To examine the hospitalization rate and mortality associated with forced mass transfer of nursing home residents with the highest levels of functional impairment.
Retrospective cohort study.
119 Texas and Louisiana nursing homes that were identified as being “at-risk” for evacuation for Hurricane Gustav.
6,464 long-stay residents residing in “at-risk” nursing homes for at least three consecutive months prior to landfall of Hurricane Gustav.
Using Medicare claims and instrumental variable analysis, we compared the differential mortality (death at 30 and 90 days) and hospitalization rates (at 30 and 90 days) of the most functionally-impaired long-stay residents who evacuated for Hurricane Gustav relative to the most functionally impaired residents who did not evacuate.
Results suggest that the effect of evacuation was associated with an 8% increase in hospitalizations by 30 and 90 days for the most functionally impaired residents. Evacuation was not significantly related to mortality for the most functionally impaired residents.
Our results suggest that the most functionally impaired nursing home residents experience an increase in hospitalizations but not mortality as a consequence of forced mass transfer. With the inevitability of nursing home evacuations for many different reasons, harm mitigation strategies focused on the most impaired residents are needed.
Nursing Home; Transitions; Hurricane
The study was designed to examine the 30- and 90-day mortality and hospitalization rates among nursing facility (NF) residents in the affected areas of Louisiana and Mississippi following Hurricane Katrina and to assess the rate of significant posthurricane functional decline.
A secondary data analysis was conducted using Medicare claims merged with NF resident data from the Minimum Data Set. Thirty- and 90-day mortality and hospitalization rates for long-stay (>90 days) residents residing in 141 at-risk NFs during Hurricane Katrina were compared to rates for residents residing at the same facilities during the same time period in prior nonhurricane years (2003 and 2004). Functional decline was assessed as a 4+ drop in function using a 28-point Minimum Data Set Activities of Daily Living Scale.
There were statistically significant differences (all P<.0001) in mortality, hospitalization, and functional decline among residents exposed to Hurricane Katrina. At 30 days, the mortality rate was 3.88% among the exposed cohort compared with 2.10% and 2.28% for residents in 2003 and 2004, respectively. The 90-day mortality rate was 9.27% compared with 6.71% and 6.31%, respectively. These mortality differences translated into an additional 148 deaths at 30 days and 230 deaths at 90 days. The 30-day hospitalization rate was 9.87% compared with 7.21% and 7.53%, respectively. The 90-day hospitalization rate was 20.39% compared with 18.61% and 17.82%, respectively. Finally, the rate of significant functional decline among survivors was 6.77% compared with 5.81% in 2003 and 5.10% in 2004.
NF residents experienced a significant increase in mortality, hospitalization, and functional decline during Hurricane Katrina.
nursing home; long term care; disaster preparedness; hurricanes; emergency management
In response to the hurricane-related deaths of nursing home residents, there has been a steady increase in the number of facilities that evacuate under storm threat. This study examined the effects of evacuation during Hurricane Gustav on residents who were cognitively impaired.
Nursing homes in counties located in the path of Hurricane Gustav were identified. The Minimum Data Set resident assessment files were merged with the Centers for Medicare enrollment file to determine date of death for residents in identified facilities. Difference-in-differences analyses were conducted adjusting for residents’ demographic characteristics and acuity.
The dataset included 21,255 residents living in 119 at risk nursing homes over three years of observation. Relative to the two years before the storm, there was a 2.8 percent increase in death at 30 days and a 3.9 percent increase in death at 90 days for residents with severe dementia who evacuated for Hurricane Gustav, controlling for resident demographics and acuity.
The findings of this research reveal the deleterious effects of evacuation on residents with severe dementia. Interventions need to be developed and tested to determine the best methods for protecting this at risk population when there are no other options than to evacuate the facility.
Alzheimer’s disease; disaster; nursing homes; evacuation; hurricane; mortality
To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf-hurricanes
Observational study using Medicare claims, and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 non-hurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days.
Among 36,389 NH residents exposed to a storm, the 30 and 90 day mortality/hospitalization rates increased compared to non-hurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7-5.3% and hospitalization by 1.8-8.3%, independent of other factors.
Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.
Despite improvements in the care of critically-ill patients, hospital mortality for acute lung injury remains high at approximately 40%. We developed a classification rule to stratify mechanically ventilated patients with acute lung injury according to hospital mortality and compared this rule to the APACHE III prediction.
We used data of 2022 participants in ARDS Network trials to build a classification rule based on 54 variables collected prior to randomization.
We used a classification tree approach to stratify patients according to hospital mortality using a training subset of 1800 participants, and estimated expected prediction errors using tenfold cross validation. We validated our classification tree using a subset of 222 participants not included in model building, and calculated areas under the receiver operating characteristic curves (AUCs).
Measurements and Main Results
We identified combinations of age (>63 years), BUN (>15 mg/dl), shock, respiratory rate (>21 breaths/minute), and minute ventilation (>13.9 L/minute) as important predictors of hospital mortality at 90 days. The classification tree had a similar expected prediction error in the training set (28% versus 26%; p=0.18) and AUC in the validation set (0.71 versus 0.73; p=0.71) as did a model based on APACHE III.
Our tree-based classification rule performed similarly to APACHE III in stratifying patients according to hospital mortality, is simpler to use, contains risk factors that may be specific to acute lung injury, and identified minute ventilation as a potential novel predictor of death in patients with acute lung injury.
Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones.
Our decision model included five treatment strategies: (1) laparoscopic cholecystectomy (LC) alone followed by expectant management, (2) preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC, (3) LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE), (4) LC followed by postoperative ERCP, and (5) LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National CMS data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability.
Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to one health input: specificity of IOC, and three costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC.
The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.
The objective of this pilot study was to evaluate possible differences in insulin sensitivity, food intake, and cravings between the follicular and luteal phases of the menstrual cycle in women with premenstrual syndrome (PMS).
Subjects were screened for PMS using the Penn Daily Symptom Rating (DSR) scale. Each subject had two overnight admissions (once in each cycle phase) to the Hospital of the University of Pennsylvania. They performed 3-day diet histories prior to each hospitalization. After admission, subjects received dinner and a snack, then were fasted until morning, when they underwent a frequently sampled intravenous glucose tolerance test (FSIGT). Insulin sensitivity was determined by Minimal Model analysis. Blinded analysis of diet histories and inpatient food intake was performed by a registered dietitian.
There was no difference found in insulin sensitivity between cycle phases (n = 7). There were also no differences in proportions of macronutrients or total kilocalories by cycle phase, despite a marked difference in food cravings between cycle phase, with increased food cravings noted in the luteal phase (p = 0.002). Total DSR symptom scores decreased from a mean of 186 (± 29.0) in the luteal phase to 16.6 (± 14.2) in the follicular phase. Women in this study consumed relatively high proportions of carbohydrates (55%–64%) in both cycle phases measured.
These findings reinforce the suggestion that although the symptom complaints of PMS are primarily confined to the luteal phase, the neuroendocrine background for this disorder may be consistent across menstrual cycle phases.
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are sequelae of severe trauma. It is unknown if certain races are at greater risk of developing ALI/ARDS, and once established, if there are racial differences in the severity of lung injury or mortality.
Retrospective cohort study of 4,397 trauma patients (1,831 Caucasians, 871 African-Americans, 886 Hispanics, and 809 Asian/Pacific Islanders) requiring ICU admission between 1996-2007 at an urban level I trauma center.
African-American patients were most likely to present in shock with penetrating trauma and receive a massive transfusion. The incidence of ALI/ARDS was similar by race (p=0.99). Among patients who developed ALI/ARDS, there was no evidence to support a difference in initial PaO2/FiO2 (p=0.33), lung injury score (p=0.67) or mortality (p=0.78) by race.
Despite differences in baseline characteristics, the incidence of ALI/ARDS, severity of lung injury, and mortality were similar by race.
acute respiratory distress syndrome; acute lung injury; trauma; race; epidemiology; adult
The goal of this study was to compare internal carotid artery (ICA) intima-media thickness (IMT) with common carotid artery (CCA) IMT as global markers of cardiovascular disease (CVD).
Cross-sectional measurements of the mean CCA IMT and maximum ICA IMT were made on ultrasound images acquired from the Framingham Offspring cohort (n = 3316; mean age, 58 years; 52.7% women). Linear regression models were used to study the associations of the Framingham risk factors with CCA and ICA IMT. Multivariate logistic regression models and receiver operating characteristic (ROC) curve analysis were used to compare the associations of prevalent CVD with CCA and ICA IMT and determine sensitivity and specificity.
The association between age and the mean CCA IMT corresponded to an increase of 0.007 mm/y; the increase was 0.037 mm/y for the ICA IMT. Framingham risk factors accounted for 28.6% and 27.5% of the variability in the CCA and ICA IMT, respectively. Age and gender contributed 23.5% to the variability of the CCA IMT and 22.5% to that of the ICA IMT, with the next most important factor being systolic blood pressure (1.9%) for the CCA IMT and smoking (1.6%) for the ICA IMT. The CCA IMT and ICA IMT were statistically significant predictors of prevalent CVD, with the ICA IMT having a larger area under the ROC curve (0.756 versus 0.695).
Associations of risk factors with CCA and ICA IMT are slightly different, and both are independently associated with prevalent CVD. Their value for predicting incident cardiovascular events needs to be compared in outcome studies.
atherosclerosis; carotid artery; disease prevalence; intima-media thickness; risk factors
Measuring extravascular lung water may be useful for predicting outcome in adults with acute lung injury. The present commentary briefly reviews the potential role and limitations of extravascular lung water measurement in critically ill children.
In expert hands, the intra-thoracic esophago-gastric anastamosis usually provides a low rate of strictures and leaks. However, anastomoses can be technically challenging and time consuming when minimally invasive techniques are used. We present our preliminary results of a standardized 25mm/4.8mm circular stapled anastomosis using a trans-orally placed anvil.
Materials and Methods
We evaluated a prospective cohort of 37 consecutive patients offered minimally invasive Ivor Lewis Esophagectomy at a tertiary referral center. The esophagogastric anastomosis was created using a 25mm anvil (Orvil, Autosuture, Norwalk, CT) passed trans-orally, in a tilted position, and connected to a 90cm long PVC delivery tube through an opening in the esophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (EEA XL 25mm with 4.8mm Staples, Autosuture, Norwalk, CT) inserted into the gastric conduit. Primary outcomes were leak and stricture rates.
Thirty-seven patients (mean age 65 yrs) with distal esophageal adenocarcinoma (n=29), squamous cell cancer (n=5), or high-grade dysplasia in Barrett's Esophagus (n=3) underwent an Ivor Lewis Esophagectomy between October 2007 and August 2009. The abdominal portion of the operation was completed laparoscopically in 30 patients (81.1%). The thoracic portion was done using a muscle sparing mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 patients (37.8%). There were no intra-operative technical failures of the anastomosis or deaths. Five patients had strictures (13.5%) and all were successfully treated with endoscopic dilations. One patient had an anastomotic leak (2.7%) that was successfully treated by re-operation and endoscopic stenting of the anastomosis.
The circular stapled anastomosis with the transoral anvil allows for an efficient, safe and reproducible anastomosis. This straightforward technique is particularly suited to the completely minimally invasive Ivor Lewis Esophagectomy.
Esophagectomy; Esophageal Cancer; Minimally Invasive; Anastomose; Stapler; Complications
The objectives of the pilot study were to modify existing psychological first aid (PFA) materials so they would be appropriate for use with institutionalized elders, evaluate the feasibility of using nursing home staff to deliver the intervention to residents, and solicit feedback from residents about the intervention. The STORM Study, an acronym for “services for treating older residents’ mental health”, is the first step in the development of an evidence-based disaster mental health intervention for this vulnerable and underserved population.
Demographic characteristics were collected on participating residents and staff. Program evaluation forms were completed by staff participants during the pilot test and nurse training session. Staff and resident discussion groups were conducted during the pilot test to collect qualitative data on the use of PFA in nursing homes.
Results demonstrate the feasibility of the PFA program to train staff to provide residents with PFA during disasters.
Future research should focus on whether PFA improves coping and reduces stress in disaster exposed nursing home residents.
psychological first aid; disaster mental health; nursing homes; older adults; trauma; training; intervention
The Florida Center for Public Health Preparedness in the University of South Florida College of Public Health and the Florida Department of Health (FDOH) collaborated to design, develop, and deliver two competency-based epidemiology training programs aimed at increasing the epidemiologic preparedness and response capability of the FDOH workforce. They were also designed to meet the requirements of the National Incident Management System and recommendations or needs identified in national studies. The basis for the trainings is an epidemiology competency set developed by the Northwest Center for Public Health Practice at the University of Washington School of Public Health and Community Medicine. The target audiences for the two trainings are non-epidemiologists or practicing epidemiologists who have relatively little formal education in epidemiology. Both courses have online as well as onsite modules. Alternate tabletop exercises have been completed and delivered for anthrax and plague. Both trainings require participant demonstration of skills. The trainings have been well received, appear to be effective, and are used to credential members of Florida's epidemiology strike teams.
Ca+ sparks are rare in healthy adult mammalian skeletal muscle but may appear when adult fiber integrity is compromised, and occur in embryonic muscle but decline as the animal develops. Here we used cultured adult mouse flexor digitorum brevis muscle fibers to monitor occurrence of Ca2+ sparks during maintenance of adult fiber morphology and during eventual fiber morphological dedifferentiation after various times in culture. Fibers cultured for up to 3 days retain normal morphology and striated appearance. Ca2+ sparks were rare in these fibers. At 5–7 days in culture, many of the original muscle fibers exhibit sprouting and loss of striations, as well as the occurrence of spontaneous Ca2+ sparks. The average rate of occurrence of Ca2+ sparks is >10-fold higher after 5–7 days in culture than in days 1–3. With the use of fibers cultured for 7 days, application of the Ca2+ channel blockers Co2+ or nifedipine almost completely suppressed the occurrence of Ca2+ sparks, as previously shown in embryonic fibers, suggesting that Ca2+ sparks may be generated by similar mechanisms in dedifferentiating cultured adult fibers and in embryonic fibers before final differentiation. The sarcomeric disruption observed under transmitted light microscopy in dedifferentiating fibers was accompanied by morphological changes in the transverse (T) tubular system, as observed by fluorescence confocal imaging of both an extracellular marker dye and membrane staining dyes. Changes in T tubule morphology coincided with the appearance of Ca2+ sparks, suggesting that Ca2+ sparks may either be a signal for, or the result of, disruption of DHPR-ryanodine receptor 1 coupling.
calcium ion signaling; muscle remodeling; fluo 4; calcium ion imaging
To investigate whether participation in a clinical audit and education session would improve GP management of patients who smoke.
GPs who participated in an associated smoking cessation research program were invited to complete a three-stage clinical audit. This process included a retrospective self-audit of smoking cessation management practices over the 6 months prior to commencing the study, attending a 2.5 hour education session about GP management of smoking cessation, and completion of a second retrospective self-audit 6 months later. Twenty-eight GPs completed the full audit and education process, providing information about their smoking cessation management with 1114 patients. The main outcome measure was changes in GP management of smoking cessation with patients across the audit period, as measured by the clinical audit tool.
The majority of GPs (57%) indicated that as a result of the audit process they had altered their approach to the management of patients who smoke. Quantitative analyses confirmed significant increases in various forms of evidence-based smoking cessation management practices to assist patients to quit, or maintain quitting across the audit period. However comparative analyses of patient data challenged these findings, suggesting that the clinical audit process had less impact on GP practice than suggested in GP's self-reported audit data.
This study provides some support for the combined use of self-auditing, feedback and education to improve GP management of smoking cessation. However further research is warranted to examine GP- and patient-based reports of outcomes from clinical audit and other educational interventions.