Pain Management in Home Health Care: Relationship With Dementia and Facility Admissions

BackgroundPain is common yet under-studied among older Medicare home health (HH) patients with Alzheimer's disease and related dementias (ADRD).AimsExamine (1) the association between ADRD and severe pain in Medicare HH patients; and (2) the impact of severe pain and ADRD on unplanned facility admissions in this population.DesignAnalysis of the Outcome and Assessment Information Set (OASIS) and Medicare claims data.Settings/Participants6,153 patients ≥65 years receiving care from a nonprofit HH agency in 2017.MethodsStudy outcomes included presence of severe pain and time-to-event measures of unplanned facility admissions (hospital, nursing home, or rehabilitation facilities). ADRD was identified using ICD-10 diagnosis codes and cognitive impairment symptoms. Logistic regression and Cox proportional hazard models were used to examine, respectively, the association between ADRD and severe pain, and the independent and interaction effects of severe pain and ADRD on unplanned facility admission.ResultsPatients with ADRD (n = 1,525, 24.8%) were less likely to have recorded severe pain than others (16.4% vs. 23.6%, p < .001). Adjusting for demographics, comorbidities, mental and physical functional status, and use of HH services, having severe pain was related to a 35% increase (hazard ratio [HR] = 1.35, p = .002) in the risk of unplanned facility admission, but the increase in such risk was the same whether or not the patient had ADRD.ConclusionsHH patients with ADRD may have under-recognized pain. Severe pain is a significant independent predictor of unplanned facility admissions among HH patients.     

Prone Positioning of Patients With Coronavirus Disease 2019 Who Are Nonintubated in Hypoxic Respiratory Distress: Single-Site Retrospective Health Records Review

IntroductionIn March and April 2020 of the coronavirus disease 2019 pandemic, site clinical practice guidelines were implemented for prone positioning of patients with suspected coronavirus disease 2019 in hypoxic respiratory distress who are awake, alert, and spontaneously breathing. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning of patients with coronavirus disease 2019 infection in adult acute respiratory distress or adult respiratory distress syndrome, who are awake, alert, spontaneously breathing, and nonintubated.MethodsA retrospective chart review of patients who were coronavirus disease 2019 positive in the emergency department from March 30, 2020 to April 30, 2020 was conducted for patients with a room air pulse oximetry <90% and a preprone position pulse oximetry ≤94% who tolerated prone positioning for at least 30 minutes. The primary outcome was the change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median and mean differences were compared with the Wilcoxon signed-rank test and paired t-test.ResultsOf the 440 patients with coronavirus disease 2019, 31 met inclusion criteria. Median pulse oximetry increased as 83% (interquartile range, 75%-86%) on room air, 90% (interquartile range, 89%-93%) with supplemental oxygen, and 96% (interquartile range, 94%-98%) with prone positioning (z = -4.48, P < .001). A total of 45% (n = 14) were intubated during their hospital stay, and 26% (n = 8) of the included patients died.DiscussionIn patients with coronavirus disease 2019 who are awake, alert, and spontaneously breathing, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.     

Mechanical ventilation and mortality among 223 critically ill patients with coronavirus disease 2019: A multicentric study in Germany

BackgroundThere are large uncertainties with regard to the outcome of patients with coronavirus disease 2019 (COVID-19) and mechanical ventilation (MV). High mortality (50–97%) was proposed by some groups, leading to considerable uncertainties with regard to outcomes of critically ill patients with COVID-19.ObjectivesThe aim was to investigate the characteristics and outcomes of critically ill patients with COVID-19 requiring intensive care unit (ICU) admission and MV.MethodsA multicentre retrospective observational cohort study at 15 hospitals in Hamburg, Germany, was performed. Critically ill adult patients with COVID-19 who completed their ICU stay between February and June 2020 were included. Patient demographics, severity of illness, and ICU course were retrospectively evaluated.ResultsA total of 223 critically ill patients with COVID-19 were included. The majority, 73% (n = 163), were men; the median age was 69 (interquartile range = 58–77.5) years, with 68% (n = 151) patients having at least one chronic medical condition. Their Sequential Organ Failure Assessment score was a median of 5 (3–9) points on admission. Overall, 167 (75%) patients needed MV. Noninvasive ventilation and high-flow nasal cannula were used in 31 (14%) and 26 (12%) patients, respectively. Subsequent MV, due to noninvasive ventilation/high-flow nasal cannula therapy failure, was necessary in 46 (81%) patients. Renal replacement therapy was initiated in 33% (n = 72) of patients, and owing to severe respiratory failure, extracorporeal membrane oxygenation was necessary in 9% (n = 20) of patients. Experimental antiviral therapy was used in 9% (n = 21) of patients. Complications during the ICU stay were as follows: septic shock (40%, n = 90), heart failure (8%, n = 17), and pulmonary embolism (6%, n = 14). The length of ICU stay was a median of 13 days (5–24), and the duration of MV was 15 days (8–25). The ICU mortality was 35% (n = 78) and 44% (n = 74) among mechanically ventilated patients.ConclusionIn this multicentre observational study of 223 critically ill patients with COVID-19, the survival to ICU discharge was 65%, and it was 56% among patients requiring MV. Patients showed high rate of septic complications during their ICU stay.     

Clinical efficacy of casirivimab-imdevimab antibody combination treatment in patients with COVID-19 Delta variant

IntroductionCasirivimab-imdevimab, an antibody cocktail containing two severe acute respiratory syndrome coronavirus 2 neutralizing antibodies, reduces the viral load and the risk of coronavirus disease 2019 (COVID-19)-related hospitalization or death. The objective of this study was to evaluate the clinical efficacy of casirivimab-imdevimab in patients with COVID-19 Delta variant in Japan.MethodsThis study was conducted at five institutions and assessed a total of 461 patients with COVID-19 who met the inclusion criteria. The treatment group received a dose of casirivimab-imdevimab consisting of a cocktail of two monoclonal antibodies, (casirivimab 600 mg and imdevimab 600 mg intravenously). The control consisted of age- and sex-matched COVID-19 patients (n = 461) who sufficed the inclusion criteria but did not receive casirivimab-imdevimab. The outcome was the requirement of oxygen therapy.ResultsIn the treatment group, patients received oxygen therapy (n = 30), nasal canula (n = 23), high flow nasal cannula (n = 5), and mechanical ventilation (n = 2). In the control group, patients received oxygen therapy (n = 56), nasal canula (n = 45), high flow nasal cannula (n = 8), and mechanical ventilation (n = 3). The administration of oxygen therapy was significantly lower in the treatment group than the control group (6.5% vs. 12.1%, P = 0.0044). All these patients admitted to our hospitals and received additional therapy and recovered.ConclusionsOur results demonstrate that the casirivimab-imdevimab combination antibody treatment is associated with reduced rates of requiring oxygen therapy among high-risk patients with COVID-19 Delta variant.     

Clinical characteristics and prognosis of immunosuppressed inpatients with COVID-19 in Japan

IntroductionWe aimed to analyze the clinical characteristics and outcomes of immunosuppressed inpatients with coronavirus disease 2019 (COVID-19).MethodsIn this observational study, we utilized a large nationwide registry of hospitalized patients with COVID-19 in Japan. Patients’ baseline characteristics and outcomes were compared according to the immunosuppressed states of the patients. The impact of different therapeutic agents on the clinical courses of the patients was evaluated.ResultsData of 14,760 patients were included, and 887 (5.9%) were immunosuppressed. The immunosuppressed state of the patient resulted from solid tumor (43.3%, n = 384), chemotherapy within 3 months (15.6%, n = 138), collagen disease (16.9%, n = 150), use of immunosuppressive agents (16.0%, n = 142), and metastatic solid tumor (13.5%, n = 120). Immunosuppressed patients were older and had a higher severity of illness at admission and during hospitalization than non-immunosuppressed patients. The mortality rates for major diseases causing immunosuppression were as follows: solid tumor, 12.5% (48/384; P < 0.001; relative risk [RR], 3.41); metastatic solid tumor, 31.7% (38/120; P < 0.001; RR, 8.43); leukemia, 23.1% (9/39; P < 0.001; RR, 5.87); lymphoma, 33.3% (20/60; P < 0.001; RR, 8.63); and collagen disease, 15.3% (23/150; P < 0.001; RR 3.97). Underlying diseases with high mortality rates were not necessarily associated with high rates of invasive supportive care.ConclusionsThe prognosis of immunosuppressed COVID-19 inpatients varied according to the different immunosuppressed states. Multiple factors, including the severity of the underlying diseases, might have affected their invasive supportive care indications.     

The relationship between nursing skill mix and severity of illness of patients admitted in Australian and New Zealand intensive care units

BackgroundCritically ill patients in the intensive care environment require an appropriate nursing workforce to improve quality of care and patient outcomes. However, limited information exists as to the relationship between severity of illness and nursing skill mix in the intensive care.ObjectiveThe aim of this study was to describe the variation in nursing skill mix across different hospital types and to determine if this was associated with severity of illness of critically ill patients admitted to adult intensive care units (ICUs) in Australia and New Zealand.Design & SettingA retrospective cohort study using the Australia and New Zealand Intensive Care Society Adult Patient Database (to provide information on patient demographics, severity of illness, and outcome) and the Critical Care Resources Registry (to provide information on annual nursing staffing levels and hospital type) from July 2014 to June 2020. Four hospital types (metropolitan, private, rural/regional, and tertiary) and three patient groups (elective surgical, emergency surgical, and medical) were examined.Main outcome measureThe main outcome measure was the proportion of critical care specialist registered nurses (RNs) expressed as a percentage of the full-time equivalent (FTE) of total RNs working within each ICU each year, as reported annually to the Critical Care Resources Registry.ResultsData were examined for 184 ICUs in Australia and New Zealand. During the 6-year study period, 770 747 patients were admitted to these ICUs. Across Australia and New Zealand, the median percentage of registered nursing FTE with a critical care qualification for each ICU (n = 184) was 59.1% (interquartile range [IQR] = 48.9–71.6). The percentage FTE of critical care specialist RNs was highest in private [63.7% (IQR = 52.6–78.2)] and tertiary ICUs [58.1% (IQR = 51.2–70.2)], followed by metropolitan ICUs [56.0% (IQR = 44.5–68.9)] with the lowest in rural/regional hospitals [55.9% (IQR = 44.9–70.0)]. In ICUs with higher percentage FTE of critical care specialist RNs, patients had higher severity of illness, most notably in tertiary and private ICUs. This relationship was persistent across all hospital types when examining subgroups of emergency surgical and medical patients and in multivariable analysis after adjusting for the type of hospital and relative percentage of each diagnostic group.ConclusionsIn Australian and New Zealand ICUs, the highest acuity patients are cared for by nursing teams with the highest percentage FTE of critical care specialist RNs. The Australian and New Zealand healthcare system has a critical care nursing workforce which scales to meet the acuity of ICU patients across Australia and New Zealand.     

Asymptomatic latent syphilis in geriatric patients in association with stoke: Analysis using routine syphilis tests

IntroductionWe investigated the association between stroke and asymptomatic latent syphilis (ALS) in geriatric patients.MethodsThis retrospective observational study included patients aged >65 years who underwent routine qualitative rapid plasma reagin (RPR) and Treponema pallidum Latex Agglutination (TPLA) tests at a 161-bed community acute care hospital with long-term care facilities in Kamakura, Japan, from August 2014 to February 2019. Asymptomatic patients with a positive TPLA test result were diagnosed with ALS. Ninety-six patients with ALS were included in the study. Fifty-one patients (53.1%) had a positive RPR test. Comorbidities included hypertension (n = 44; 45.8%), chronic kidney disease (n = 44; 45.8%), and fracture (n = 29; 30.2%). No significant differences were found in sex, age, or comorbidities in univariate analyses. Multivariate analysis of the TPLA-positive geriatric patients revealed that a positive RPR test (odds ratio = 9.06; 95% confidence interval = 1.69–48.5; p = 0.01) was associated with a history of stroke.ConclusionsFor geriatric patients with ALS, a positive qualitative RPR test was associated with a history of stroke. Medical evaluation and management of the risk factors for stroke are more necessary for ALS with a positive RPR qualitative test.     

Prevalence of hemorrhagic ovarian cysts in patients with rare inherited bleeding disorders

BackgroundIn comparison with the general population, women with bleeding disorders are more prone to develop obstetrical and gynecological problems. However, no comprehensive evaluation has investigated the prevalence of hemorrhagic ovarian cysts (HOCs) in rare bleeding disorders (RBDs). In this study, we sought to determine the prevalence of HOCs in a large cohort of Iranian patients with RBDs.MethodsA total of 210 symptomatic patients suspected of HOCs with RBD were included. The median age of the study population was 24 years. Patients were diagnosed with fibrinogen disorders (n = 7, 3%), factor (F) II (n = 4, 2%), FV (n = 28, 13%), FVII (n = 4, 2%), FX (n = 6, 3%), FXIII (n = 122, 58%), combined FV and FVIII (n = 8, 4%), Glanzmann’s thrombasthenia (n = 10, 5%), and von Willebrand disease (VWD) type 3 (n = 21, 10%).ResultsFollowing further clinical and ultrasound examinations of these 210 patients, 68 (32.4%) were confirmed with a diagnosis of HOCs. Of which, FXIII deficiency with 46 cases (67.6%), followed by VWD type 3 (6 cases, 8.8%) showed the highest number. Other coagulation defects associated with HOCs were including fibrinogen deficiency (n = 2, 3%), FII (n = 2, 3%), FV (n = 4, 6%), FVII (n = 2, 3%), FX (n = 1, 1.5%), combined FV and FVIII (n = 2, 3%), and Glanzmann’s thrombasthenia (n = 3, 4.5%).ConclusionThis study found a high prevalence of HOCs in patients with RBDs, indicating the importance of early diagnosis and optimal management of obstetric and gynecological complications in these patients.     

A Retrospective Analysis of the Impact of the Coronavirus Disease 2019 Pandemic on Health Care Workers in a Tertiary Hospital in Turkey

IntroductionSeveral vaccines have been developed and approved for use against severe acute respiratory syndrome coronavirus-2; however, the use of personal protective equipment remains important owing to the lack of effective specific treatment and whole community immunity. Hydroxychloroquine sulfate was a treatment option in the early days of the pandemic; however, it was subsequently removed owing to a lack of evidence as an effective treatment.We aimed to evaluate the testing and infection characteristics of coronavirus disease 2019 among health care personnel and determine the effectiveness of prophylactic hydroxychloroquine sulfate use to prevent transmission.MethodsThis retrospective observational study was conducted between May 1 and September 30, 2020. The health care personnel included in the study were physicians, nurses, and paraprofessional support personnel. The health records of health care personnel who had been tested for severe acute respiratory syndrome coronavirus-2 using polymerase chain reaction were retrospectively analyzed.ResultsIn total, 508 health care personnel were included in the study. A total of 152 (29.9%) health care personnel were diagnosed with coronavirus disease 2019. The positive polymerase chain reaction rate was 80.3% (n = 122). A comparison of infected and uninfected health care personnel showed a difference in age and occupation and no difference in sex, working area, and prophylactic hydroxychloroquine sulfate use.DiscussionProtective measures in low-risk areas of our hospital require improvements. All health care personnel should be trained on personal protective equipment use. There was no evidence to support the effectiveness of prophylactic hydroxychloroquine sulfate against severe acute respiratory syndrome coronavirus-2 transmission.     

The implementation of automated red blood cell exchange (erythrocytapheresis) as a treatment modality in sickle cell disease patients: Single center experience

BackgroundImprovements of health infrastructure, preventive care and clinical management is important to reduce the morbidity and mortality of sickle cell disease (SCD).ObjectiveThis prospective, investigator-initiated non-randomized open-label intervention, single centre study describes the implementation of the automated erythrocytapheresis in low-middle income country as a treatment modality for SCD patients to improve the standard of care and highlights its benefits and challenges.MethodologyEligible patients with SCD who had overt stroke, abnormal/conditional transcranial doppler (TCD), or other indications were subjected to regular automated erythrocytapheresis program.ResultsFrom 18th Dec 2017 till 17th Dec 2022, 21 subjects were enrolled; seventeen (80.9 %) were Egyptian and four (19.1 %) were non-Egyptian (three Sudanese and one Nigerian). Totalling 133 sessions had been performed mainly in working hours with fluctuating frequency per month. All sessions maintained isovolumic status and were performed using central venous access. The target HbS concentration was set from the start; the mean final FCR % fraction was 51, most of the session (n = 78, 58.7 %) were able to achieve target FCR. The majority of session pass smoothly with no adverse event (n = 81, 60.9 %), except for certain challenges as shortage of the required blood (n = 38), hypotension (n = 2), hypocalcaemia (n = 2).ConclusionAutomated erythrocytapheresis is safe and effective modality for management of patients with sickle cell disease.     

Trends in Place of Death for Individuals With Deaths Attributed to Advanced Chronic or End-Stage Kidney Disease in the United States

ContextAn important aspect of end-of-life care, place of death is understudied in advanced chronic (CKD) and end-stage kidney disease (ESKD).ObjectiveWe sought to examine trends and factors associated with where advanced CKD/ESKD patients die.MethodsWe conducted a retrospective cross-sectional study using mortality data from 2003 to 2017 for deaths attributed primarily to advanced CKD/ESKD in the United States.ResultsBetween 2003 and 2017, 222,247 deaths were attributed to advanced CKD/ESKD. From 2003 to 2017, deaths occurring in hospitals declined from 56.0% (n = 5356) to 35.6% (n = 7764), whereas increases occurred in deaths at home (13.5% [n = 1292] to 24.3% [n = 5306]), nursing facilities (18.6% [n = 1776] to 19.3% [n = 4221]), and hospice facilities (0.3% [n = 29] to 13.4% [n = 2917]). Nonwhite race was associated with increased odds of hospital death (Black [OR = 1.59; 95% CI = 1.55, 1.62]; Native American [OR = 1.47; 95% CI = 1.32, 1.63]; Asian [OR = 1.43; 95% CI = 1.32, 1.55] and reduced odds of nursing facility (Black [OR = 0.622; 95% CI = 0.600, 0.645]; Native American [OR = 0.638; 95% CI = 0.572, 0.712]; Asian [OR = 0.574; 95% CI = 0.533, 0.619], or hospice facility death (Black [OR = 0.843; 95% CI = 0.773, 0.918]; Native American [OR = 0.380; 95% CI = 0.289, 0.500]; Asian [OR = 0.609; 95% CI = 0.502, 0.739]). Older age was associated with reduced odds of hospital death (≥85 [OR = 0.334; 95% CI = 0.312, 0.358]) and increased odds of home (≥85 [OR = 1.55; 95% CI = 1.43, 1.68]), nursing facility (≥85 [OR = 3.09; 95% CI = 2.76, 3.45]) or hospice facility death (≥85 [OR = 1.60; 95% CI = 1.49, 1.72]).ConclusionsHospitals remain the most common place of death from advanced CKD/ESKD; however, the proportion of home, nursing facility, and hospice facility deaths have increased.     

Prehospital management of acute respiratory distress in suspected COVID-19 patients

BackgroundIn December 2019, coronavirus disease (COVID-19) emerged in China and became a world-wide pandemic in March 2020. Emergency services and intensive care units (ICUs) were faced with a novel disease with unknown clinical characteristics and presentations. Acute respiratory distress (ARD) was often the chief complaint for an EMS call. This retrospective study evaluated prehospital ARD management and identified factors associated with the need of prehospital mechanical ventilation (PMV) for suspected COVID-19 patients.MethodsWe included 256 consecutive patients with suspected COVID-19-related ARD that received prehospital care from a Paris Fire Brigade BLS or ALS team, from March 08 to April 18, 2020. We performed multivariate regression to identify factors predisposing to PMV.ResultsOf 256 patients (mean age 60 ± 18 years; 82 (32%) males), 77 (30%) had previous hypertension, 31 (12%) were obese, and 49 (19%) had diabetes mellitus. Nineteen patients (7%) required PMV. Logistic regression observed that a low initial pulse oximetry was associated with prehospital PMV (ORa = 0.86, 95%CI: 0.73–0.92; p = 0.004).ConclusionsThis study showed that pulse oximetry might be a valuable marker for rapidly determining suspected COVID-19-patients requiring prehospital mechanical ventilation. Nevertheless, the impact of prehospital mechanical ventilation on COVID-19 patients outcome require further investigations.     

Hospital service use in the last year of life by Indigenous Australians who died of heart failure or cardiomyopathy: A linked data study

BackgroundAboriginal and Torres Strait Islander peoples experience disproportionate rates of heart failure. However, information regarding their use of hospital services in the last year of life is poorly delineated to inform culturally appropriate end-of-life health services.ObjectivesTo quantify hospital service use in the last year of life of Aboriginal and Torres Strait Islander peoples who died of heart failure or cardiomyopathy in Queensland, Australia.MethodsA subgroup analysis of a larger retrospective linkage study using administrative health data in Queensland, Australia. Individuals that identified as an Aboriginal and Torres Strait Islander person from their first hospital admission in the last year of life, who died of heart failure or cardiomyopathy from 2008 to 2018, were included.ResultsThere were 99 individuals, with emergency department presentation/s recorded for 85 individuals. Over 50% of individuals presenting to the Emergency Department were from regional areas (n = 43, 51%). The 99 individuals had a total of 472 hospital admissions, excluding same day admissions for haemodialysis, and 70% (n = 70) died in hospital. Most admissions were coded as acute care (n = 442, 94%), and fewer were coded as palliative care (n = 19, 4%). Median comorbidities or factors that led to hospital contact = 5 (interquartile range 3–9).ConclusionAcute care hospital admissions in the last year of life by this population are common for those who died of heart failure or cardiomyopathy. Multimorbidity is prevalent in the last year of life, underscoring the importance of primary health care, provided by nurses and Indigenous health workers.