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1.

Context

In most resource-rich countries, a large and growing proportion of older adults with complex needs will die while in a residential aged care (RAC) facility.

Objectives

This study describes the impact of facility size (small/large), ownership model (profit/nonprofit) and provider (independent/chain) on resident comfort, and symptom management as reported by RAC staff.

Methods

This retrospective “after-death” study collected decedent resident data from a subsample of 51 hospital-level RAC facilities in New Zealand. Symptom Management at the End-of-Life in Dementia and Comfort Assessment in Dying at End of life with Dementia (SM-EOLD and CAD-EOLD, respectively) scales were used by RAC staff who were closely associated with 217 deceased residents. Data collection occurred from January 2016 to February 2017.

Results

Results indicated that residents of large, nonprofit facilities experienced greater comfort at the end of life (CAD-EOLD) as indicated by a higher mean score of 37.21 (SD = 4.85, 95% CI = 34.4, 40.0) than residents of small for-profit facilities who recorded a lower mean score of 31.56 (SD = 6.20, 95% CI = 29.6, 33.4). There was also evidence of better symptom management for residents of chain facilities, with a higher mean score for symptom management (SM-EOLD total score) recorded for residents of chain facilities (mean = 28.07, SD = 7.64, 95% CI = 26.47, 29.66) than the mean score for independent facilities (mean = 23.93, SD = 8.72, 95% CI = 21.65, 26.20).

Conclusion

Findings suggest that there are differences in the quality of end-of-life care given in RAC based on size, ownership model, and chain affiliation.  相似文献   

2.

Objectives

To investigate behavioral and demographic features of levels of consciousness in young children with brain injury, including the classifications of consciousness: conscious state (CS), minimally conscious state (MCS), and vegetative state (VS), and to investigate the course of recovery in children with disorders of consciousness (DOC).

Design

Retrospective chart review and post hoc analysis.

Setting

Pediatric inpatient rehabilitation unit.

Participants

Children aged 6 months to 5 years (N=54) admitted for inpatient rehabilitation directly from an acute care hospital following new neurologic injury from 2011 to 2016.

Interventions

Not applicable.

Main Outcome Measures

Clinically abstracted behavioral features of DOC and levels of consciousness at admission and discharge, based on established guidelines from the Aspen Neurobehavioral Conference Workgroup.

Results

Children in MCS were younger than children in CS. Commonly observed behaviors in children in VS were mouth movements or vocalizations, flexion withdrawal or motor posturing, visual or auditory startle, and localization to sound. Common features of MCS were contingent affect, visual fixation or pursuit, automatic motor behavior, and contingent communicative intent. No children in MCS showed command following or intelligible verbalizations. All children in CS showed functional object use, while functional communication was observed in a subset. By discharge, more than half of children in VS emerged to MCS, and a third emerged from MCS to CS. No child emerged from VS to CS.

Conclusions

Visual and motor skills may be most applicable, and language-based skills may be least applicable for the assessment of DOC in very young children. Accurate classifications of consciousness may have important prognostic implications, and additional research is needed to develop clear guidelines for assessment of DOC in this population.  相似文献   

3.

Context

Stability of preferences for life-sustaining treatment may vary depending on personal characteristics.

Objective

We estimated the stability of preferences for end-of-life treatment over 12 years and whether advance directives and medical conditions were associated with change in preferences for end-of-life treatment.

Design

Mailed survey of older physicians.

Methods

Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University. Eight hundred ninety eight physicians who completed the life-sustaining treatment questionnaire anytime in 1999, 2002, 2005, and 2011 (mean age 68.2 years at baseline). Preferences for life-sustaining treatment were assessed using a checklist questionnaire in response to a standard “brain injury” scenario and considered as a package using the latent class transition model.

Results

End-of-life preferences grouped into three classes: most aggressive (wanting most interventions; 14% of physicians), least aggressive (declining most interventions; 61%), and an intermediate class (declining most interventions except intravenous fluids and antibiotics; 25%). Physicians without an advance directive were more likely to desire more treatment and were less likely to transition out the most aggressive class. Transition probabilities from class to class did not vary over time. Persons with cancer expressed preference for the least aggressive treatment, whereas persons with cardiovascular disease and depression had preferences for more aggressive treatment.

Conclusion

Transitions in end-of-life preferences and the factors influencing change and stability suggest that periodic reassessment for planning end-of-life care is needed.  相似文献   

4.
5.

Context

Quality of life (QoL) is increasingly recognized as an important outcome of cancer treatment. Previous studies have examined clinical predictors of QoL, but with the increasing prevalence of wearable sensors that monitor sleep and activity patterns, further investigation into whether these behaviors are predictive of post-treatment QoL is now feasible. Among patients receiving aggressive cancer treatment such as hematopoietic cell transplantation (HCT), analysis of circadian rhythms (24-hour patterns of sleep and activity) via wearable sensors is limited.

Objective

To evaluate the relationship between overall QoL and circadian rhythms in patients receiving allogeneic HCT.

Methods

Patients wore an ActiGraph GT3X (Pensacola, FL) activity monitor for at least 72 hours before the initiation of conditioning chemotherapy and transplantation and completed a QoL (Functional Assessment of Cancer Therapy-General [FACT-G]) assessment. QoL assessments were also completed 1, 3, and 6 months after HCT.

Results

Patients (n = 45, M age = 55) were mostly male (66%) with a total FACT-G score of 80.96 (SD = 16.05) before HCT. Mixed models revealed robust cross-sectional associations between overall QoL and multiple circadian rhythmicity parameters, including durations of high physical activity, overall circadian rhythmicity, and earlier starts of daily activity (P's < .01). Recovery of QoL after transplant was predicted by longer pre-transplant durations of high physical activity (P = .04) and earlier evening retirement (P = .04).

Conclusion

Our findings suggest that wearable sensor information is a promising method of predicting recovery of QoL after HCT. Additional studies are needed to confirm these findings in a larger sample.  相似文献   

6.

Context

The nursing home (NH) culture change (CC) movement, which emphasizes person-centered care, is particularly relevant to meeting the unique needs of residents near the end of life.

Objectives

We aimed to evaluate the NH-reported adoption of person-centered end-of-life culture change (EOL-CC) practices and identify NH characteristics associated with greater adoption.

Methods

We used NH and state policy data for 1358 NHs completing a nationally representative 2016/17 NH Culture Change Survey. An 18-point EOL-CC score was created by summarizing responses from six survey items related to practices for residents who were dying/had died. NHs were divided into quartiles reflecting their EOL-CC score, and multivariable ordered logistic regression was used to identify NH characteristics associated with having higher (quartile) scores.

Results

The mean EOL-CC score was 13.7 (SD = 3.0). Correlates of higher scores differed from those previously found for non-EOL-CC practices. Higher NH leadership scores and nonprofit status were consistently associated with higher EOL-CC scores. For example, a three-point leadership score increase was associated with higher odds of an NH performing in the top EOL-CC quartile (odds ratio [OR] = 2.0, 95% CI: 1.82–2.30), whereas for-profit status was associated with lower odds (OR = 0.7, 95% CI: 0.49–0.90). The availability of palliative care consults was associated with a greater likelihood of EOL-CC scores above the median (OR = 1.5, 95% CI: 1.10–1.93), but not in the top or bottom quartile.

Conclusion

NH-reported adoption of EOL-CC practices varies, and the presence of palliative care consults in NHs explains only some of this variation. Findings support the importance of evaluating EOL-CC practices separately from other culture change practices.  相似文献   

7.
8.

Background

Despite the evidence and available guidelines about endotracheal suction (ETS), a discrepancy between published guidelines and clinical practice persists. To date, ETS practice in the adult intensive care unit (ICU) population across New Zealand and Australia has not been described.

Objective

To describe ICU nurses' ETS practice in New Zealand and Australia including the triggers for performing endotracheal suction.

Methods

A single day, prospective observational, binational, multicentre point prevalence study in New Zealand and Australian ICUs. All adult patients admitted at 10:00 on the study day were included.

Main outcome measures

In addition to patient demographic data, we assessed triggers for ETS, suction canister pressures, use of preoxygenation, measures of oxygenation, and ETS at extubation.

Results

There were 682 patients in the ICUs on the study day, and 230 were included in the study. Three of 230 patients were excluded for missing data. A total of 1891 ETS events were performed on 227 patients during the study day, a mean of eight interventions per patient. The main triggers reported were audible (n = 385, 63%) and visible (n = 239, 39%) secretions. Less frequent triggers included following auscultation (n = 142, 23%), reduced oxygen saturations (n = 140, 22%), and ventilator waveforms (n = 53, 9%). Mean suction canister pressure was ?337 mmHg (standard deviation = 189), 67% of patients received preoxygenation (n = 413), and ETS at extubation was performed by 84% of nurses.

Conclusion

Some practices were inconsistent with international guidelines, in particular concerning patient assessment for ETS and suction canister pressure.  相似文献   

9.

Objective

To determine whether prehospital point-of-care lactate (pLA) is associated with mortality, admission, and duration of hospital stay.

Design

A retrospective clinical audit, where elevated lactate was defined as ≥2 mmol/L.

Setting

The ambulance service and primary referral hospital in the Australian Capital Territory from 1st July 2014 to 30th June 2015.

Participants

Adult patients (≥18 years) who had pLA measured and were transported to the primary referral hospital.

Main outcome measures

Mortality, admission, and duration of hospital stay.

Results

Two hundred fifty-three patients with a median pLA of 2.5 mmol/L (interquartile range [IQR]: 1.5–3.7) were analysed. Overall mortality was 8.3%; 68% were admitted to the hospital; 8.3% to the intensive care unit (ICU). pLA was non-significantly higher in those who died compared to survivors (3.5 [IQR: 2.75–5.85] vs 2.4 [1.5–3.6]; W = 1631.5; p = 0.053). pLA was higher for those admitted to the hospital (2.9 [1.9–3.9] vs 2.0 [1.4–3.1]; W = 5094.5, p = 0.001) and the ICU (3.2 [2.4–5.7] vs 2.4 [1.5–3.6]; W = 1578.5; p = 0.008). There was no relationship between pLA and duration of stay. Considered as a screening tool, at a cut-off of 2.5 mmol/L, pLA had a likelihood ratio+ of 1.61 for mortality and 1.44 for ICU admission; the odds ratio for mortality was 3.76 (95% confidence interval = 1.30, 13.89).

Conclusions

Elevated prehospital lactate was associated with significantly increased ICU and hospital admissions. There may be value in pLA as a screening tool.  相似文献   

10.

Objective

To decrease hospital expenses by administering oral acetaminophen rather than intravenous (IV) acetaminophen to women who undergo laparoscopic hysterectomy.

Design

A quality improvement project using a between-groups, pre-/postimplementation design for women undergoing total laparoscopic hysterectomy. Retrospective chart review was used to compare data of women who received intraoperative IV acetaminophen before implementation versus women who received oral acetaminophen after implementation. Pain scores and opioid consumption in morphine equivalents were recorded at four time points.

Setting/Local Problem

A 369-bed hospital in the southeastern United States, where, in 2016, nearly $260,000 was spent on perioperative IV acetaminophen for all operating room cases.

Participants

Women between the ages of 18 and 55 years scheduled to have total laparoscopic hysterectomy were included. Excluded were women with a history of chronic pain, opioid use, or liver pathology; women with a contraindication to nonsteroidal anti-inflammatory drugs; and women whose procedures were converted from laparoscopic to open.

Intervention/Measurements

Women were instructed to take oral acetaminophen the day before surgery in divided doses, with 1 g every 6 hours, for a total dose of 3 g. On the day of surgery, women received the final 1-g dose of oral acetaminophen.

Results

There were no significant differences between groups for pain scores or total opioids received before implementation (mean = 3.28, standard deviation = 2.05) compared with after implementation (mean = 3.65, standard deviation = 1.63; t [18] = –.043, p = .674). The preimplementation cost per individual was $30.03 for 1 g of IV acetaminophen, and the postimplementation cost was $0.36 for 2 500-mg oral acetaminophen tablets, a 98.8% relative cost decrease per woman.

Conclusion

Replacing IV acetaminophen with preemptive oral acetaminophen has the potential to save money without compromising care.  相似文献   

11.

Objective

To evaluate a personal computer (PC) gaming platform as a means of improving postural balance in stroke patients.

Participants

Stroke patients (N=54) were enrolled and randomly divided into experimental and control groups.

Design

The experimental group underwent 12 weeks of rehabilitation involving playing PC games with the proposed gaming platform, whereas the control group played PC games with a computer mouse in the standing position.

Interventions

The experimental PC gaming platform allowed trunk movements in 3 directions, including lateral, downward, or upward reaching.

Main Outcome Measures

Balance control was assessed before and after the intervention with the Midot Posture Scale Analyzer (a pressure platform) by measuring the center of pressure during quiet stance. The Berg Balance Scale, Fullerton Advanced Balance Scale, and timed Up and Go tests were used to evaluate functional balance.

Results

Analysis of covariance was used to assess how the PC games improve balance abilities. There were significant differences between the experimental and control groups in the results of sway kinematics and functional balance tests. The experimental group showed greater improvement than the control group.

Conclusion

This new gaming platform with adaptive PC games could be a useful therapy to stroke rehabilitation in patients with postural imbalance.  相似文献   

12.

Objective

To compare the Mobility Enhancement roBotic (MEBot) wheelchair’s capabilities with commercial electric-powered wheelchairs (EPWs) by performing a systematic usability evaluation.

Design

Usability in effectiveness, efficacy, and satisfaction was evaluated using quantitative measures. A semistructured interview was employed to gather feedback about the users’ interaction with MEBot.

Setting

Laboratory testing of EPW driving performance with 2 devices in a controlled setting simulating common EPW driving tasks.

Participants

A convenience sample of expert EPW users (N=12; 9 men, 3 women) with an average age of 54.7±10.9 years and 16.3± 8.1 years of EPW driving experience.

Interventions

Not applicable.

Main Outcome Measures

Powered mobility clinical driving assessment (PMCDA), Satisfaction Questionnaire, National Aeronautics and Space Administration’s Task Load Index.

Results

Participants were able to perform significantly higher number of tasks (P=.004), with significantly higher scores in both the adequacy-efficacy (P=.005) and the safety (P=.005) domains of the PMCDA while using MEBot over curbs and cross-slopes. However, participants reported significantly higher mental demand (P=.005) while using MEBot to navigate curbs and cross-slopes due to MEBot’s complexity to perform its mobility applications which increased user’s cognitive demands.

Conclusions

Overall, this usability evaluation demonstrated that MEBot is a promising EPW device to use indoors and outdoors with architectural barriers such as curbs and cross-slopes. Current design limitations were highlighted with recommendations for further improvement.  相似文献   

13.

Objective

Determine the relationship between functional status and degree of specific organ involvement, physical performance, and subjective well-being chronic graft-vs-host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation.

Design

Observational cohort.

Setting

Outpatient clinic.

Participants

Adult patients (N=121) with cGVHD with 634 assessments.

Interventions

Not applicable.

Main Outcome Measures

Karnofsky Performance Status (KPS). Skin, fascia/joints, lungs, upper and lower extremity range of motion, liver, eye, mucosal, and gastrointestinal involvement were measured using the National Institutes of Health GVHD scale. Physical performance was assessed with the 2-minute walk test (2MWT) and hand grip strength. Subjective measures were the Patient Health Questionnaire 9 (PHQ-9) and Lee Symptom Burden (LSB) scale.

Results

Myofascial (P<.001) and lung (P=.001) involvement, 2MWT (P<.001), LSB (P<.001), and PHQ-9 (P=.03) had the largest associations with KPS with liver (P=.05) and hand grip strength (P<.001) more modest associations with KPS.

Conclusions

Patients with cGVHD experience multifactorial impairment in function associated with potentially modifiable symptoms physiatrists have the expertise to address to enhance function. More research is needed to determine rehabilitation interventions to mitigate the impact of cGVHD on function.  相似文献   

14.

Objective

To examine the perceived value, benefits, drawbacks, and ideas for technology development and implementation of surface electromyography recordings in neurologic rehabilitation practice from clinical stakeholder perspectives.

Design

A qualitative, phenomenological study was conducted. In-depth, semistructured interviews and focus groups were completed. Sessions included questions about clinician perspectives and demonstrations of surface electromyography systems to garner perceptions of specific system features.

Setting

The study was conducted at hospital systems in a large metropolitan area.

Participants

Adult and pediatric physical therapists, occupational therapists, and physiatrists from inpatient, outpatient, and research settings (N=22) took part in the study.

Interventions

Not applicable.

Main Outcome Measures

Interviews and focus groups were audio-recorded, transcribed verbatim, then coded for analysis into themes.

Results

Four major themes emerged: (1) low-tech clinical practice and future directions for rehabilitation; (2) barriers to surface electromyography uptake and potential solutions; (3) benefits of surface electromyography for targeted populations; and (4) essential features of surface electromyography systems.

Conclusions

Surface electromyography systems were not routinely utilized for assessment or intervention following neurologic injury. Despite recognition of potential clinical benefits of surface electromyography use, clinicians identified limited time and resources as key barriers to implementation. Perspectives on design and surface electromyography system features indicated the need for streamlined, intuitive, and clinically effective applications. Further research is needed to determine feasibility and clinical relevance of surface electromyography in rehabilitation intervention.  相似文献   

15.

Objective

Determine agreement between self-reported dose and dose reflected in administrative records of outpatient physical, occupational, and speech therapies at 6 and 12 months after severe traumatic brain injury (TBI), for the purpose of examining accuracy and predictors of accuracy of self-reported health care utilization in this population.

Design

Secondary analysis of survey used in a larger study; participants were queried about therapy doses using a structured interview, either alone or assisted by relatives if they so chose, with responses compared to administrative records.

Setting

Rehabilitation center providing outpatient TBI therapies.

Participants

Sixty-five people with severe TBI living in the community provided 6-month data (N=65); 54 provided 12-month data.

Interventions

Not applicable.

Main Outcome Measures

Degree of agreement with administrative records of scheduled and billed therapy appointments, measured using intraclass correlation coefficients (ICCs), with linear regression used to predict accuracy from demographic variables and cognitive status.

Results

ICCs were in the moderate range at 6 months, but were more variable, with some in the poor range, at 12 months. Agreement was higher for scheduled than for billed (attended) appointments. Assisted and unassisted patients provided comparable agreement with records. No demographic factors were associated with accuracy, but lower cognitive FIM scores, as hypothesized, tended to predict lower agreement at 6 months.

Conclusions

People with severe TBI can provide reasonable estimates of commonly prescribed outpatient therapy doses at 6 months postinjury. Accuracy may be improved by inviting patients to request assistance from relatives and by asking them to consider attended (vs scheduled) sessions.  相似文献   

16.
17.

Purpose

A systematic review and meta-analysis was conducted to evaluate the effects of smartphone-based mobile learning for nurses and nursing students.

Methods

Electronic literature search of PubMed, Cochrane Library, Embase, SCOPUS, Web of Science, ProQuest Central, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Educational Resource Information Center (ERIC) was conducted. Two authors independently reviewed empirical studies for inclusion and extracted the design, sample size, intervention method, outcome variables, and statistical values of them. Methodological quality was assessed using Cochrane collaboration risk of bias tool. To estimate the effect size, meta-analysis was performed using R meta program.

Results

Authors identified 11 randomized or nonrandomized controlled trials of a total of 3,419 studies. Overall effect sizes by random-effects model was large [Hedges'g (g) = 1.12, 95% confidence interval (CI) 0.72–1.52], with learning attitude (g = 1.69), skills (g = 1.41), knowledge (g = 1.47), and confidence in performance (g = 1.54). For heterogeneity, subgroup analyses using meta-analysis of variance were performed, but no significant difference was found. Finally, a funnel plot and Egger's regression test along with trim-and-fill analysis and fail-safe N were conducted to check for publication bias, but no significant bias was detected.

Conclusion

Smartphone-based mobile learning had significantly positive influence on nursing students' knowledge, skills, confidence in performance, and learning attitude. Smartphone-based mobile learning may be an alternative or supportive method for better education in nursing fields.  相似文献   

18.

Objective(s)

Determine the associations between having participation-focused strategies and receiving rehabilitation services in the pediatric intensive care unit (PICU) with caregiver stress over 6 months post-PICU discharge.

Design

Substudy of a data from Wee-Cover, a prospective cohort study.

Setting

Two PICU sites.

Participants

Caregivers (N=168) of children 1-17 years old admitted into a PICU for ≥48 hours.

Main Outcome Measures

Data were collected from caregivers at enrollment and 3 and 6 months post-PICU discharge. Caregiver stress was assessed using the Pediatric Inventory for Parents. Having strategies to support their child’s participation in home-based activities was assessed using the Participation and Environment Measure (PEM). In PEM, caregivers report on strategies used to support their child’s participation in home-based activities. Data were dichotomized (yes, no) to denote having participation-focused strategies and if their child received PICU rehabilitation services. Additional covariates were history of a preexisting condition, child age, length of PICU stay, and change in functional capacities at PICU discharge.

Results

History of a preexisting condition, time, and change in functional capacities significantly predicted caregiver stress frequency and difficulty. The interaction of having strategies-by-rehabilitation-by-time significantly predicted caregiver stress frequency and difficulty.

Conclusion(s)

Results highlight the role of early rehabilitation and the importance of working with caregivers to develop participation-focused strategies to support their child’s functioning post-PICU. Families of children with a preexisting condition or those who experience a decrease in function during a PICU stay are susceptible to higher levels of stress and may be a priority population to target for rehabilitation services.  相似文献   

19.

Background

Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate.

Objectives

We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT).

Methods

Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded.

Results

There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000).

Conclusions

The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.  相似文献   

20.

Introduction

In this study, 68Ga-PDTMP was introduced as a novel agent for PET bone scanning.

Methods

68Ga-PDTMP was prepared with radiochemical purity of higher than 98% at the optimized conditions.

Results

Stability tests showed no decrease in radiochemical purity, even after 120 min. The capacity binding of 76.3% ± 0.7% after 10 min incubation for 68Ga-PDTMP was observed.

Conclusion

Biological studies in normal mice demonstrated that most of the remained activity is transmitted from blood into bones. The results show that 68Ga-PDTMP can be considered as a potential radiolabelled complex for PET bone scanning.  相似文献   

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