“I just need to know they are going to do what they say they’re going to do with my mom.” Understanding hospice expectations from the patient,caregiver and admission nurse perspective

Objective

The objective of this paper is to understand patient, caregiver and hospice admission nurses needs during the hospice admission conversation so patients and their caregivers can make informed decisions about hospice.

Reduction in fear of falling through intense tai chi exercise training in older, transitionally frail adults

OBJECTIVES: To determine whether an intense tai chi exercise program could reduce fear of falling better than a wellness education (WE) program in older adults who had fallen previously and meet criteria for transitioning to frailty. DESIGN: Cluster-randomized, controlled trial of 48 weeks' duration. SETTING: Ten matched pairs of congregate living facilities in the greater Atlanta area. PARTICIPANTS: Sample of 291 women and 20 men, aged 70 to 97. MEASUREMENTS: Activity-related fear of falling using the Activities-Specific Balance Confidence Scale (ABC) and the Fall Efficacy Scale at baseline and every 4 months for 1 year. Demographics, time to first fall and all subsequent falls, functional measures, Centers for Epidemiologic Studies Depression Scale, medication use, level of physical activity, comorbidities, and adherence to interventions. RESULTS: Mean ABC was similar in both cohort groups at the time of randomization but became significantly higher (decreased fear) in the tai chi cohort at 8 months (57.9 vs 49.0, P<.001) and at study end (59.2 vs 47.9, P<.001). After adjusting for covariates, the mean ABC after 12 months of intervention was significantly greater in the tai chi group than in the WE group, with the differences increasing with time (mean difference at 12 months=9.5 points, 95% confidence interval=4.8-14.2, P<.001). CONCLUSION: Tai chi led to a significantly greater reduction in fear of falling than a WE program in transitionally frail older adults. The mean percentage change in ABC scores widened between tai chi and WE participants over the trial period. Tai chi should be considered in any program designed to reduce falling and fear of falling in transitionally frail older adults.     

Hemodynamics during liver transplantation: the interactions between cardiac output and portal venous and hepatic arterial flows.

Liver blood flow and systemic hemodynamics were measured intraoperatively in 34 patients after liver transplantation. Ultrasound transit-time flow probes measured hepatic arterial and portal venous flow over 10 to 75 min 1 to 3 hr after reperfusion. Cardiac output was measured by thermodilution. Mean cardiac output was 9.5 +/- 2.8 L/min; the mean total liver blood flow of 2,091 +/- 932 ml/min was 23% +/- 11% of cardiac output. Mean portal flow of 1,808 +/- 929 ml/min was disproportionately high at 85% +/- 10% of total liver blood flow. Correlation analysis showed a significant (p less than 0.01; r = 0.42) correlation between cardiac output and portal venous flow and a trend toward negative correlation (p = 0.087) between cardiac output and hepatic arterial flow. These data show that increased flow in the newly transplanted liver is predominantly portal venous flow and is associated with high cardiac output and reduced hepatic arterial flow. In the last 13 patients studied, portal flow was reduced by 50% and the hepatic artery response was measured. We saw a significant (p less than 0.05) increase in hepatic artery flow from 322 +/- 228 to 419 +/- 271 ml/min, indicating an intact hepatic arterial buffer response. The hepatic artery response also showed that it is a reversible rather than a fixed resistance that contributes to the low hepatic artery flow in these patients.     

Plasma cysteine, cystine, and glutathione in cirrhosis

Plasma contains three forms of cyst(e)ine: cysteine, cystine, and protein-bound cysteine. The former is a thiol and the latter two are disulfides. The levels of all three types of cyst(e)ine, as well as the cysteinyl tripeptide glutathione, were measured in the plasma of 14 normal and 10 cirrhotic individuals. All subjects ate mixed foods. Some cirrhotic patients were studied during nasogastric hyperalimentation with Vivonex (Norwich Eaton Pharmaceuticals, Norwich, N.Y.) as well as during total parenteral nutrition with FreAmine III (American McGaw, Irvine, Calif.); neither formula contains cyst(e)ine. Regardless of the nature of the diet, cirrhotic patients had significantly subnormal values for cysteine, glutathione, and albumin. In addition, the following significant changes were found to be diet-dependent: (a) elevated methionine during Vivonex, (b) subnormal taurine during mixed foods and total parenteral nutrition, (c) depressed protein-bound cysteine during total parenteral nutrition, (d) depressed cyst(e)ine thiol/disulfide ratio during mixed foods, and (e) depressed total thiol during Vivonex and total parenteral nutrition. The data indicate multiple abnormalities in sulfur metabolism in cirrhosis.     

Dialysis Facility Characteristics and Variation in Employment Rates: A National Study

Background: Investigation of factors associated with variation in dialysis patient employment has focused primarily on patient-level factors. Little is known about facility-level factors that may be associated with patient employment.Design, setting, participants, and measurements: The ESRD Facility Survey (CMS-2744A) began in 2004 to collect counts of employed patients aged 18 to 54, in addition to dialysis unit census, types and timing of treatments offered, and staffing. Using the 2004 ESRD Facility Survey File, we investigated dialysis unit characteristics and facility employment rate of patients aged 18 to 54 in a logistic regression analysis that included hospital-based chronic renal care facilities, nonhospital renal disease treatment centers, independent special purpose renal dialysis facilities, and renal disease treatment centers.Results: Across all facilities, 18.9% of prevalent patients aged 18 to 54 were employed, but facility employment rates ranged from 0 to 100%. Facility employment rate was positively associated independently with availability of a 5 p.m. or later dialysis shift (odds ratio (OR) 1.54, 95% confidence interval (CI) 1.42 to 1.68), availability of peritoneal dialysis or home hemodialysis (HD) training (OR 1.19, 95% CI 1.11 to 1.28), and provision of frequent HD (OR 1.26, 95% CI 1.07 to 1.49), after adjusting for patient/social worker ratio, rurality of unit location, and unit size. In addition, patient receipt of Vocational Rehabilitation (VR) services was more often reported in facilities with higher employment rates.Conclusions: Promoting gainful employment among ESRD patients continues to be a quality improvement need. A dataset that allows adjustment for patient-level variables would facilitate increased understanding of the contribution of dialysis facility variables to patient employment.Gainful employment among “the maximum practical number of patients” was specified as a goal in 1986 Congressional legislation governing responsibilities of End-Stage Renal Disease (ESRD) Networks (1). ESRD Network Organizations, which function as liaisons between the federal government and providers of ESRD services (2), subsequently began to collect annual counts of employed patients in each dialysis facility within their respective Network geographic areas. Variation in facility employment rates and the association of these rates with facility characteristics has not been investigated, however.Studies of factors associated with variation in dialysis patient employment have focused primarily on patient-level factors, especially individuals’ educational background, occupational status before dialysis, treatment modality, and health status/comorbidity. Higher educational level and prior occupational status are the patient-level factors that have been most consistently identified as predictors of patient employment (3–8). A study by Rasgon et al. (9) showed, however, that facility-level variables may also influence patient employment status. The researchers found that blue-collar workers receiving dialysis in a facility that provided a multidisciplinary predialysis program designed to assist patients in maintaining employment were significantly more likely to continue employment than blue-collar workers who were treated at facilities that did not provide such a program.We undertook this study to examine the potential association of facility characteristics with variation in patient employment rates across dialysis facilities, using a national database. We investigated dialysis facility characteristics and aggregate employment within facilities of prevalent patients aged 18 to 54, as reported on the 2004 ESRD Facility Survey. The ESRD Facility Survey is completed annually for the Centers for Medicare and Medicaid Services (CMS) by all Medicare-approved facilities providing outpatient services to ESRD patients. In 2004, the survey began to collect aggregate information on the number of patients aged 18 to 54 in the facility and the number of patients aged 18 to 54 who were employed at the end of the calendar year, in addition to counts of patients entering and leaving the facility and counts of patients in specific treatment modality categories at the end of the survey period. The survey also annually captures several facility characteristics that are recognized as potentially relevant for patient employment, i.e., availability of a late dialysis shift (10), availability of home dialysis treatment options (11), provision of frequent hemodialysis (HD) treatment (12), and level of social worker staffing (13).     

Sources of variability in echocardiographic measurements

Experienced echocardiographers performed and interpreted echocardiograms of 16 normal volunteers in an experiment designed to quantify the sources of variability in echocardiographic measurements. The experimental factors were 16 subjects, two echocardiographic technicians, replication between 2 successive days, replication between two echocardiograms taken approximately 20 minutes apart, two subject positions and subject gender. The experimental factors in echocardiographic interpretation were four interpreters each interpreting two copies of each echocardiogram.The major conclusions of this study are: (1) Relatively little of the variability in echocardiographic measurements can be attributed to the technicians if the latter are experienced. (2) There appears to be relatively little variability in measurement with respect to days of replication within days, except for heart rate and the right ventricular internal dimension measurements. (3) The variability that resulted when an interpreter read unidentified copies of the same echocardiogram on different occasions was as large or larger than the variability that occurred when different interpreters read the same echocardiogram. (4) There is significant extraneous variability in the measurement of the thickness of the ventricular septum and posterior wall in normal subjects. (5) The position of the subject systematically influences the value of the measurements of the right ventricular internal dimension, but has relatively little or no effect on other measurements.It is concluded that each echocardiogram should be read at least twice by each of at least two interpreters. Minimally, each echocardiogram should be read either by one interpreter on two separate occasions or by two interpreters. The reported result for a measurement should be the mean of the values. If possible, an interpreter reading the same echocardiogram more than once should be “blinded” to the identity of the echocardiograms so that bias on subsequent readings is minimized.