Predialysis Kidney Function and Its Rate of Decline Predict Mortality and Hospitalizations After Starting Dialysis

Objective

To determine whether kidney function level and its rate of decline in the immediate predialysis period among veterans transitioning to end-stage renal disease (ESRD) predict postdialysis mortality and hospitalization.

Functional Status Is Associated With 30-Day Potentially Preventable Hospital Readmissions After Inpatient Rehabilitation Among Aged Medicare Fee-for-Service Beneficiaries

ObjectivesTo determine the association between patients' functional status at discharge from inpatient rehabilitation and 30-day potentially preventable hospital readmissions. A secondary objective was to examine the conditions resulting in these potentially preventable readmissions.DesignRetrospective cohort study.SettingInpatient rehabilitation facilities submitting claims to Medicare.ParticipantsNational cohort (N=371,846) of inpatient rehabilitation discharges among aged Medicare fee-for-service beneficiaries in 2013 to 2014. The average age was 79.1±7.6 years. Most were women (59.7%) and white (84.5%).InterventionsNot applicable.Main Outcome Measures(1) Observed rates and adjusted odds of 30-day potentially preventable hospital readmissions after inpatient rehabilitation and (2) primary diagnoses for readmissions.ResultsThe overall rate of any 30-day hospital readmission after inpatient rehabilitation was 12.4% (n=46,265), and the overall rate of potentially preventable readmissions was 5.0% (n=18,477). Functional independence was associated with lower observed rates and adjusted odds ratios for potentially preventable readmissions. Observed rates for the highest versus lowest quartiles within each functional domain were as follows: self-care: 3.4% (95% confidence interval [CI], 3.3–3.5) versus 6.9% (95% CI, 6.7–7.1), mobility: 3.3% (95% CI, 3.2–3.4) versus 7.2% (95% CI, 7.0–7.4), and cognition: 3.5% (95% CI, 3.4–3.6) versus 6.2% (95% CI, 6.0–6.4), respectively. Similarly, adjusted odds ratios were as follows: self-care: .70 (95% CI, .67–.74), mobility: .64 (95% CI, .61–.68), and cognition: .84 (95% CI, .80–.89). Infection-related conditions (44.1%) were the most common readmission diagnoses followed by inadequate management of chronic conditions (31.2%) and inadequate management of other unplanned events (24.7%).ConclusionsFunctional status at discharge from inpatient rehabilitation was associated with 30-day potentially preventable readmissions in our sample of aged Medicare beneficiaries. This information may help identify at-risk patients. Future research is needed to determine whether follow-up programs focused on improving functional independence will reduce readmission rates.     

Elective Percutaneous Coronary Intervention in Ambulatory Surgery Centers

ObjectivesThe aim of this study was to explore characteristics and outcomes of patients undergoing elective percutaneous coronary intervention (PCI) in ambulatory surgery centers (ASCs).BackgroundLittle is known about patients who underwent ASC PCI before Medicare reimbursement was instituted in 2020.MethodsUsing commercial insurance claims from MarketScan, adults who underwent hospital outpatient department (HOPD) or ASC PCI for stable ischemic heart disease from 2007 to 2016 were studied. Propensity score analysis was used to measure the association between treatment setting and the primary composite outcome of 30-day myocardial infarction, bleeding complications, and hospital admission.ResultsThe unmatched sample consisted of 95,492 HOPD and 849 ASC PCIs. Patients who underwent ASC PCI were more likely to be younger than 65 years, to live in the southern United States, and to have managed or consumer-driven health insurance. ASC PCI was also associated with decreased fractional flow reserve utilization (odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.20 to 0.48; p < 0.001). In unmatched, multivariate analysis, ASC PCI was associated with increased odds of the primary outcome (OR: 1.25; 95% CI: 1.01 to 1.56; p = 0.039) and bleeding complications (OR: 1.80; 95% CI: 1.11 to 2.90; p = 0.016). In propensity-matched analysis, ASC PCI was not associated with the primary outcome (OR: 1.23; 95% CI: 0.94 to 1.60; p = 0.124) but was significantly associated with increased bleeding complications (OR: 2.49; 95% CI: 1.25 to 4.95; p = 0.009).ConclusionsCommercially insured patients undergoing ASC PCI were less likely to undergo fractional flow reserve testing and had higher odds of bleeding complications than HOPD-treated patients. Further study is warranted as Medicare ASC PCI volume increases.     

Palliative dilation of esophageal carcinoma

The authors' experience with palliative dilation of 46 consecutive patients evaluated for squamous cell carcinoma of the esophagus was retrospectively reviewed. Thirty-nine of 46 patients (85%) underwent dilation in order to palliate symptoms, enable endoscopy and biopsy, or prepare for placement of an esophageal prosthesis. Thirty-two of the 46 patients (70%) were treated with radiation therapy and seven (15%) underwent placement of an esophageal prosthesis. Thirty-five of the 39 patients dilated (90%) noted improvement in swallowing, allowing resumption of a soft or regular diet. Complications were noted in three of the 39 patients dilated (8%). The authors conclude that peroral dilation is a safe, effective, and probably underutilized method of palliation in patients with squamous cell esophageal carcinoma.     

压力性损伤居家老年患者医院-社区-家庭三元联动护理实践

总结压力性损伤居家老年患者医院-社区-家庭三元联动护理实践经验。护理要点包括：明确医院及社区职责,成立医院-社区联动护理合作团队,加强组织管理;加强社区医护人员培训,提高伤口管理能力;制订压力性损伤居家老年患者评估记录单,提高社区医护人员伤口评估能力;及时会诊,指导社区医护人员进行伤口管理;建立医院-社区双向转诊,实施分级治疗;加强多学科协作,促进伤口愈合;开展延续性居家护理,提高患者及其照护者配合治疗、护理的依从性。经医院-社区-家庭三元联动护理,30例压力性损伤居家老年患者中,治愈26例,好转4例,治愈率达86.67%。     

移动卒中单元救治流程的优化及应用效果

目的 探讨优化移动卒中单元（mobile utroke unit,MSU）救治流程对急性缺血性脑卒中患者的效果。 方法 回顾性分析该院2020年1月—6月MSU出车接诊的30例急性缺血性脑卒中静脉溶栓患者,其中MSU救治流程优化后静脉溶栓的18例患者为试验组,MSU运行初期、流程优化前实施静脉溶栓的12例患者为对照组。收集两组的临床资料,比较两组的护理效率及临床结局。结果 试验组的卒中专科护士首次静脉穿刺成功例数、发病至静脉溶栓时间、呼叫120至静脉溶栓时间、MSU到达现场至静脉溶栓时间均优于对照组,差异具有统计学意义（P<0.05）。两组发病至呼叫120时间、呼叫120至MSU到达现场时间、静脉溶栓24 h内症状性颅内出血例数、静脉溶栓后90 d改良Rankin量表评分≤2分的例数比较,差异无统计学意义（P>0.05）。结论 通过优化救治流程可有效缩短患者发病至静脉溶栓时间、呼叫120至静脉溶栓时间及MSU到达现场至静脉溶栓时间,提高护士工作效率,提升患者救治质量。     

Pre-hospital transfusion of post-traumatic hemorrhage: Medical and regulatory aspects

Data of good methodological quality have recently become available to support prehospital use of transfusion in the severe trauma setting. Consistent with recent guidelines for the implementation of damage control resuscitation in the hospital in this setting and in the wake of numerous cohort study data from wartime medicine, they are now guided by recent guidelines for the use of freeze-dried plasma. The main difficulties to overcome in order to implement a practice are of a regulatory and logistic nature.     

徒手旋转在头位难产产妇助产护理中的应用

目的:观察并分析在头位难产助产护理中对产妇应用徒手旋转的效果。方法:选取本院产科收治的84例头位难产产妇为研究对象,按入院顺序将其分为对照组(42例,常规助产护理)与观察组(42例,徒手旋转助产护理)。评价两组的助产护理效果。结果:观察组产妇自然分娩率及新生儿Apgar评分显著高于对照组,第二产程时间、产后出血量以及新生儿不良反应发生率则明显低于对照组,数据差异明显,P<0.05。结论:徒手旋转的助产护理方式可缩短头位难产产妇的产程时间,降低剖宫产率及新生儿并发症发生率,确保分娩的顺利进行。