Clinical Insignficance of Monoclonal T-Cell Populations and Duodenal Intraepithelial T-Cell Phenotypes in Celiac and Nonceliac Patients.

Refractory celiac disease (RCD) is a rare condition, usually managed at specialized centers. However, gastroenterologists and pathologists in general practices are often the first to consider a diagnosis of RCD in celiac patients with persistent symptoms. The distinction between type I and type II RCD is crucial as patients with RCD II have a shortened life expectancy.

Depressive symptoms and the risk of incident delirium in older hospitalized adults.

Objectives: To determine whether specific subsets of symptoms from the Geriatric Depression Scale (GDS), assessed at hospital admission, were associated with the incidence of delirium.

Design: Secondary analysis of a prospective cohort study of patients from the Delirium Prevention Trial.

Setting: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998.

Cerebral perfusion changes in older delirious patients using 99mTc HMPAO SPECT.

Background: Prior studies describe variable cerebral blood flow changes in delirium. This study aims to investigate cerebral blood flow changes in older hospitalized patients with delirium, the population in which most cases of delirium occur.

Methods: Participants included hospitalized general medical patients aged 65 years and older with documented delirium and no relevant medical conditions or preexisting abnormalities on neuroimaging prospectively studied using 99mTc HMPAO single photon emission computed tomography (SPECT) scans obtained during and after resolution of delirium.

Older adults discharged from the hospital with delirium: 1-year outcomes.

Objectives: To compare 1-year institutionalization and mortality rates of patients who were delirious at discharge, patients whose delirium resolved by discharge, and patients who were never delirious in the hospital.

Design: Secondary analysis of prospective cohort data from the Delirium Prevention Trial.

Setting: General medicine service at Yale New Haven Hospital, March 25, 1995, through March 18, 1998, with follow-up interviews completed in 2000.

What do we know about diverticular disease? A brief overview.

Diverticulosis and its complications, particularly diverticulitis, are extremely common in western countries. The major factor in the development of diverticulosis is a lack of adequate fiber intake. Diverticulitis may be complicated by abscess formation, fistula formation, peritonitis, or obstruction.

Clinical yield of computed tomography brain scans in older general medical patients.

Objectives: To evaluate the clinical yield of computed tomography (CT) brain scans in a prospective cohort of older patients admitted to the general medicine service.

Design: Nested cohort study of 117 subjects enrolled in previous prospective cohort study of 919 subjects.

Setting: University-affiliated teaching hospital.

Goal setting as a shared decision making strategy among clinicians and their older patients.

Objective: Older adults are less likely than other age groups to participate in clinical decision-making. To enhance participation, we sought to understand how older adults consider and discuss their life and health goals during the clinical encounter.

Methods: We conducted six focus groups: four with community-dwelling older persons (n=42), one with geriatricians and internists (n=6), and one with rehabilitation nurses (n=5).

Will older persons and their clinicians use a shared decision-making instrument?

Objective: To examine experiences of older persons and their clinicians with shared decision making (SDM) and their willingness to use an SDM instrument.

Design: Qualitative focus group study.

Participants: Four focus groups of 41 older persons and 2 focus groups of 11 clinicians, purposively sampled to encompass a range of sociodemographic and clinical characteristics.

Premature death associated with delirium at 1-year follow-up.

Background: While previous studies have demonstrated the increased mortality risk associated with delirium, little is known about the mortality time course. The objective of this study is to estimate the fraction of a year of life lost associated with delirium at 1-year follow-up.

Methods: Hospitalized patients 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center from March 25, 1995, through March 18, 1998, were followed up for 1 year after discharge, and patients who died were identified, along with the date of death.

Consequences of preventing delirium in hospitalized older adults on nursing home costs.

Objectives: To determine whether costs of long-term nursing home (NH) care for patients who received a multicomponent targeted intervention (MTI) to prevent delirium while hospitalized were less than for those who did not receive the intervention.

Design: Longitudinal follow-up from a randomized trial.

Setting: Posthospital discharge settings: community-based care and NHs.

A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method.

Objectives: To validate a chart-based method for identification of delirium and compare it with direct interviewer assessment using the Confusion Assessment Method (CAM).

Design: Prospective validation study.

Setting: Teaching hospital.

Physicians' interactions with third-party payers: is deception necessary?

Published reports indicate that physicians sometimes use deceptive tactics with third-party payers. Many physicians appear to be willing to deceive to secure care that they perceive as necessary, particularly when illnesses are severe and appeals procedures for care denials are burdensome. Physicians whose practices include larger numbers of Medicaid or managed care patients seem more willing to deceive third-party payers than are other physicians.

Treatment options in knee osteoarthritis: the patient's perspective.

Background: The objectives of this study were to (1) examine patient treatment preferences for knee osteoarthritis, (2) determine the influence of specific medication characteristics on patients' choices, and (3) examine whether patient preferences are consistent with current practice.

Methods: A total of 100 consecutive patients with symptomatic knee osteoarthritis completed an interactive computer questionnaire administered during a face-to-face interview. We measured the relative impact of specific medication characteristics (including administration, risks, benefits, and cost) on patients' choice, and the percentage of patients preferring nonselective nonsteroidal antiinflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors, glucosamine and/or chondroitin sulfate, opioid derivatives, and capsaicin across varying risks, benefits, and costs.

Involuntary job loss as a risk factor for subsequent myocardial infarction and stroke: findings from the Health and Retirement Survey.

Background: The role of stress in the development of cardiovascular disease is well established. Previous research has demonstrated that involuntary job loss in the years immediately preceding retirement can be a stressful life event shown to produce adverse changes in physical and affective health. The objective of this study was to estimate the risk of myocardial infarction (MI) and stroke associated with involuntary job loss among workers nearing retirement in the United States.

Achieving goals in geriatric assessment: role of caregiver agreement and adherence to recommendations.

Objectives: To determine predictors of recommendation adherence and goal attainment of family caregivers of patients at a geriatric assessment center.

Design: One-year prospective cohort study.

Setting: Outpatient geriatric assessment center in Connecticut.

The role of adherence on the effectiveness of nonpharmacologic interventions: evidence from the delirium prevention trial.

Background: The impact of adherence on outcome for a nonpharmacologic intervention strategy has not been previously examined.

Objective: To examine the impact of level of adherence on effectiveness of the intervention strategy in a large clinical trial of nonpharmacologic interventions to prevent delirium.

Methods: The subjects included 422 consecutive patients 70 years or older admitted to the medicine service at a university hospital.

The effects of a targeted multicomponent delirium intervention on postdischarge outcomes for hospitalized older adults.

Purpose: We sought to determine whether a multicomponent hospital-based intervention targeted toward risk factors for delirium had any effect on patient outcomes 6 months later.

Methods: We studied 705 patients aged 70 years or older who had been enrolled in a controlled trial of a multicomponent intervention at an academic medical center and who survived for at least 6 months after hospitalization. Outcomes included self-rated health, functional status, incontinence, depression, cognitive status, delirium, home health visits, homemaker visits, rehospitalization, and nursing home placement.

Screening and management of adult hearing loss in primary care: clinical applications.

Hearing loss is one of the most common chronic health conditions and has important implications for patient quality of life. However, hearing loss is substantially underdetected and undertreated. We present clinical cases to illustrate common situations in which primary care physicians may be called on to identify or to manage hearing loss.

Risk communication in rheumatoid arthritis.

Objective: Some people believe that certain issues should be protected from all trade-offs. These issues are referred to as "protected values." We investigated whether some patients with rheumatoid arthritis (RA) treat the risk of adverse effects (AE) as "protected values," i.

Burden of illness score for elderly persons: risk adjustment incorporating the cumulative impact of diseases, physiologic abnormalities, and functional impairments.

Background/objectives: To develop and validate a new risk adjustment index-the Burden of Illness Score for Elderly Persons (BISEP)-which integrates multiple domains, including diseases, physiologic abnormalities, and functional impairments. RESEARCH DESIGN SUBJECTS: The index was developed in a prospective cohort of 525 patients aged > or = 70 years from the medicine service of a university hospital. The index was validated in a cohort of 1246 patients aged > or = 65 years from 27 hospitals.

Patient preferences for treatment of lupus nephritis.

Objective: To examine the amount of improvement in renal survival that lupus patients require before choosing cyclophosphamide over azathioprine for the treatment of lupus nephritis.

Methods: Patients were presented with descriptions of cyclophosphamide and azathioprine and asked to indicate their preferred choice if each conferred an equal probability of renal survival. Strength of preference was assessed by systematically increasing the probability of renal survival of the more toxic treatment until the respondent's choice switched.

Evaluation of a guided protocol for quality improvement in identifying common geriatric problems.

Objectives: Many common geriatric problems are underrecognized and undertreated. A simple and reliable tool to facilitate a standard approach to evaluating geriatric patients might improve the quality of medical care delivered to geriatric patients. The objective of this study was to evaluate a standardized, semistructured quality-improvement protocol (the guided geriatric care protocol) for the assessment of common geriatric problems.

Physicians' ratings of their knowledge, attitudes, and end-of-life-care practices.

Purpose: Health care institutions are examining ways to improve physicians' skills in the delivery of end-of-life (EOL) care. Experts have suggested that influencing physicians' knowledge and attitudes concerning EOL care can influence subsequent EOL practices, including hospice use for appropriate patients; yet few studies have examined empirically the influence of physicians' knowledge and attitudes on such practices. The authors assessed the influences of self-rated knowledge and attitudes on physicians' discussions and referrals for hospice care.

Development and validation of a risk-adjustment index for older patients: the high-risk diagnoses for the elderly scale.

Objectives: The purpose of this study was to develop and validate a risk-adjustment index for 1-year mortality specific to older people, based on administrative discharge diagnoses.

Design: Two prospective cohort studies, in tandem. The index developed in the initial cohort was subsequently validated in a separate cohort.