Profiling the multidimensional needs of new nursing home residents: evidence to support planning

IntroductionNursing home (NH) residents have various needs that affect the care they require. This article describes the diverse needs that new NH residents have, emphasizing the proportion of people with milder needs in multiple areas.MethodsResearch was conducted on all older adults newly admitted to not-for-profit NHs in the Winnipeg Health Region, between April 1, 2005, and March 31, 2007, provided that they were assessed using the Resident Assessment Instrument Minimum Data Set (RAI/MDS 2.0) within 30 days of admission (n = 1061). Using the Activities of Daily Living (ADL) Hierarchy scale, residents were first defined as low, intermediate, or high ADL dependent. Residents' needs were also defined using the RAI/MDS 2.0 cognitive performance (CPS) and pain scales, by their degree of behavioral problems and visual challenges, and by their frequency of bladder and bowel incontinence. Cluster analysis was used to create subgroups of residents by their severity of clinical challenges.ResultsOf our cohort, 26.8% were low ADL dependent. Although some of these residents had moderate to severe needs in another area, many (46.8% of low ADL-dependent residents; 12.5% of our entire cohort) had milder needs across all clinical domains. Conversely, about one-third of our cohort was high ADL dependent; 31.7% of these residents had moderate to severe challenges in one clinical domain, and 35.5% had moderate to severe comorbid challenges.ConclusionsOverall, 12.5% of our cohort had lower needs, demonstrating the capacity for community-based programs to offset NH demands. Also, the diversity of residents' needs highlights the importance of having both the appropriate resources and strategies available to provide quality NH care. Future research is discussed for both low- and higher-need NH residents.     

A novel biomarker in the diagnosis of parapneumonic effusion: neutrophil gelatinase-associated lipocalin

Background

The protein neutrophil gelatinase-associated lipocalin (NGAL) is a mediator synthesized and released by neutrophils. Its physiological function is as yet unclear. Levels in blood increase in several inflammatory diseases. High serum values indicate poor prognosis for several diseases. Pleural effusion may appear as the result of various pathologies. The most common cause is heart failure (HF). Other common causes include parapneumonic (PPE) and malignant (MPE) pleural effusions, and pulmonary embolism. Tubercular effusion (TE) is commonly encountered in Turkey and similar developing countries. The purpose of this study was to investigate the effectiveness of NGAL, a current inflammation marker, in discriminating between different etiological diseases that cause pleural effusion.

Methods

The study was performed at the Recep Tayyip Erdo?an University Faculty of Medicine Chest Diseases Clinic. One hundred patients were included in the study, 25 with parapneumonic effusion, 25 with heart failure-related effusion, 25 with tubercular effusion and 25 with cancer-related effusion. NGAL was measured in patients’ serum and pleural fluids.

Results

Serum NGAL levels in PPE (171?±?56 ng/ml) were significantly higher (p?<?0.001) than those in HF (86?±?31 ng/ml), CA (103?±?42 ng/ml) and TE (63?±?19 ng/ml). Pleural NGAL levels were also significantly higher in PPE compared to HF, MPE and TE (p?<?0.001). Serum NGAL levels exhibited a positive correlation with white blood cell (WBC), neutrophil, C-reactive protein (CRP), sedimentation, serum LDH, creatinine, pleural leukocyte and pleural neutrophil numbers. The most significant correlation was between NGAL level and WBC (p?<?0.001, r?=?0.579). Both serum and pleural NGAL levels are highly effective in differentiating patients with PPE from those without PPE (AUC: 0.910 and 0.790, respectively).

Conclusions

NGAL can be used in the diagnosis of diseases with an acute inflammatory course. Serum and pleural NGAL levels can differentiate PPE from other diseases causing pleural fluid with high sensitivity and specificity.

     

Prognosis of patients with mild–moderate coronary artery stenosis detected by coronary computed tomography angiography

Background

In addition to the diagnostic performance, coronary computed tomography angiography (CTA) can give important data regarding the prognosis of coronary artery disease (CAD). In this study we aimed to evaluate the prognostic role of coronary CTA in patients with suspected CAD and mild–moderate coronary stenosis.

Methods

A total of 1115 patients (602 male, 54%; age 58.4 ± 11.4) without previous CAD were enrolled. Patients underwent coronary CTA imaging using dual-source 64-slice CT scanner. For categorization of the coronary atherosclerotic plaques (CAP), the coronary system was divided into 16 separate segments. For each segment, CAPs were categorized as: calcified, noncalcified and mixed.

Results

During follow-up of 29.7 ± 13.2 months, cardiovascular events defined as ST segment elevation myocardial infarction (4 patients), non-ST segment elevation myocardial infarction (5 patients) and unstable angina pectoris (20 patients) requiring revascularization or hospital admission were recorded. Cox hazard regression analysis revealed an association between the severity of luminal stenosis (HR: 4.73, 95% CI: 1.36–16.47, p < 0.05) and extent (HR: 1.10, 95% CI: 1.00–1.22, p = 0.051) and the adverse coronary events in the follow-up. Multivariate Cox hazard regression analysis revealed that nonobstructive (≤ 50%) lesions were the only factor causing increased probability of coronary events in the follow-up (HR: 4.77, 95% CI: 1.36–16.74, p < 0.05).

Conclusion

The presence and severity of luminal stenosis shown by coronary CTA were associated with prognosis of coronary events in the follow-up. These results may improve the risk stratification in patients evaluated by coronary CTA and provide strategies for the individualized prevention programs.     

Effectiveness of school-based and high-risk human papillomavirus vaccination programs against cervical dysplasia in Manitoba,Canada

The effectiveness of a vaccination program is influenced by its design and implementation details and by the target population characteristics. Using routinely collected population-based individual-level data, we assessed the effectiveness (against cervical dysplasia) of Manitoba's quadrivalent human papillomavirus (qHPV) routine school-based vaccination program and a short-lived campaign that targeted women at high-risk of developing cervical cancer. Females ≥9 years old who received the qHPV vaccine in Manitoba (Canada) between September 1, 2006, and March 31, 2013 (N = 31,442) were matched on age and area of residence to up to three unvaccinated females. Cox proportional hazards models were used to estimate qHPV VE against high-grade (HSILs) and low-grade squamous intraepithelial lesions (LSILs) and atypical squamous cells of undetermined significance (ASCUS). Among 14–17-year-old participants who had Pap cytology after enrollment, the adjusted qHPV VE estimates were 30% (17–58%) and 36% (21–48%) against the detection of HSILs and LSILs, respectively. There was, however, no evidence of program effectiveness among females vaccinated at ≥18 years of age and among those with a history of abnormal cytology, who were mostly vaccinated as part of the high-risk program. Estimates of VE for females vaccinated in the school-based program are consistent with the expected benefits from qHPV vaccination. No similar benefits were detected among women vaccinated at an older age, and those with abnormal cytology, who were targeted by the high-risk program. Further efforts should be targeted at achieving higher vaccine coverage among preadolescents, prior to the initiation of sexual activity.     

Omalizumab treatment in asthma-COPD overlap syndrome

Introduction: Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) is a poorly understood disease with an increasing morbidity and mortality. Currently, the most effective treatment for ACOS is unknown and omalizumab for ACOS has not yet been reported. Methods: We report our experience with anti-IgE, omalizumab treatment on 3 patients with ACOS as a retrospective case study. Results: After 1 year of omalizumab treatment, patients experienced significantly lower rates of asthma exacerbation and hospitalization and better asthma control test results. Conclusion: Our study shows that omalizumab may be an effective and safe therapy for patients with ACOS. However larger randomized trials are needed.     

The impact of CYP2C9 and VKORC1 genetic polymorphism and patient characteristics upon warfarin dose requirements in an adult Turkish population

In this study, we investigated the contribution of vitamin K epoxide reductase (VKORC1) and cytochrome P450 2C9 (CYP2C9) genotypes, age, and body surface area (BSA) on warfarin dose requirements and in an adult Turkish population. Blood samples were collected from 100 Turkish patients with stable warfarin dose requirements and an international normalized ratio (INR) of the prothrombin time within the therapeutic range. Genetic analyses for CYP2C9 genotypes (*2 and *3 alleles) and VKORC1 −1639 G>A polymorphism were performed and venous INR determined. The mean warfarin daily dose requirement was higher in CYP2C9 homozygous wild-type patients, compared to those with the variant *3 allele (P < 0.05), similar to those with the variant *2 allele (P > 0.05) and highest in patients with the VKORC1 −1639 GG genotype compared to those with the GA genotype and the AA genotype (P < 0.01). The time to therapeutic INR was longer in CYP2C9 homozygous wild-type patients compared with those with the variant *2 and *3 alleles (P < 0.01), and longer in patients with the VKORC1 (position −1639) GG genotype compared with those with the GA genotype and the AA genotype (P < 0.01). The multivariate regression model including the variables of age (R ² = 4.4%), BSA (R ² = 27.4%), CYP2C9 (R ² = 8.1%), and VKORC1 genotype (R ² = 34.1%) produced the best model for estimating warfarin dose (R ² = 60.4%). VKORC1 genotype and CYP2C9 polymorphism affect daily dose requirements and time to therapeutic INR in Turkish patients receiving warfarin for anticoagulation.     

Effect of cataract surgery in patients with neovascular age-related macular degeneration: further evidence from disciform scars

Purpose

To evaluate the effect of cataract surgery on disease activation and visual outcomes in neovascular age-related macular degeneration (AMD).

Methods

In this retrospective case–control study, study arm consisted of neovascular AMD patients, who underwent phacoemulsification surgery. Patients did not have any disease activation at least 6 months before the inclusion, and all had at least 12-month follow-up thereafter. Control group consisted of phakic patients, who did not undergo eye surgery during the study period. Primary outcomes were the presence of the disease activation and the change in best-corrected visual acuity (BCVA).

Results

A total of 114 neovascular AMD patients [55 (48%) in exudative group and 59 (52%) in disciform group] were included. Preoperative logMAR BCVA was significantly improved after cataract surgery [0.8 (0.6–1.0) vs. 0.4 (0.4–0.7), P < 0.001 in exudative AMD; 1.85 (1.1–1.9) vs. 1.09 (0.8–1.9), P = 0.001 in disciform scar], but this improvement was not maintained during the study period in patients with both exudative AMD and disciform scar [0.6 (0.3–1.1), P = 0.313 in exudative AMD; 1.30 (1–1.9), P = 0.03 in disciform scar]. The incidence of disease activation was not statistically significant between surgery and control groups in patients with exudative AMD [5 (25%) patients in surgery group and 8 (22%) patients in the control group, P = 0.886, Cox proportional hazards regression analysis]. In disciform scar, disease activation was observed in 4 (17%) patients in the surgery group; however, no patient in the control group had disease activation (P = 0.009, HRs could not be estimated, 95% CI 0.001–43.49, Cox proportional hazards regression analysis).

Conclusion

Cataract surgery has benefit on early postoperative visual improvement in patients with neovascular AMD. The incidence of disease activation was not affected after surgery in exudative AMD.

     

A rare cause of cerebral venous thrombosis: cryptococcal meningoencephalitis

Cryptococcal meningoencephalitis (CM) is a serious central nervous system infection caused by Cryptococcus neoformans, seen mostly in immunocompromised hosts and less in immunocompetent patients. The vast majority of cryptococcosis cases are seen as human immunodeficiency virus infections with advanced immunosuppression. Meningitis and meningoencephalitis are the most common clinical manifestations. Nevertheless, immunocompetent patients with CM are rarely reported. Cerebral venous sinus thrombosis is a rare complication of CM. Here, we report an immunocompetent patient with CM from a non-endemic area, who presented with an acute onset and atypical symptoms associated with cerebral venous thrombosis.