Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study

Background

As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction.

Methods

This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010–2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups.

Results

VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01–2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22–2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11–0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55–1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation.

Conclusions

The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.

     

Tumors of DNA mismatch repair-deficient hosts exhibit dramatic increases in genomic instability

DNA mismatch repair (MMR) deficiency is associated with an increased mutational burden and predisposition to certain malignancies. Relatively little is known, however, about gene-specific mutation frequencies within MMR-deficient primary tumors. Thymic lymphomas from Msh2^−/− mice were thus analyzed by using a lacI-based transgenic shuttle-phage mutation detection system. All tumors exhibited greatly elevated lacI gene mutation frequencies, ranging from 3.2- to 17.4-fold above the ≈15-fold elevations present within normal Msh2^−/− thymi. In addition, lacI genes harboring multiple changes, including clusters of mutations, were found in thymic tumor DNA. The results suggest that an additional mutator activity, such as an error-prone DNA polymerase, leads to increased genomic instability in these MMR-deficient tumors.     

Is eating home-prepared food a necessary condition for high dietary quality? Cross-sectional analysis of the UK National Diet and Nutrition Survey, 2008–16

Background

Despite inconclusive evidence, the idea that home food preparation and skills are a limiting factor in achieving a healthy diet is widespread, and corresponding skills interventions and dietary guidelines proliferate. The aim of this study was to determine whether eating home-prepared (HP) food is a necessary condition for high dietary quality by exploring whether individuals can eat healthily while consuming little HP food.

Evidence-Based Practice in physiotherapy: a systematic review of barriers,enablers and interventions

Background

Despite clear benefits of the Evidence-Based Practice (EBP) approach to ensuring quality and consistency of care, its uptake within physiotherapy has been inconsistent.

Objectives

Synthesise the findings of research into EBP barriers, facilitators and interventions in physiotherapy and identify methods of enhancing adoption and implementation.

Data sources

Literature concerning physiotherapists’ practice between 2000 and 2012 was systematically searched using: Academic Search Complete, Cumulative Index of Nursing and Allied Health Literature Plus, American Psychological Association databases, Medline, Journal Storage, and Science Direct. Reference lists were searched to identify additional studies.

Study selection

Thirty-two studies, focusing either on physiotherapists’ EBP knowledge, attitudes or implementation, or EBP interventions in physiotherapy were included.

Data extraction and synthesis

One author undertook all data extraction and a second author reviewed to ensure consistency and rigour. Synthesis was organised around the themes of EBP barriers/enablers, attitudes, knowledge/skills, use and interventions.

Results

Many physiotherapists hold positive attitudes towards EBP. However, this does not necessarily translate into consistent, high-quality EBP. Many barriers to EBP implementation are apparent, including: lack of time and skills, and misperceptions of EBP.

Limitations

Only studies published in the English language, in peer-reviewed journals were included, thereby introducing possible publication bias. Furthermore, narrative synthesis may be subject to greater confirmation bias.

Conclusion and implications

There is no “one-size fits all” approach to enhancing EBP implementation; assessing organisational culture prior to designing interventions is crucial. Although some interventions appear promising, further research is required to explore the most effective methods of supporting physiotherapists’ adoption of EBP.     

Adjuvanticity of stearyl tyrosine on inactivated poliovirus vaccine

Preliminary studies of some of the properties of stearyl tyrosine have shown that it is non-toxic, free of adverse reactions at the sites of injection, non-pyrogenic, stable upon storage and easy to sterilize. Formalin inactivated poliovirus vaccine (IPV) adjuvanted with stearyl tyrosine hydrochloride induced significantly higher titres of antibodies in non-human primates, after two injections, than the non-adjuvanted vaccine. Furthermore, the adjuvanted vaccine, even when diluted 1:4, showed consistently higher antibody titres as well as a longer persistence of antibodies than the non-adjuvanted undiluted vaccine. These studies suggest that stearyl tyrosine is an excellent and cost effective adjuvant for IPV. Hence further investigation with this novel synthetic compound would be worthwhile to ascertain its adjuvanticity for IPV in human subjects.     

An exploratory investigation of schema modes in social anxiety disorder: Empirical findings and case conceptualization

Background

Current “gold standard” treatments for social anxiety disorder (SAD) are limited by the limited emphasis of key etiological factors in conceptualization, and many individuals with SAD experience residual symptoms posttreatment. Hence, the novel application of the Schema Therapy Mode Model may provide a helpful framework for extending clinical understanding and treatment options for SAD. This exploratory study aimed to investigate the presence and pattern of schema modes among SAD individuals.

Method

Forty individuals with SAD completed questionnaire measures of symptomatology, social anxiety-relevant cognitions, schema modes, childhood trauma, and parental style.

Results

Key maladaptive schema modes identified in SAD were Vulnerable Child, Punitive Critic, Demanding Critic, Compliant Surrender, and Detached Self-Soother.

Conclusion

Outcomes provide the basis for a proposed schema mode case conceptualization for SAD and are hoped to provide a rationale for testing the applicability of Schema Therapy as a novel treatment for SAD. Key limitations are discussed.