Comparison of Functional Outcomes Associated with Hospital at Home Care and Traditional Acute Hospital Care

OBJECTIVES: To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care.
DESIGN: Survey questionnaire of participants in a prospective nonrandomized clinical trial.
SETTING: Three Medicare managed care health systems and a Veterans Affairs Medical Center.
PARTICIPANTS: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbations of chronic heart failure or chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in HaH and 130 in an acute care hospital.
INTERVENTION: Treatment in a HaH care model that substitutes for care provided in the traditional acute care hospital.
MEASUREMENTS: Change in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores from 1 month before admission to 2 weeks post admission to HaH or acute hospital and the proportion of groups that experienced improvement, no change, or decline in ADL and IADL scores.
RESULTS: Patients treated in HaH experienced modest improvements in performance scores, whereas those treated in the acute care hospital declined (ADL, 0.39 vs −0.60, P =.10, range −12.0 to 7.0; IADL 0.74 vs −0.70, P =.007, range −5.0 to 10.0); a greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P =.10) or IADLs (46% vs 17%, P =.04).
CONCLUSION: HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.     

不同种类质子泵抑制剂对氯吡格雷抗血小板疗效的影响

氯吡格雷作为一种新型的抗血小板药,已与阿司匹林联合广泛应用于临床,成为冠心病抗血小板药物治疗的基石。双联抗血小板治疗使胃肠道并发症的出现增多,故临床上常规加用质子泵抑制剂,以预防双联抗血小板治疗引发的胃肠道并发症。但国外最新研究发现质子泵抑制剂会影响氯吡格雷的疗效,降低其抗血小板的活性,使临床心血管不良事件发生率增加。     

Reversible Pheripheral Edema in Female Patients Taking Proton Pump Inhibitors for Peptic Acid Diseases

Pheripheral edema was observed in five female patients after taking proton pump inhibitors omeprazole, lansoprazole, or pantoprazole for 7–15 days for peptic acid diseases in recommended standard doses. Edema disappeared two to three days after stopping therapy but reappeared in all five patients after being reexposed to the drugs. In three of the patients drug kinetic investigations were performed and revealed a slow metabolizer status. During dose-finding studies for intravenous proton pump inhibitors omeprazole and pantoprazole, three of six young female volunteers receiving omeprazole and two young female volunteers receiving pantoprazole developed peripheral edema within 8 hr when high doses of the proton pump inhibitors were applied by continuous infusion together with large volumes of fluid. The edema disappeared within 24 hr after stopping the infusion therapy. Serum hormone concentrations in these patients did not change during therapy, neither did the edema factor C1-esterase inhibitor. As a possible mechanism, a competitive inhibition at the receptor site of female hormones involved in water regulation is suspected.     

Functional Decline and Recovery of Activities of Daily Living in Hospitalized, Disabled Older Women: The Women's Health and Aging Study I

OBJECTIVES: To determine, in disabled, older, community-dwelling women who were hospitalized, the rates and predictors of functional decline, the probability and time course of subsequent functional recovery, and predictors of functional recovery.
DESIGN: Population-based observational cohort.
SETTING: Woman's Health and Aging Study.
PARTICIPANTS: A subset of the 1,002 moderately to severely disabled community-dwelling older women who were hospitalized over 3 years (N=457).
MEASUREMENTS: Functional decline and complete and partial recovery were defined using a 0 to 6 scale of dependencies in activities of daily living (ADLs) evaluated every 6 months over 3 years. Complete recovery was defined as returning to baseline function (function at visit immediately preceding hospitalization) after functional decline; partial recovery was defined as any improvement in the ADL scale after functional decline. Multiple logistic regression analysis was used to determine predictors of functional decline. Kaplan-Meier curves estimate the proportions recovering as a function of time since hospitalization. Discrete-time proportional hazards models regress the time-to-recovery hazards on the predictor variables.
RESULTS: Thirty-three percent of hospitalized women experienced functional decline at the first visit after hospitalization. Frailty, longer length of stay, and higher education were associated with functional decline. Fifty percent fully recovered over the subsequent 30 months, with 33% recovering within 6 months and an additional 14% over the following 6 months. Younger women were more likely to recover (aged 80 to 70, hazard ratio=0.39, 95% confidence interval=0.24–0.64).
CONCLUSION: Although most recovery of function occurs by 6 months after the first visit after a hospitalization, a substantial proportion of disabled community-dwelling women recover over the following 2 years.     

Research Into the Effect of Proton Pump Inhibitors on Lungs and Leukocytes

BackgroundProton pump inhibitors (PPI) are the most commonly used medication in the world. They are prescribed as an effective treatment choice for gastrointestinal system diseases linked to hyperacidity, especially. Additionally, non-indication and unnecessary use are very common. Many publications in recent times have reported significant side effects. However, there are insufficient studies about the mechanism for these side effects.MethodsTwenty-four Wistar albino rats were used in this study. Rats were divided into 3 groups of control, group-administered H₂ receptor blockers and a group-administered PPI. Medications were administered for 30 days intraperitoneal. After 30 days, rats were euthanized and lung tissue was obtained. Lung was stained for immunohistochemical catalase, superoxide dismutase, Glutathione peroxidase, myeloperoxidase, and toluidine blue and investigated with a light microscope. Transmission electron microscopy (TEM) was used to investigate lung tissues and neutrophil leukocytes. Additionally, lung tissue had biochemical hydrogen peroxide (H₂O₂) levels researched.ResultsH₂O₂ amounts, produced by lysosomes with important duties for neutrophil functions in lung tissues, were found to be statistically significantly reduced in the group-administered PPI. Results from investigations of specimens obtained with immunohistochemical staining observed increases in antioxidant amounts in the PPI group. Investigation with TEM identified more inflammation findings in the lung tissue from the group-administered PPI compared to the control group and the group-administered H₂ receptors.ConclusionIn conclusion, we identified long-term PPI use disrupts neutrophil leukocyte functions in the lung. All clinicians should be much more careful about PPI use.     

The Vulnerable Elders-13 Survey Predicts 5-Year Functional Decline and Mortality Outcomes in Older Ambulatory Care Patients

OBJECTIVES: To test the predictive properties of the Vulnerable Elders-13 Survey (VES-13) a short tool that predicts functional decline and mortality over a 1- to 2-year follow-up interval over a 5-year interval.
DESIGN: Longitudinal evaluation with mean follow-up of 4.5 years.
SETTING: Two managed-care organizations.
PARTICIPANTS: Six hundred forty-nine community-dwelling older adults (≥75) enrolled in the Assessing Care of Vulnerable Elders observational study who screened positive for symptoms of falls or fear of falling, bothersome urinary incontinence, or memory problems.
MEASUREMENTS: VES-13 score (range 1–10, higher score indicates worse prognosis), functional decline (decline in count of 5 activities of daily living or nursing home entry), and deaths.
RESULTS: Higher VES-13 scores were associated with greater predicted probability of death and decline in older patients over a mean observation period of 4.5 years. For each additional VES-13 point, the odds of the combined outcome of functional decline or death was 1.37 (95% confidence interval (CI)=1.25–1.50), and the area under the receiver operating curve was 0.75 (95% CI=0.71–0.80). In the Cox proportional hazards model predicting time to death, the hazard ratio was 1.23 (95% CI=1.19–1.27) per additional VES-13 point.
CONCLUSION: This study extends the utility of the VES-13 to clinical decisions that require longer-term prognostic estimates of functional status and survival.     

A Comparison of Cognitive and Everyday Functional Performance Among Older Adults With and Without Hypertension

Secondary data analyses examined the differences in cognitive and instrumental activities of daily living (IADL) performance among hypertensive individuals taking one of four classes of antihypertensive medications, hypertensive individuals not taking any antihypertensive medications, and normotensive individuals (N?=?770). After adjusting for covariates, significant group differences were evident on all measures (speed of processing, motor speed, reaction time, p < .05) except memory and timed IADL (p > .05). Follow-up a priori planned comparisons compared hypertensive individuals not on medications to each of the four antihypertensive medication groups. Results indicated that only those on beta-blockers were significantly slower in speed of processing (p < .05). A priori planned comparisons also revealed that normotensive individuals had better cognitive performance on measures of processing speed, motor speed, and reaction time than hypertensive individuals regardless of antihypertensive medication use. Additionally, normotensive individuals performed significantly better on memory (digit and spatial span) than individuals with hypertension on medications. No differences were found between groups on memory (Hopkins Verbal Learning Test) or timed IADL performance. With regard to antihypertensive medications, the use of beta blockers was associated with slowed processing speed. These analyses provide empirical evidence that hypertension primarily impacts speed of processing, but not severe enough to affect IADL performance. Given the contribution of processing speed to memory and executive function performance, this is an important finding. Clinicians need to take into consideration the potential negative impact that beta blockers may have on cognition when determining the best treatment of hypertension among older adult patients.     

Functional Disability and Associated Factors Among Older Zuni Indians

Few studies have focused on American Indian elderly and functional disability, and none have explored potential moderating or mediating factors that may lend themselves to subsequent intervention. The purpose of this study was to describe the extent of functional disability in elders and to determine which factors were associated with a higher number of Activities of Daily Living (ADL) limitations. The study was a secondary data analysis of an existing survey of American Indian elders in one southwest tribe. Functional disability was defined as limitations in ADLs and was measured by the percent of respondents reporting specific limitations and by the mean total ADL limitations. Multiple linear regression analyses were used to determine the demographic, socioeconomic and health factors associated with ADL limitations. In the 90 elders surveyed, 40 percent of respondents reported a limitation with bathing, 31 percent with walking, and 22 percent with dressing. Only 6 percent of the elders surveyed, however, reported their health status as "poor" on a 5-point scale. Factors associated with more ADL limitations included poorer health status, less frequent exercise, and more elder care services used. Rates of functional disability in this tribe were higher than those found in the U.S. for all races. Further studies are needed to understand functional disability in American Indian elders and their need for long-term care services.     

A predictive index for functional decline in hospitalized elderly medical patients

Objective: To prospectively develop and validate a predictive index to identify on admission elderly hospitalized medical patients at risk for functional decline. Design: Two prospective cohort studies, in tandem. The predictive model developed in the initial cohort was subsequently validated in a separate cohort. Setting: General medical wards of a university teaching hospital. Patients: For the development cohort, 188 hospitalized general medical patients aged ≥70 years. For the validation cohort, 142 comparable patients. Measurement and main results: The subjects and their nurses were interviewed twice weekly using standardized, validated instruments. Functional decline occurred among 51/188 (27%) patients in the development cohort. Four independent baseline risk factors (RFs) for functional decline were identified: decubitus ulcer (adjusted relative risk [RR] 2.7; 95% confidence interval [CI] 1.4, 5.2); cognitive impairment (RR 1.7; CI 0.9, 3.1); functional impairment (RR 1.8; CI 1.0, 3.3); and low social activity level (RR2.4; CI 1.2, 5.1). A risk-stratification system was developed by adding the numbers of RFs. Rates of functional decline for the low- (0 RF), intermediate- (1–2 RFs), and high- (3–4 RFs) risk groups were 8%, 28%, and 63%, respectively (p<0.0001).The corresponding rates in the validation cohort, of whom 34/142 (24%) developed functional decline, were 6%, 29%, and 83% (p<0.0001). The rates of death or nursing home placement, clinical outcomes associated with functional decline in the hospital, were 6%, 19%, and 41% (p<0.002) in the development cohort and 10%, 32%, and 67% (p<0.001) in the validation cohort, respectively, for the three risk groups. Conclusions: Functional decline among hospitalized elderly patients is common, and a simple predictive model based on four risk factors can be used on admission to identify elderly persons at greatest risk. Supported in part by grants from the John A. Hartford Foundation (Grant #88345-3G), the Robert Leete and Clara Guthrie Patterson Trust, the Retirement Research Foundation (Grants #90-44, 91-66), and the Sandoz Foundation for Gerontological Research (Grants #11, 27). Dr. Inouye is a Dana Foundation Faculty Scholar and recipient of Academic Award #lK08AB00524-01 from the National Institute on Aging.     

Correlation Between Proton Pump Inhibitors and the Complications of Liver Cirrhosis: A Systematic Review and Meta-Analysis

BackgroundMany studies and meta-analyses have investigated the associations among proton pump inhibitors (PPIs), spontaneous bacterial peritonitis (SBP), portosystemic encephalopathy (PSE), and other infections. However, these studies had limitations, including the omission of several relevant studies and drawing conclusions, based on the abstracts without consulting the full-text of the articles. To evaluate the association between PPIs and complications arising from cirrhosis and risks of PPI use in patients with cirrhosis.MethodsData were extracted from the EMBASE, PubMed, Cochrane, and Google Scholar databases. The Newcastle-Ottawa scale was used to assess the quality of the selected studies.ResultsA total of 29 studies (13 case–control and 16 cohort studies) involving 20,484 patients were included in the meta-analysis. The total relative risk (RR) for the 23 studies which investigated SBP was 1.31, and the 95% CI was 1.10-1.55 (I² = 73.0%). The total RR for the 7 studies which examined PSE was 1.25 (95% CI 0.85-1.84, I² = 96.1%). For the 7 studies which analyzed overall infection, the total RR was 1.37 (95% CI 1.07-1.76, I² = 79.3%). The RR for the 2 cohort studies that assessed mortality was 1.39 (95% CI 0.85-2.27, I² = 0.0%).ConclusionPPI use in cirrhosis patients increased the SBP and overall infection risk. PPIs should be considered with appropriate indications when the benefits exceed the risks in cirrhosis patients with ascites.