RESUMEN
INTRODUCTION: Elevated parathyroid hormone (PTH) levels contribute to age-related bone loss. Practitioners should be aware of iatrogenic and/or correctable determinants of PTH elevation. METHODS: We performed a cross-sectional study including 302 of 609 eligible residents at a state veterans home. Multiple regression analysis was used to determine the effect of 25-OH-D level, glomerular filtration rate (GFR), calcium supplements, diuretics, and mobility status on PTH levels. The dose of calcium carbonate and diuretics was determined as milligram per kilogram of body weight. RESULTS: The multiple regression process identified GFR, 25-OH-D level, as well as the dose of furosemide and calcium per kilogram of body weight as significant contributors to PTH. In a 70-kg resident, a daily dose of 40 mg of furosemide was associated with an increase of 22.8 pg/mL in PTH, while 500 mg of elemental calcium carbonate (in the absence of a proton pump inhibitor) was associated with a decrease of 8.7 pg/mL in PTH. An increase of 10 ng/mL in 25-OH-D was associated with a decrease of 5.7 pg/mL in PTH. DISCUSSION: Clinicians should be aware of the adverse effects of loop diuretics on urinary calcium excretion and PTH levels. Residents who ingest furosemide should be targeted to receive recommended doses of vitamin D and calcium.
Asunto(s)
Hogares para Ancianos/estadística & datos numéricos , Hiperparatiroidismo/sangre , Hiperparatiroidismo/epidemiología , Casas de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Antiácidos/uso terapéutico , Calcifediol/metabolismo , Calcio/metabolismo , Carbonato de Calcio/uso terapéutico , Causalidad , Comorbilidad , Estudios Transversales , Diuréticos/uso terapéutico , Femenino , Tasa de Filtración Glomerular , Humanos , Masculino , Persona de Mediana Edad , Limitación de la Movilidad , Análisis de Regresión , Insuficiencia Renal/epidemiología , Insuficiencia Renal/metabolismo , Wisconsin/epidemiologíaRESUMEN
OBJECTIVE: To determine the effect of various doses of vitamin D(2) and D(3), as well as ambulatory status (a surrogate for sun exposure), on 25-OH-D levels. DESIGN: Cross-sectional study with multiple regression analysis. SETTING: A state veterans home for veterans and their spouses. PARTICIPANTS: Three hundred two of 609 eligible residents. MEASUREMENTS: Serum 25-OH-D and parathyroid hormone (PTH) level, supplemental dose of vitamins D(2) and D(3) per kilogram of body weight, and 3 levels of ambulatory status. RESULTS: The mean 25-OH-D level was 28.6 + 9.2 ng/mL; 6.6% of subjects had values of 16 ng/mL or below. Thirty-two percent of participants had 25-OH-D levels below 30 ng/mL and PTH elevation based on stage of kidney disease, evidence that the suboptimal 25-OH-D level had physiologic consequences. Residents unable to transfer independently had 25-OH-D levels 1.6 ng/mL lower than those able to transfer independently. A regression analysis performed in residents unable to transfer independently (less likely to be exposed to the sun) demonstrated that the average increase in 25-OH-D level per 100 IU of D(3) in a 70-kg resident was 2.1 ng/mL versus 1.8 ng/mL for vitamin D(2). CONCLUSION: Nursing home residents should receive at least 800-1000 IU of D(3) per day in an effort to maintain optimal vitamin D levels.
Asunto(s)
Conservadores de la Densidad Ósea/administración & dosificación , Colecalciferol/administración & dosificación , Ergocalciferoles/administración & dosificación , Casas de Salud , Deficiencia de Vitamina D/sangre , Deficiencia de Vitamina D/prevención & control , Anciano , Anciano de 80 o más Años , Calcifediol/sangre , Calcifediol/deficiencia , Estudios Transversales , Monitoreo de Drogas , Femenino , Evaluación Geriátrica , Tasa de Filtración Glomerular , Humanos , Enfermedades Renales/complicaciones , Masculino , Persona de Mediana Edad , Limitación de la Movilidad , Hormona Paratiroidea/sangre , Análisis de Regresión , Índice de Severidad de la Enfermedad , Luz Solar , Resultado del Tratamiento , Veteranos , Deficiencia de Vitamina D/diagnóstico , Deficiencia de Vitamina D/epidemiología , Wisconsin/epidemiologíaRESUMEN
OBJECTIVES: To assess the effect of between-meal weekly risedronate and daily calcium 630 mg and vitamin D 400 IU on bone turnover markers. DESIGN: Randomized,double-blind,placebo-controlled trial. SETTING: Skilled nursing home (NH). PARTICIPANTS: Sixty skilled-NH residents (46 men, 14 women), mean age+/-standard deviation of 76+/-6, were randomized to receive risedronate 30 mg (n=31) or matching placebo (n=29) once weekly for 12 weeks. All received 315 mg calcium with 200 IU vitamin D twice daily. MEASUREMENTS: Bone-specific alkaline phosphatase (BSAP), N-telopeptide of type 1 collagen (NTx), 25-hydroxyvitamin D (25OHD), and parathyroid hormone were measured at baseline and 6 and 12 weeks. RESULTS: Risedronate reduced BSAP significantly more than placebo (P<.05) at 6 weeks but not at 12 weeks; no treatment effect on serum NTx was observed. Defining hypovitaminosis D as a serum 25OHD concentration below 32 ng/mL, 50 of 53 (94%) study participants were low at baseline (mean 25OHD 19 ng/mL). Vitamin D levels remained insufficient in 74% of participants after 12 weeks. CONCLUSION: In this NH population, weekly risedronate administered using a between-meal dosing schedule reduced serum BSAP at 6 weeks of treatment; this effect was not observed at 12 weeks. The overall lack of change in bone turnover markers suggests that this risedronate dose and schedule would not be expected to increase bone density or reduce fracture risk in this population. Hypovitaminosis D was common and not reliably corrected by 400 IU of vitamin D daily. Despite an extremely high osteoporotic fracture risk in NH residents, additional study is required to determine under which conditions pharmacological treatment is efficacious in this population and define approaches that assure vitamin D repletion.
Asunto(s)
Conservadores de la Densidad Ósea/administración & dosificación , Remodelación Ósea/efectos de los fármacos , Ácido Etidrónico/análogos & derivados , Casas de Salud , Vitamina D/análogos & derivados , Anciano , Fosfatasa Alcalina/sangre , Calcio/administración & dosificación , Colágeno Tipo I/sangre , Método Doble Ciego , Esquema de Medicación , Quimioterapia Combinada , Ácido Etidrónico/administración & dosificación , Femenino , Humanos , Masculino , Péptidos/sangre , Ácido Risedrónico , Vitamina D/administración & dosificación , Vitamina D/sangreRESUMEN
BACKGROUND: Despite vaccination, influenza commonly causes morbidity and mortality in institutional settings. Influenza control with rimantadine and amantadine is limited by emergence and transmission of drug-resistant influenza A variants, ineffectiveness against influenza B, and toxicity. This study evaluated the efficacy and tolerability of zanamivir versus rimantadine for influenza outbreak control in long-term care facilities. METHODS: This double-blind, randomized, controlled study prospectively enrolled nursing home residents for 3 influenza seasons (1997 to 2000). Vaccine was offered to all subjects. Following influenza outbreak declaration, subjects were randomized to inhaled zanamivir 10 mg or standard of care (rimantadine 100 mg for influenza A or placebo for influenza B) once daily for 14 days. The proportion of randomized subjects developing symptomatic, laboratory-confirmed influenza during prophylaxis was the primary endpoint. RESULTS: Of 482 randomizations (238 zanamivir, 231 rimantadine, 13 placebo), 96% of subjects were elderly or had high-risk conditions; over 90% were vaccinated. Symptomatic, laboratory-confirmed influenza occurred in 3% of zanamivir subjects and 8% of rimantadine subjects during chemoprophylaxis (P = .038; additional protective efficacy for zanamivir over rimantadine = 61%). Since only 25 subjects were randomized during 2 influenza B outbreaks and none developed influenza, the influenza B data were excluded from further analysis. Zanamivir was well tolerated and unassociated with emergence of resistant virus; rimantadine-resistant variants were common. CONCLUSIONS: This is the first prospective, controlled study demonstrating effectiveness of chemoprophylaxis for influenza outbreak control. Zanamivir prevents symptomatic, laboratory-confirmed influenza more effectively than rimantadine, is unassociated with resistant virus, and has a favorable safety profile. Zanamivir is an appropriate alternative for influenza outbreak control among institutionalized vaccinated elderly.
Asunto(s)
Infección Hospitalaria/prevención & control , Brotes de Enfermedades/prevención & control , Gripe Humana/tratamiento farmacológico , Gripe Humana/epidemiología , Casas de Salud , Rimantadina/administración & dosificación , Zanamivir/administración & dosificación , Administración por Inhalación , Anciano , Antivirales/administración & dosificación , Antivirales/efectos adversos , Quimioprevención , Infección Hospitalaria/virología , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Estudios de Seguimiento , Evaluación Geriátrica , Humanos , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Cuidados a Largo Plazo , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Rimantadina/efectos adversos , Medición de Riesgo , Análisis de Supervivencia , Resultado del Tratamiento , Vacunación/estadística & datos numéricos , Zanamivir/efectos adversosRESUMEN
OBJECTIVES: To prospectively detect amantadine-resistant influenza when amantadine was used for influenza A outbreak control. DESIGN: Prospective clinical surveillance and viral culture of all new respiratory illnesses during the course of amantadine prophylaxis. SETTING: A 721-bed, 14-ward nursing home for veterans and spouses during an influenza A outbreak (1993-94). PARTICIPANTS: Residents of a veterans hospital and their spouses. MEASUREMENTS: Nasopharyngeal and throat viral culture. All residents with positive cultures who developed new respiratory symptoms while receiving or residing on a unit receiving amantadine prophylaxis had antiviral-resistance testing and polymerase chain reaction restriction analyses performed. RESULTS: Amantadine prophylaxis was administered sequentially on nine of 14 wards to all well residents for 14 to 31 days/ward to control influenza outbreaks between December 9, 1993, and January 28, 1994. Amantadine treatment was simultaneously provided to 29 ill residents. Between December 3, 1993, and January 22, 1994, 68 culture-positive cases of influenza A were detected. Twenty subjects were receiving or residing on units receiving amantadine prophylaxis. Amantadine sensitivity testing could be performed on 16 residents; 12 residents had amantadine resistant strains. Four of the 12 had not received any antiviral treatment. Illness onset ranged from 1 to 22 days after amantadine prophylaxis was begun on the individual's unit. Two ribonucleic acid (RNA) mutations in the gene coding the M2 protein transmembrane region were observed that were clustered in time and space. Isolates from two roommates, one receiving amantadine for 18 days and one on no antiviral, had identical RNA sequences. CONCLUSION: Antiviral resistance may be responsible for failure of prophylaxis in nursing home outbreaks. Strategies that use different classes of antivirals for prophylaxis and treatment may limit emergence and transmission of resistant virus.
Asunto(s)
Amantadina/farmacología , Antivirales/farmacología , Infección Hospitalaria/prevención & control , Brotes de Enfermedades/prevención & control , Farmacorresistencia Viral , Virus de la Influenza A , Gripe Humana/prevención & control , Casas de Salud , Amantadina/uso terapéutico , Antivirales/uso terapéutico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/transmisión , Humanos , Virus de la Influenza A/efectos de los fármacos , Gripe Humana/epidemiología , Gripe Humana/transmisión , Pruebas de Sensibilidad Microbiana , Estudios Prospectivos , Veteranos , Wisconsin/epidemiologíaRESUMEN
OBJECTIVES: Twenty-five to thirty percent of hip fractures occur in men, and nursing home residents have a 5-10-fold greater fracture risk than community-dwellers. Osteoporosis prevalence in men in long-term care, however, is poorly defined. Our objectives were to determine the prevalence of osteoporosis, as assessed by peripheral bone mineral density (BMD), in a group of institutionalized veterans, and to determine how many men with low BMD had received a prior diagnosis of osteoporosis. METHODS: Subjects were residents in a 740-bed skilled nursing facility (78% men). Male residents (n = 103) competent to give informed consent underwent bilateral calcaneal and forearm BMD by dual-energy X-ray absorptiometry (DXA). Prior osteoporosis documentation was sought in medical records. RESULTS: Twenty percent of veterans (95% confidence interval (CI) 12-28%) exhibited calcaneal osteoporosis (T-score < -2.5), and 62% (CI 52-72%) were osteoporotic at the forearm. Forearm and calcaneal BMD were correlated (r = 0.678, P < 0.001). BMD of the left and right forearm, and of left and right calcaneus, were highly correlated (r = 0.880, P < 0.001 and r = 0.931, P < 0.001, respectively). Documentation of osteoporosis existed for one of 20 men with calcaneal osteoporosis and four of 59 men with forearm osteoporosis. CONCLUSIONS: Osteoporosis was prevalent but poorly documented in institutionalized veterans. Discordance in T-scores between forearm and heel was similar to that reported in other studies. The broad range of T-scores among subjects suggests that peripheral BMD measurement may be useful for clinical fracture risk stratification. Correlation among skeletal sites indicates that measuring a single site may be practical.
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Densidad Ósea/fisiología , Osteoporosis/diagnóstico , Osteoporosis/epidemiología , Absorciometría de Fotón , Anciano , Anciano de 80 o más Años , Calcáneo , Antebrazo , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Análisis de Regresión , Veteranos/estadística & datos numéricos , Wisconsin/epidemiologíaAsunto(s)
Brotes de Enfermedades , Arquitectura y Construcción de Instituciones de Salud , Virus de la Influenza A , Gripe Humana/epidemiología , Instituciones de Cuidados Especializados de Enfermería , Humanos , Gripe Humana/transmisión , Estaciones del Año , Ventilación , Veteranos , Wisconsin/epidemiologíaRESUMEN
Influenza A was cultured in 62 double rooms. The roommate was infected in 12 (19.4%). During 3,294 resident-seasons, influenza was cultured in 208 single rooms (6.3%). Those who lived in double rooms with a culture-positive roommate had a 3.07 relative risk (CI95, 1.61-5.78) of acquiring influenza.
Asunto(s)
Virus de la Influenza A/patogenicidad , Gripe Humana/transmisión , Casas de Salud , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Humanos , Virus de la Influenza A/aislamiento & purificación , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/epidemiología , Gripe Humana/microbiología , Habitaciones de Pacientes , Medición de Riesgo , Wisconsin/epidemiologíaAsunto(s)
Infecciones Estafilocócicas/tratamiento farmacológico , Staphylococcus aureus/genética , ADN Bacteriano/análisis , Electroforesis en Gel de Campo Pulsado , Hospitales de Veteranos , Humanos , Incidencia , Resistencia a la Meticilina , Recurrencia , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/patología , Staphylococcus aureus/efectos de los fármacosRESUMEN
OBJECTIVE: To identify delayed prophylaxis from a pre-existing database and strategies to improve performance. SETTING: A skilled nursing facility with 14 floors (4 buildings). The "outbreak unit" was a 50- to 60-bed floor. METHODS: We performed surveillance during six seasons using one protocol. Prophylaxis was started when influenza was cultured in the building and 10% of residents on the floor had a new respiratory illness within 7 days. We defined delayed prophylaxis as four or more residents on a floor with positive cultures whose specimens had been collected within 5 days before the application of prophylaxis. RESULTS: We identified 14 examples of delayed prophylaxis. In three, delayed prophylaxis was related to the 3.9-day delay between culture collection and culture report There was a high degree of commonality among building attack rates within a season. During six seasons, the first case in the last building occurred 27 to 64 days after the first case in the facility. The two seasons with the greatest activity (68 and 154 cases, respectively) began with explosive, multi-floor outbreaks in a single building. The match between the circulating strain and the vaccine was good, except in 1997-1998 when there were seven examples of delayed prophylaxis. CONCLUSIONS: Influenza may involve buildings sequentially with a commonality of building attack rates. Explosive, multi-floor outbreaks early in the season could lead to a lower threshold for prophylaxis within a larger area when initial cases are encountered later in the season. This strategy could have prevented five examples of delayed prophylaxis. Rapid testing of multiple specimens while waiting for culture confirmation could have prevented three examples of delayed prophylaxis.
Asunto(s)
Infección Hospitalaria/epidemiología , Brotes de Enfermedades/prevención & control , Control de Infecciones/normas , Gripe Humana/epidemiología , Instituciones de Cuidados Especializados de Enfermería/normas , Anciano , Infección Hospitalaria/prevención & control , Infección Hospitalaria/virología , Femenino , Humanos , Virus de la Influenza A/aislamiento & purificación , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Gripe Humana/virología , Masculino , Premedicación/estadística & datos numéricos , Estudios de Tiempo y Movimiento , Wisconsin/epidemiologíaRESUMEN
OBJECTIVES: To determine adverse clinical events and resource utilization associated with culture-positive influenza A in nursing home residents. DESIGN: A retrospective cohort study with cases and controls. SETTING: Seven hundred twenty-one-bed skilled nursing facility. PARTICIPANTS: One hundred fifty-four residents (21% of all residents) from whom influenza A was isolated during the 1997/98 season and matched controls. MEASUREMENTS: Baseline parameters, staff interventions, diagnostic tests, and adverse events were recorded from 60 days before to 60 days after specimen collection. The difference between each individual's before and after measurements determined excess utilization secondary to influenza. Controls were studied to determine time series effects. RESULTS: Baseline Minimum Data Set and nutritional parameters demonstrated significantly greater (P <.05) feeding dependency and lower serum albumin in the control group. Time series effects in the control group were negligible. Among cases, there were nine deaths within 30 days; among controls, there were four (chi2 P =.26). Within 30 days of onset, an average excess of 18 notations by nursing staff, one phone call to the physician, and one to family was noted per case. In half of cases, a nonscheduled physician visit was required. There was a 20% excess in physician orders for oxygen and bronchodilators. Chest x-rays were performed in half of the cases, and antibiotics were prescribed to half. Sixteen percent of cases had radiographic pneumonia, and 2% had congestive heart failure. The average cost for excess chest x-rays, laboratory services, antimicrobials, ambulance calls, hospital days, and emergency room and physician visits was $943.44. This does not include efforts by nursing home staff who accommodate functional decline on-site. CONCLUSION: An unexpected finding was that there were more impaired individuals who were less likely to have influenza detected or less likely to acquire influenza in the control group than in the influenza group. The morbidity, mortality, excess staff effort, and measured expenditure justify efforts to prevent influenza.