Jul-07

Use of Antibiotics in Elderly Patients with Exacerbated COPD: The OLD-Chronic Obstructive Pulmonary Disease Study Raffaele Antonelli Incalzi, MD, Andrea Corsonello, MD, Claudio Pedone, MD, Giulio Masotti, MD, Franco Rengo, MD, Vittorio Grassi, MD, and Vincenzo Bellia, MD Objectives: To verify how frequently geriatric patients hospitalized for exacerbated chronic obstructive pulmonary disorder (COPD) had not been given antibiotics at home and to identify the relationship between the patient’s condition and the prescribing practice. Design: Observational study. Setting: General medicine acute care wards. Participants: Four hundred fifty-nine elderly patients admitted to the hospital because of exacerbated COPD. Measurements: Indices of severity of COPD exacerbation, such as age, St. George Respiratory Questionnaire (SGRQ) score, number of exacerbations in the previous year, and Cumulative Illness Rating Scale score were considered in the analyses. Results: Ninety (19.6%) patients had an antibiotic prescribed before admission. The prescription was not associated with older age and was weakly associated with greater comorbidity. Having more than four exacerbations (odds ratio (OR)=2.16, 95% confidence interval (CI)=1.27–3.66) and a SGRQ symptoms subscore greater than 70 (OR=1.61, 95% CI=1.0–2.68) were independent correlates of the use of antibiotics before admission, although 67% of patients reporting more than four exacerbations in the previous year and 73.1% of patients with a SGRQ symptoms subscore greater than 70 had not been given any antibiotic prescription at home. Conclusion: The majority of older patients hospitalized for exacerbated COPD had not been given antibiotics at home, although they had at least one index of exacerbation severity. J Am Geriatr Soc 2006;54(4):642-647. Critical Review of Resident Assessment Protocols David Dosa, MD, MPH, Barbara Bowers, PhD, RN, FAAN, and David R. Gifford, MD, MPH Objectives: To evaluate the quality of all 18 federally mandated Resident Assessment Protocols (RAPs) by measuring their adherence to established criteria for clinical practice guidelines (CPGs). Design: Analytical evaluation. Setting: United States nursing homes. Participants: Eighteen federally mandated RAPs. Measurements: Each RAP was evaluated using review criteria based on the 1992 Institute of Medicine criteria for measuring the quality of clinical practice guidelines. Criteria included measurements of RAP validity, reliability/reproducibility, clinical applicability, clinical flexibility, clarity/format, scheduled review, expertise needed to complete, multidisciplinary process, and resources needed to complete. Two reviewers, each a geriatrician with expertise in nursing home medicine, evaluated each RAP on the degree of compliance with each criterion using a 2-point scale for each criterion. Results: Overall, no individual RAP met all of the review criteria. The Urinary Incontinence RAP best approximated all the review criteria. The Pressure Ulcer RAP received the lowest score. Notable deficiencies in most of the RAPs included poor validity, documentation, reliability, clinical flexibility, and clinical applicability. Conclusion: The RAPs synthesize large amounts of information into key points and recommendations. Nevertheless, RAPs perform poorly when held to formal standards expected for CPGs. Based on these findings, the authors and a technical expert panel convened by the Agency for Health Care Research and Quality generated recommendations that might improve the use and quality of future RAPs. J Am Geriatr Soc 2006;54(4):659-666. What's New in Stroke? The Top 10 for 2004/05 Silvina B. Tonarelli, MD, and Robert G. Hart, MD During the past decade, stroke has emerged from the dark ages of therapeutic nihilism to the current dawn of treatment activism, fueled by an unprecedented amount of high-quality clinical research. Here, the choices for the “Top 10” studies of 2004/05 influencing the management of patients with stroke and threatened stroke are reviewed. Nine are randomized, clinical trials involving a total of 61,810 participants. Three studies involved intracerebral hemorrhage, an important stroke subtype in which few trials have previously been carried out. Three studies involved acute treatment of stroke, and their results emphasize that “time is brain,” and minutes count, in management of acute ischemic and hemorrhagic stroke. The 10th study was a longitudinal cohort analysis of participants with atrial fibrillation pooled from six clinical trials that validated predictive schemes to identify those who benefit most from anticoagulation. The practical management implications of these studies refine and improve care of geriatric patients with cerebrovascular disease. J Am Geriatr Soc 2006;54(4):674-679.