will never be possible to prevent hypoxaemia once and for all. In order to do as much as possible to exclude this maternal risk during a caesarean section, regional anaesthesia is being performed more often. Appropriate techniques are: lumbar (catheter), epidural, or spinal anaesthesia. Because of the large dose of the local anaesthetic necessary, caudal anaesthesia is normally excluded. The advantage of these techniques, especially with relation to the safety of the mother, can only be guaranteed for the following prerequisites: when maternal hypotension can be excluded or treated in time; when the block inadvertently spreads too high and is diagnosed in time; when intravascular injection of the local anaesthetic is avoided. Regional anaesthesia techniques do not endanger the cardiocirculation of the fetus, or its respiration, metabolism or neurological adaptability. Furthermore, these techniques are more advantageous when the developmental period is prolonged. The use of long-acting local anaesthetics is beneficial, as only a small quantity passes through the placenta and mixture with adrenaline is avoided. This is important because adrenaline may jeopardize the perfusion of the pregnant uterus because of the increased sensitivity of its alpha-receptors. For epidural anaesthesia, 0.75% bupivacaine is most frequently administered on account of the rapid onset of action and enhanced motor block.(ABSTRACT TRUNCATED AT 250 WORDS)

[Disposable needles for epidural anaesthesia - basic requirements (author's transl)]. / Anforderungen an Einmal-Injektionsnadeln zur Periduralanaesthesie.

Disposable needles for epidural single-shot and catheter techniques are being marketed increasingly by different firms. As a result of our experience, the basic requirements of each of the component parts in the needle assembly are outlined. It is clear that the materials used to date are failing in some requirements and we assume that the manufactures have possibly not taken account of the suggestions of practicing anaesthesists.

[Postspinal headache -- a clinical problem (author's transl)]. / Zur Problematik des postspinalen Kopfschmerzes.

A prospective study was made in 255 patients following spinal anaesthesia to detect the incidence of post operative headache, reference also being made to the size of needle used for lumbar puncture. There was a difference in the frequency of headache related to the size of needle used (9.7% with 22 gauge needle as against 6.7% with 25 gauge needle). Also the value of prophylaxis of headache by means of an epidural blood patch was shown (1.3%). Age also played a role, the older the patient, the less the risk of headache. The social class of the patient played no role at all.

[Spinal anaesthesia using bupivacain--clinical experience of more than 6000 cases (author's transl)]. / Klinische Verläufe von über 6000 Spinalanaesthesien mit Bupivacain.

The following report of our experience using isobaric Bupivacaine 0.5% in 6,228 operations (intrathecal technique) will consider the intra operative period. In 55.8% of cases the lower extremities were operated upon and in 44.2% the lower abdomen. In 1,487 cases (23.9%) side effects/complications were evident and a classification of such is as follows: anaesthetic technique 5.29%, cardiorespiratory 15.69%, operator/operative technique 6.13%. The percentage remained relatively constant irrespective of age but a higher pre op risk classification (A.S.A. System) resulted in a marked increase in the above figures. The principal side effects encountered were as follows: Bradycardia 7.5%, hypotonia 6.3%, insufficient analgesia 3.9%, extrasystoles 2.9%. Grave complications occured in 0.15% and within this group 4 patients died intraoperatively; a relationship with the mode of anaesthesia has not been proven.

[Deep spinal anaesthesia and saddle-block technique in surgery during pregnancy (author's transl)]. / Die tiefe Spinalanästhesie oder der Sattelblock bei Eingriffen während der Schwangerschaft.

The efficacy of peridural, spinal, and saddle-block technique in the operative treatment of the gravid patient is briefly described. Factors influencing height and spread of analgesia are indicated. In our series of 288 patients, where intrathecal techniques have been used, we compare the spread of analgesia in those positioned in the horizontal (following injection), and those propped to an angle of 45 degrees. We discuss the operative possibilities with such techniques. In conclusion we describe the side effects encountered and their treatment.

Excretion of norephedrine by man after oral administration of oxyfedrine.

After oral administration of oxyfedrine to healthy volunteers, norephedrine was identified in the urine by thin layer chromatography and gas liquid chromatography and mass spectrography. 30 hours after single oral doses of 8, 16 or 24 mg of oxyfedrine, about 4, 8 and 9 mg, respectively, of norephedrine were found in the urine, i.e. on a molar base 75-100% of the dose was excreted as norephedrine. The peak of excretion occurred within 2-4 hours after administration of the drug. No accumulation of oxyfedrine and/or its metabolite was observed after administration of 16 mg of oxyfedrine t.i.d. for three days. It could not be decided whether oxyfedrine was metabolized to norephedrine by liver enzymes, as in rats, or was spontaneously degraded to norephedrine, e.g. in duodenal fluid before absorption. 30-150 min after oral oxyfedrine (24 mg) norephedrine was demonstrable in duodenal fluid. Thus, in addition to the direct beta-sympathomimetic effects of oxyfedrine, it may also have indirect sympathomimetic effects because of the noradrenaline-releasing properties of its metabolite norephedrine.