Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation

Objective

To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation.

Design

Observational study.

Setting

Postacute rehabilitation facility.

Participants

Patients (N=2754) aged ≥65 years admitted over a 4-year period.

Interventions

Not applicable.

Main Outcome Measure

Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement.

Results

Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean ± SD, 63.3±18.0 vs 59.6±24.7) and at discharge (mean ± SD, 86.8±10.4 vs 62.2±22.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]=1.51; 95% confidence interval [CI], 1.16–1.98; P=.003), women (adjusted OR=1.24; 95% CI, 1.01–1.52; P=.045), patients living alone (adjusted OR=1.61; 95% CI, 1.31–1.98; P<.001), and patients without in-home help prior to admission (adjusted OR=1.39; 95% CI, 1.15–1.69; P=.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19–23) and those cognitively intact also had increased odds of functional recovery (adjusted OR=1.56; 95% CI, 1.13–2.15; P=.007; adjusted OR=2.21; 95% CI, 1.67–2.93; P<.001, respectively).

Conclusions

Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome.     

Does the Emergency Medical Treatment and Labor Act Affect Emergency Department Use?

Background

Emergency departments (EDs) face increasing patient volumes and economic pressures. These problems have been attributed to the Emergency Medical Treatment and Labor Act (EMTALA).

Study objective

To determine whether modifying EMTALA might reduce ED use.

Methods

We surveyed ED patients to assess their knowledge of hospitals’ obligations to treat all patients regardless of insurance and to determine whether knowledge is associated with ED use.

Results

Among 4136 study subjects, 72% reported awareness of the law. Sixty-one percent of subjects were moderate ED users (≥ 1 additional ED visit in 12 months). Moderate users more often knew the law (74% vs. 70%, p = 0.005). Multivariate regression showed that factors associated with moderate use were: awareness of EMTALA (odds ratio [OR] 1.44; 95% confidence interval [CI] 1.24–1.67), adult patient (OR 1.94; 95% CI 1.69–2.22), and government insurance (OR 2.67; 95% CI 2.30–3.08) or uninsured (OR 1.72; 95% CI 1.42–2.08). Only 8% of subjects were high-frequency users (≥5 visits). High-frequency users were more often aware of EMTALA (78% vs. 72%, p = 0.02). Covariates associated with high frequency were EMTALA awareness (OR 1.69; 95% CI 1.28–2.24), adult patient (OR 2.59; 95% CI 2.00–3.36), and government insurance (OR 3.73; 95% CI 2.76–5.06) or uninsured (OR 3.77; 95% CI 2.65–5.35).

Conclusion

Many patients know that the law requires hospitals to provide care. This knowledge is associated with more frequent ED use. EMTALA changes might reduce ED use, but broader policy implications should be considered.     

Factors Associated With Home Discharge Among Veterans With Stroke

Objective

To determine which patient-, treatment-, and facility-level characteristics were associated with home discharge among patients hospitalized for stroke within the Department of Veterans Affairs.

Design

Retrospective observational study.

Setting

Veterans Affairs facilities nationwide.

Participants

Veterans hospitalized for stroke during fiscal year 2007 to fiscal year 2008 (N=12,565).

Intervention

Not applicable.

Main Outcome Measure

Discharge location after hospitalization.

Results

There were 10,130 (80.6%) veterans discharged home after hospitalization for acute stroke. Married veterans were more likely than nonmarried veterans to be discharged home (odds ratio [OR]=1.23; 95% confidence interval [CI]=1.11–1.35). Compared with veterans admitted to the hospital from home, patients admitted from extended care were less likely to be discharged home (OR=.04; 95% CI=.03–.07). Compared with those with occlusion of cerebral arteries, patients with intracerebral hemorrhage (OR=.61; 95% CI=.50–.74) or other central nervous system hemorrhage (OR=.78; 95% CI=.63–.96) were less likely to be discharged home, whereas patients with occlusion of precerebral arteries (OR=1.36; 95% CI=1.07–1.73) were more likely to return home. Evidence of congestive heart failure (OR=.85; 95% CI=.76–.95), fluid and electrolyte disorders (OR=.86; 95% CI=.77–.96), internal organ procedures and diagnostics (OR=.87; 95% CI=.78–.97), and serious nutritional compromise (OR=.49; 95% CI=.40–.62) during hospitalization remained independently associated with lower odds of home discharge. Longer hospitalizations and receipt of rehabilitation services while hospitalized acutely were negatively associated, whereas treatment on more bed sections and rehabilitation accreditation of the facility were positively associated with home discharge. Region exerted a statistically significant effect on home discharge.

Conclusions

We found sociological, clinical, and facility-level factors associated with home discharge after hospitalization for acute stroke. Findings document the importance of considering a broad range of characteristics rather than focusing only on a few specific traits during discharge planning.     

Risk Factors for Serious Underlying Pathology in Adult Emergency Department Nontraumatic Low Back Pain Patients

Background

Nontraumatic low back pain (LBP) is a common emergency department (ED) complaint and can be caused by serious pathologies that require immediate intervention or that lead to death.

Objective

The primary goal of this study is to identify risk factors associated with serious pathology in adult nontraumatic ED LBP patients.

Methods

We conducted a health records review and included patients aged ≥ 16 years with nontraumatic LBP presenting to an academic ED from November 2009 to January 2010. We excluded those with previously confirmed nephrolithiasis and typical renal colic presentation. We collected 56 predictor variables and outcomes within 30 days. Outcomes were determined by tracking computerized patient records and performance of univariate analysis and recursive partitioning.

Results

There were 329 patients included, with a mean age of 49.3 years; 50.8% were women. A total of 22 (6.7%) patients suffered outcomes, including one death, five compression fractures, four malignancies, four disc prolapses requiring surgery, two retroperitoneal bleeds, two osteomyelitis, and one each of epidural abscess, cauda equina, and leaking abdominal aortic aneurysm graft. Risk factors identified for outcomes were: anticoagulant use (odds ratio [OR] 15.6; 95% confidence interval [CI] 4.2–58.5), decreased sensation on physical examination (OR 6.9; CI 2.2–21.2), pain that is worse at night (OR 4.3; CI 0.9–20.1), and pain that persists despite appropriate treatment (OR 2.2; CI 0.8–5.6). These four predictors identified serious pathology with 91% sensitivity (95% CI 70–98%) and 55% specificity (95% CI 54–56%).

Conclusion

We successfully identified risk factors associated with serious pathology among ED LBP patients. Future prospective studies are required to derive a robust clinical decision rule.     

Predicting Peripheral Venous Access Difficulty in the Emergency Department Using Body Mass Index and a Clinical Evaluation of Venous Accessibility

Background

Peripheral venous (PV) cannulation, one of the most common technical procedures in Emergency Medicine, may prove challenging, even to experienced Emergency Department (ED) staff. Morbid obesity (body mass index [BMI] ≥ 40) has been reported as a risk factor for PV access failure in the operating room.

Objectives

We investigated PV access difficulty in the ED, across BMI categories, focusing on patient-related predicting factors.

Methods

Prospective, observational study including adult patients requiring PV lines. Operators were skilled nurses and physicians. PV accessibility was clinically evaluated before all cannulation attempts, using vein visibility and palpability. Patient and PV placement characteristics were recorded. Primary outcome was failure at first attempt. Outcome frequency and comparisons between groups were examined. Predictors of difficult cannulation were explored using logistic regression. A p-value <0.05 was considered significant.

Results

PV lines were placed in 563 consecutive patients (53 ± 23 years, BMI: 26 ± 7 kg/m²), with a success rate of 98.6%, and a mean attempt of 1.3 ± 0.7 (range 1–7). Failure at the first attempt was recorded in 21% of patients (95% confidence interval [CI] 17.6–24.4). Independent risk factors were: a BMI ≥ 30 (odds ratio [OR] 1.98, 95% CI 1.09–3.60), a BMI < 18.5 (OR 2.24; 95% CI 1.07–4.66), an unfavorable (OR 1.66, 95% CI 1.02–2.69), and very unfavorable clinical assessment of PV accessibility (OR 2.38, 95% CI 1.15–4.93).

Conclusion

Obesity, underweight, an unfavorable, and a very unfavorable clinical evaluation of PV accessibility are independent risk factors for difficult PV access. Early recognition of patients at risk could help in planning alternative approaches for achieving rapid PV access.     

Predictors of Lapse and Relapse to Smoking in Successful Quitters in a Varenicline Post Hoc Analysis in Japanese Smokers

Background

The efficacy of the smoking-cessation agent varenicline has been reported in Asian smokers; however, few studies have investigated factors that contribute to lapse and relapse.

Objective

This post hoc analysis aimed to identify predictors of smoking lapse and relapse.

Methods

This was a post-hoc analysis based on a double-blind, placebo-controlled, randomized, parallel-group study in which Japanese smokers (aged 20–75 years) who smoked ≥10 cigarettes/day and were motivated to quit were randomized to receive varenicline (0.25 mg twice daily [BID], 0.5 mg BID, 1 mg BID) or placebo for 12 weeks followed by a 40-week non-treatment follow-up. For inclusion in this analysis, participants must have been nicotine dependent (Tobacco Dependence Screener score ≥5) and must have successfully quit smoking continuously for 4 weeks (weeks 9–12). Lapse was defined by answering yes to ≥1 question in the Nicotine Use Inventory. Relapse was defined by participants having smoked for ≥7 days during follow-up measured by the Nicotine Use Inventory.

Results

Of the 619 randomized individuals, 515 had a Tobacco Dependence Screener score of ≥5, and 277 quit smoking continuously from weeks 9 to 12. Approximately 75% were male, with a mean (SD) BMI of 23.0 (3.0) kg/m². Maximum length of continuous abstinence (CA) during treatment and age (both P < 0.0001) were significant predictors of lapse. Maximum CA (P < 0.0001), age (P = 0.0002), Minnesota Nicotine Withdrawal Scale (MNWS) score for urge to smoke (P = 0.0019), and having made ≥1 serious quit attempt (P = 0.0063) were significant predictors of relapse. For participants with a maximum CA of 4 to 6 weeks versus those with a maximum CA of 10 to 11 weeks, the ORs for lapse and relapse were 4.649 (95% CI, 2.071–10.434) and 3.337 (95% CI, 1.538–7.239), respectively. In participants aged 21–34 years versus those aged 47–72 years, the ORs for lapse and relapse were 3.453 (95% CI 1.851, 6.441) and 3.442 (95% CI 1.795, 6.597), respectively. Participants with a MNWS urge to smoke score of 2 to 4 versus 0 had an OR for relapse of 3.175 (95% CI, 1.166–8.644). Participants having made ≥1 versus no serious quit attempts had an OR for relapse of 2.108 (95% CI, 1.168–3.805).

Conclusion

Shorter maximum CA and younger age at quit attempt were associated with increased risk of lapse and relapse. Higher MNWS urge to smoke score and having made ≥1 serious quit attempt were associated with increased relapse risk. ClinicalTrials.gov identifier: NCT00139750.     

Survival rates in out-of-hospital cardiac arrest patients transported without prehospital return of spontaneous circulation: An observational cohort study

Background

Some Emergency Medical Services currently use just one component of the Universal Termination of Resuscitation (TOR) Guideline, the absence of prehospital return of spontaneous circulation (ROSC), as the single criteria to terminate resuscitation, which may deny transport to potential survivors.

Objective

This study aimed to report the survival to hospital discharge rate in non-traumatic, adult out-of-hospital cardiac arrest (OHCA) patients transported to hospital without a prehospital ROSC.

Methods

An observational study of OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport to hospital with ongoing resuscitation. Multivariable logistic regression was used to determine the association of each variable with survival to hospital discharge.

Results

Of 20,207 OHCA treated by EMS, 3374 (16.4%) did not have a prehospital ROSC but met the Universal TOR guideline for transport to hospital with ongoing resuscitation. Of these patients, 122 (3.6%) survived to hospital discharge. Survival to discharge was associated with initial shockable VF/VT rhythms (OR 5.07; 95% CI 2.77–9.30), EMS-witnessed arrests (OR 3.51; 95% CI 1.73–7.15), bystander-witnessed arrests (OR 2.11; 95% CI 1.18–3.77), and public locations (OR 1.57; 95% CI 1.02–2.40).

Conclusion

In OHCA patients without a prehospital ROSC who met the Universal TOR Guideline for transport with ongoing resuscitation survival rates were above the 1% futility rate. Employing only the lack of ROSC as criteria for termination of resuscitation may miss survivors after OHCA.     

Predicting Bloodstream Infection via Systemic Inflammatory Response Syndrome or Biochemistry

Background

The yield of blood cultures is approximately 10%. This could be caused by inaccurate prediction of patients with bloodstream infection (BSI).

Objectives

To evaluate the usability of systemic inflammatory response syndrome (SIRS) or biochemical analyses as predictors for positive blood culture.

Methods

We conducted a prospective cohort study at a Danish regional hospital from February 1 to April 30, 2010. All adult patients were included on the first time blood cultures were sampled during admission. Data were obtained from medical records, databases on microbiology, biochemistry, and antibiotic treatment. Data included time of admission, date and result of blood culture, results of biochemical analyses, and clinical measurements on the day of blood culture. Prediction of BSI was analyzed according to both individual parameters and parameters combined in different sepsis score groups. Associations were calculated using multiple logistic regression.

Results

Patients with BSI (68 patients) were compared to patients without BSI (828 patients). Respiratory rate, body temperature, and C-reactive protein were strongest associated with BSI, with adjusted odds ratio (OR) 5.42, 95% confidence interval (CI) 1.13–25.9; OR 2.55, 95% CI 1.34–4.87; and OR 6.06, 95% CI 0.82–44.6, respectively. SIRS was associated with BSI, with crude OR 7.25, 95% CI 1.75–30.1. Neutrophil count and p-carbamide were not associated with BSI: adjusted OR 0.88, 95% CI 0.36–2.13 and OR 1.44, 95% CI 0.82–2.52, respectively. Only one of the sepsis score groups was associated with BSI: crude OR 2.13, 95% CI 1.08–4.19.

Conclusions

SIRS is an adequate predictor of BSI. By contrast, biochemical parameters were not useful as predictors of BSI.     

Efficacy of vasopressin during cardio-pulmonary resuscitation in adult patients: A meta-analysis

Background

Experimental and animal studies suggested that vasopressin may have a favorable survival profile during CPR. This meta-analysis aimed to determine the efficacy of vasopressin in adult cardiac patients.

Methodology

Meta-analysis of randomized control trials (RCTs) comparing the efficacy of vasopressin containing regimen during CPR in adult cardiac arrest population with an epinephrine only regimen.

Results

A total of 6120 patients from 10 RCTs were included in this meta-analysis. Vasopressin use during CPR has no beneficial impact in an unselected population in ROSC [OR 1.19, 95% CI 0.93, 1.52], survival to hospital discharge [OR 1.13, 95% CI 0.89, 1.43], survival to hospital admission [OR 1.12, 95% CI 0.99, 1.27] and favorable neurological outcome [OR 1.02, 95% CI 0.75, 1.38]. ROSC in “in-hospital” cardiac arrest setting [OR 2.20, 95% CI 1.08, 4.47] is higher patients receiving vasopressin. Subgroup analyses revealed equal or higher chance of ROSC [OR 2.15, 95% CI 1.00, 4.61], higher possibility of survival to hospital discharge [OR 2.39, 95% CI 1.34, 4.27] and favorable neurological outcome [OR 2.58, 95% CI 1.39, 4.79] when vasopressin was used as repeated boluses of 4–5 times titrating desired effects during CPR.

Conclusion

ROSC in “in-hospital” cardiac arrest patients is significantly better when vasopressin was used. A subgroup analysis of this meta-analysis found that ROSC, survival to hospital admission and discharge and favorable neurological outcome may be better when vasopressin was used as repeated boluses of 4–5 times titrated to desired effects; however, overall no beneficial effect was noted in unselected cardiac arrest population.     

Females of childbearing age have a survival benefit after out-of-hospital cardiac arrest

Background

There is controversy regarding the association between age and being female and survival to hospital discharge after out-of-hospital cardiac arrest (OHCA). We hypothesized that younger females (aged 12–49 years) would be independently associated with increased survival after OHCA when compared to other age and sex groups.

Methods

We conducted a secondary analysis of prospectively collected data from 29 United States cities that participate in the Cardiac Arrest Registry to Enhance Survival (CARES). Patients were included if they were ≥12 years of age and had a documented resuscitation attempt from October 1, 2005 through December 31, 2009. Hierarchical multivariable logistic regression analyses were used to estimate the associations between age and sex groups and survival to hospital discharge.

Results

Females were less likely to have a cardiac arrest in public, was witnessed, or was treatable with defibrillation. Females in the 12–49 year old age group had a similar proportion of survival to hospital discharge when compared to age-matched males (females 11.6% vs. males 11.2%), while males ≥50 years old were more likely to survive when compared to age matched females (females 6.9% vs. males 9.6%). Age stratified regression models demonstrated that 12–49 year old females had the largest association with survival to hospital discharge (OR 1.55, 95% CI 1.20–2.00), while females in the ≥50 year old age group had a smaller increased odds of survival to hospital discharge (OR 1.18, 95% CI 1.03–1.35), which only lasted until the age of 55 years (OR 1.12, 95% CI 0.97–1.29).

Conclusions

Younger aged females were associated with increased odds of survival despite being found with poorer prognostic arrest characteristics.     

Subjective dysphagia in older care home residents: A cross-sectional,multi-centre point prevalence measurement

Background

Dysphagia has been found to be strongly associated with aspiration pneumonia in frail older people. Aspiration pneumonia is causing high hospitalization rates, morbidity, and often death. Better insight in the prevalence of (subjective) dysphagia in frail older people may improve its early recognition and treatment.

Objective

First, to assess the prevalence of subjective dysphagia in care home residents in the Netherlands. Second, to assess the associations of subjective dysphagia with potential risk factors of dysphagia.

Design

Retrospective data-analysis of a cross-sectional, multi-centre point prevalence measurement.

Setting

119 care homes in the Netherlands.

Participants

Data of 8119 care home residents aged 65 years or older were included and analyzed.

Methods

Subjective dysphagia was assessed by a resident's response to a dichotomous question with regard to experiencing swallowing problems. If a resident was not able to respond (e.g. residents with dementia or aphasia), the question was answered by the ward care provider, or the resident's file was consulted for registered swallowing complaints and/or dysphagia. Several residents’ data were collected: gender, age, (number of) diseases, the presence of malnutrition, the Care Dependency Scale score, and the body mass index.

Results

Subjective dysphagia was found in 751 (9%) residents. A final model for subjective dysphagia after multivariate backward stepwise regression analysis revealed eight significant variables: age (B −0.022), Care Dependency Scale score (B −0.985), ‘malnutrition’ (OR 1.58; 95% CI 1.31–1.90), ‘comorbidity’ (OR 1.07; 95% CI 1.01–1.14), and the disease clusters ‘dementia’ (OR 0.55; 95% CI 0.45–0.66), ‘nervous system disorder’ (OR 1.55; 95% CI 1.20–1.99), ‘cardiovascular disease’ (OR 0.81; 95% CI 0.67–0.99) and ‘cerebrovascular disease/hemiparesis’ (OR 1.74; 95% CI 1.45–2.10).

Conclusion

It seems justified to conclude that subjective dysphagia is a relevant care problem in older care home residents in the Netherlands. Care Dependency Scale score, ‘malnutrition’, and the disease clusters ‘dementia’, ‘nervous system disorder’, and ‘cerebrovascular disease/hemiparesis’ were associated with the presence of subjective dysphagia in this study. Age, ‘comorbidity’ and ‘cardiovascular disease’ showed very small influence.     

A Survey of the Prevalence of Cell Phones Capable of Receiving Health Information among Patients Presenting to an Urban Emergency Department

Background

Mobile devices have been shown to assist patients with comprehension of health information, yet sparse data exist on what mobile devices patients own and preferences for receiving health information.

Objectives

To determine the prevalence of mobile devices capable of receiving health information among patients/visitors presenting to an urban Emergency Department (ED).

Methods

A random sample of patients/visitors ≥18 years was surveyed. The primary outcome was prevalence of mobile devices capable of receiving health information among patient/visitor units presenting to the ED. Means and 95% confidence intervals were derived for continuous data; proportions with Fisher’s exact 95% confidence intervals were derived for categorical data. Institutional review board approval was received before study initiation.

Results

Surveyors approached 1307 subjects: 68% (885) were eligible; 70% (620) agreed to participate; 4 participants were excluded, leaving 70% (616) in the final sample. Of the 616 participants, 82% stated cell phone ownership (95% confidence interval [CI] 0.79–0.85). Among cell phone owners (n = 507), 90% had the device with them (95% CI 0.87–0.92) in the ED. Of these participants (n = 456), 77% had text messaging (95% CI 0.73–0.81), 51% had Internet (95% CI 0.47–0.56), 51% had e-mail (95% CI 0.46–0.56), 39% could download audio content (95% CI 0.34–0.43), and 35% could download videos (95% CI 0.31–0.40). Even among those having an annual income ≤$20,000, nearly 80% of persons owned cell phones.

Conclusions

Cell phones capable of receiving health information are prevalent among patients/visitors presenting to an urban ED.     

Functional Status Impairment Is Associated With Unplanned Readmissions

Objective

To determine whether functional status on admission to a Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) is associated with unplanned readmission to acute care.

Design

Retrospective cohort study.

Setting

Academic hospital-based CIIRP.

Participants

Consecutive patients (N=1515) admitted to a CIIRP between January 2009 and June 2012.

Interventions

Patients' functional status, the primary exposure variable, was assessed using tertiles of the total FIM score at CIIRP admission, with secondary analyses using the FIM motor and cognitive domains. A propensity score, consisting of 25 relevant clinical and demographic variables, was used to adjust for confounding in the analysis.

Main Outcome Measures

Readmission to acute care was categorized as (1) readmission before planned discharge from the CIIRP, (2) readmission within 30 days of discharge from the CIIRP, and (3) total readmissions from both groups, with total readmissions being the a priori primary outcome.

Results

Among the 1515 patients, there were 347 total readmissions. Total readmissions were significantly associated with FIM scores, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the lowest and middle FIM tertiles versus the highest tertile (AOR=2.6; 95% CI, 1.9–3.7; P<.001 and AOR=1.7; 95% CI, 1.2–2.4; P=.002, respectively). There were similar findings for secondary analyses of readmission before planned discharge from the CIIRP (AOR=3.5; 95% CI, 2.2–5.8; P<.001 and AOR=2.1; 95% CI, 1.3–3.5l P=.002, respectively), and a weaker association for readmissions after discharge from the CIIRP (AOR=1.6; 95% CI, 1.0–2.4; P=.047 and AOR=1.3; 95% CI, 0.8–1.9; P=.28, respectively). The FIM motor domain score was more strongly associated with readmissions than the FIM cognitive score.

Conclusions

Functional status on admission to the CIIRP is strongly associated with readmission to acute care, particularly for motor aspects of functional status and readmission before planned discharge from the CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.     

Effects of Kinesio Taping on Venous Symptoms,Bioelectrical Activity of the Gastrocnemius Muscle,Range of Ankle Motion,and Quality of Life in Postmenopausal Women With Chronic Venous Insufficiency: A Randomized Controlled Trial

Objective

To assess the efficacy of Kinesio taping (KT) on venous symptoms, quality of life, severity, pain, edema, range of ankle motion (ROAM), and peripheral muscle myoelectrical activity in lower limbs of postmenopausal women with mild chronic venous insufficiency (CVI).

Design

Double-blinded randomized controlled trial with concealed allocation.

Setting

Clinical setting.

Participants

Consecutive postmenopausal women (N=123; age range, 62–67y) with early-stage CVI. None of the participants withdrew because of adverse effects.

Intervention

Participants were randomly assigned to an experimental group for standardized KT application for external gastrocnemius (EG) and internal gastrocnemius (IG) muscle enhancement and ankle function correction or a placebo control group for sham KT application. Both interventions were performed 3 times a week during a 4-week period.

Main Outcome Measures

Venous symptoms, CVI severity, pain, leg volume, gastrocnemius electromyographic data, ROAM, and quality of life were recorded at baseline and after treatment.

Results

The experimental group evidenced significant improvements in pain distribution, venous claudication, swelling, heaviness, muscle cramps, pruritus, and CVI severity score (P≤.042). Both groups reported significant reductions in pain (experimental group: 95% confidence interval [CI], 1.6 to 2.1; control group: 95% CI, −0.2 to 0.3). There were no significant changes in either group in quality of life, leg volume, or ROAM. The experimental group showed significant improvements in root mean square signals (right leg: EG 95% CI, 2.99–5.84; IG 95% CI, 1.02–3.42; left leg: EG 95% CI, 3.00–6.25; IG 95% CI, 3.29–5.3) and peak maximum contraction (right leg: EG 95% CI, 4.8–22.7; IG 95% CI, 2.67–24.62; left leg: EG 95% CI, 2.37–20.44; IG 95% CI, 2.55–25.53), which were not changed in controls.

Conclusions

KT may reduce venous symptoms, pain, and their severity and enhance gastrocnemius muscle activity, but its effects on quality of life, edema, and ROAM remain uncertain. KT may have a placebo effect on venous pain.     

The Prevalence of Quality Issues and Adverse Outcomes among 72-Hour Return Admissions in the Emergency Department

Background

Records of patients discharged from the Emergency Department (ED) who return within 72 h and are admitted are often reviewed for potential quality issues.

Objectives

We explored 72-h return admissions and determined the prevalence and predictors for substandard management on the initial visit or any adverse outcome.

Methods

Retrospective review of quality assurance data from 72-h return admissions in three hospitals from 2006–2010 was performed. Any substandard quality on the first visit or change in outcome on the return admission was considered “low quality.” Multivariate logistic regression was used to assess the relationship between cases judged as low quality vs. not low quality.

Results

Of 741,132 ED visits across 5 years, 3682 (0.5%) were 72-h return admissions. Of those, 192 (5%) were low quality. In 158 (4%) and 8 (0.2%) there were moderate and severe deviations from care standards, respectively. Similarly, in 53 (1%) and 14 (0.4%) there were moderate and severe changes in outcome. In adjusted analysis, there were higher rates of low-quality 72-h return admissions in ambulance arrivals (odds ratio [OR] 1.5, 95% confidence interval (CI) 1.1–2.1); and lower rates in Medicaid patients (OR 0.3, 95% CI 0.2–0.7). There were higher rates in low-quality 72-h return admissions in hospital 1 (OR 3.6, 95% CI 2.2–6.1) and hospital 3 (OR 3.2, 95% CI 2.0–4.7) compared to hospital 2.

Conclusions

Poor care on the initial visit or any poor outcome upon returning in 72-h return admissions is relatively rare in the ED. Reporting 72-h return admissions without chart review may not be a good way to measure clinical quality.     

The effect of time to defibrillation and targeted temperature management on functional survival after out-of-hospital cardiac arrest

Background

Cardiac arrest physiology has been proposed to occur in three distinct phases: electrical, circulatory and metabolic. There is limited research evaluating the relationship of the 3-phase model of cardiac arrest to functional survival at hospital discharge. Furthermore, the effect of post-cardiac arrest targeted temperature management (TTM) on functional survival during each phase is unknown.

Objective

To determine the effect of TTM on the relationship between the time of initial defibrillation during each phase of cardiac arrest and functional survival at hospital discharge.

Methods

This was a retrospective observational study of consecutive adult (≥18 years) out-of-hospital cardiac arrest (OHCA) patients with initial shockable rhythms. Included patients obtained a return of spontaneous circulation (ROSC) and were eligible for TTM. Multivariable logistic regression was used to determine predictors of functional survival at hospital discharge.

Results

There were 20,165 OHCA treated by EMS and 871 patients were eligible for TTM. Of these patients, 622 (71.4%) survived to hospital discharge and 487 (55.9%) had good functional survival. Good functional survival was associated with younger age (OR 0.94; 95% CI 0.93–0.95), shorter times from collapse to initial defibrillation (OR 0.73; 95% CI 0.65–0.82), and use of post-cardiac arrest TTM (OR 1.49; 95% CI 1.07–2.30). Functional survival decreased during each phase of the model (65.3% vs. 61.7% vs. 50.2%, P < 0.001).

Conclusion

Functional survival at hospital discharge was associated with shorter times to initial defibrillation and was decreased during each successive phase of the 3-phase model. Post-cardiac arrest TTM was associated with improved functional survival.     

Gabapentinoids Are Effective in Decreasing Neuropathic Pain and Other Secondary Outcomes After Spinal Cord Injury: A Meta-Analysis

Objective

To examine the effectiveness of gabapentin and pregabalin in diminishing neuropathic pain and other secondary conditions in individuals with spinal cord injury (SCI).

Data Sources

A systematic search was conducted using multiple databases for relevant articles published from 1980 to June 2013.

Study Selection

Controlled and uncontrolled trials involving gabapentin and pregabalin for treatment of neuropathic pain, with ≥3 subjects and ≥50% of study population with SCI, were included.

Data Extraction

Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference (SMD), SE, and 95% confidence interval (CI) for primary (pain) and secondary outcomes (anxiety, depression, sleep interference) was conducted.

Data Synthesis

Eight studies met inclusion criteria. There was a significant reduction in the intensity of neuropathic pain at <3 months (SMD=.96±.11; 95% CI, .74–1.19; P<.001) and between 3 and 6 months (SMD=2.80±.18; 95% CI, 2.44–3.16; P<.001). A subanalysis found a significant decrease in pain with gabapentin (SMD=1.20±.16; 95% CI, .88–1.52; P<.001) and with pregabalin (SMD=1.71±.13; 95% CI, 1.458–1.965; P<.001). A significant reduction in other SCI secondary conditions, including sleep interference (SMD=1.46±.12; 95% CI, 1.22–1.71; P<.001), anxiety (SMD=1.05±.12; 95% CI, .81–1.29; P<.001), and depression (SMD=1.22±.13; 95% CI, .967–1.481; P<.001) symptoms, was shown. A significantly higher risk of dizziness (risk ratio [RR]=2.02, P=.02), edema (RR=6.140, P=.04), and somnolence (RR=1.75, P=.01) was observed.

Conclusions

Gabapentin and pregabalin appear useful for treating pain and other secondary conditions after SCI. Effectiveness comparative to other analgesics has not been studied. Patients need to be monitored closely for side effects.     

Successful Discharge of Children with Gastroenteritis Requiring Intravenous Rehydration

Background

Emergency Department (ED) revisits are very common in children with gastroenteritis administered intravenous rehydration.

Study Objectives

To determine if bicarbonate values are associated with ED revisits in children with gastroenteritis.

Methods

We conducted a secondary analysis of prospectively collected data, which included children >3 months of age with gastroenteritis treated with intravenous rehydration. Regression analysis was employed to determine whether, among discharged children, bicarbonate independently predicts revisits within 7 days (primary outcome) and successful discharge (secondary outcome). The latter composite outcome measure was defined as discharge at the index visit and the absence of a revisit requiring intravenous rehydration.

Results

Of 226 potentially eligible children, 174 were discharged and were included in the primary outcome analysis. Of the eligible children, 18% (30/174) had a revisit that was predicted by a higher baseline bicarbonate (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0–1.3; p = 0.03), absence of a primary care provider (OR 7.8; 95% CI 1.2–51.0; p = 0.03), and ondansetron administration (OR 2.4; 95% CI 1.0–5.5; p = 0.05). Bicarbonate was not associated with successful discharge. Negatively associated independent predictors of successful discharge were volume of intravenous fluids administered (OR 0.84/10 mL/kg increase; 95% CI 0.76–0.93; p < 0.001), and baseline clinical dehydration score (OR 0.75/unit increase; 95% CI 0.58–0.97; p < 0.001). Revisits requiring intravenous rehydration and hospitalization were associated with higher bicarbonate values (21.2 ± 4.6 mEq, p = 0.001, and 22.3 ± 5.0 mEq/L, p < 0.001, respectively).

Conclusion

Lower serum bicarbonate values at the time of intravenous rehydration are not associated with unfavorable outcomes after discharge.     

Predictors of Functional Outcomes After Simple Decompression for Ulnar Neuropathy at the Elbow: A Multicenter Study by the SUN Study Group

Objective

To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE).

Design

Prospective cohort followed for 1 year.

Setting

Clinics.

Participants

Patients diagnosed with UNE (N=55).

Intervention

All subjects had simple decompression surgery.

Main Outcome Measures

The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow.

Results

Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9–23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9–24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, −0.38; 95% CI, −.67 to −.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, −.40; 95% CI, −.79 to −.01).

Conclusions

Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.     

The association between hospital type and mortality among critically ill children in US EDs

Study aim

Little is known about the setting of care for critically ill children and whether differences in outcomes are related to the presenting hospital type. This study describes the characteristics of hospitals to which critically ill children present and explores the associations between hospital factors and mortality.

Methods

This is a retrospective cohort study using data from the 2007 Healthcare Cost and Utilization Project National Emergency Department Sample, representative of all US ED visits. Subjects include children aged 0–18 with ICD9 codes for cardiac arrest, respiratory arrest and/or respiratory failure. Predictor variables include: age, sex, presence of chronic illness, self-pay, public insurance, trauma diagnosis, major trauma center, urban hospital, ED volume and teaching hospital. Multivariate logistic regression estimates predictors of mortality. Analyses integrate clusters, strata, and weights from the probability sample.

Results

There were an estimated 29 million pediatric ED visits in 2007 including 42,036 (0.1%) visits for cardiac or respiratory failure. Teaching hospitals (OR 0.57, 95% CI 0.50–0.66), trauma centers (OR 0.76, 95% CI 0.67–0.86), and urban hospitals (OR 0.78, 95% CI 0.63–0.97) were associated with lower mortality odds. Presence of a chronic illness (OR 14.5, 95% CI 10.5–20.1), diagnosis of an injury (OR 1.2, 95% CI 1.1–1.4) and self-pay status (OR 3.6, 95% CI 2.9–4.4) were associated with increased mortality odds.

Conclusions

The majority of children with cardiac and respiratory arrest present to urban teaching hospitals and trauma centers. After accounting for important confounders, mortality is lower at teaching hospitals and/or major trauma centers.