Development and Testing of the Pain Assessment Tool in Cognitively Impaired Elders (PATCIE): Nonverbal Pain Behaviors in African American and Caucasian Nursing Home Residents with Dementia.

BACKGROUND: People with dementia experience a decline in language skills required to self-report pain; researchers thus recommend the use of nonverbal behaviors to assess pain. Although multiple instruments exist for assessing nonverbal pain behaviors, psychometric data are lacking for African American nursing home residents with dementia. AIMS AND DESIGN: The purpose of this methodological study was to describe the development and testing of the Pain Assessment Tool in Cognitively Impaired Elders (PATCIE) in African American and Caucasian nursing home residents with dementia. SETTINGS/PARTICIPANTS: The convenience sample included 56 African American and 69 Caucasian residents with dementia in multiple nursing homes from three states. The research staff completed the pain assessments when the nursing home staff transferred the residents. RESULTS/CONCLUSIONS: Initially, 15 nonverbal pain behaviors were evaluated. Based on the alpha scores and additional literature review, the 15 nonverbal pain behaviors were expanded to 28 behaviors. The PATCIE had a Cronbach's alpha of .73 during movement. Construct validity for the pain behaviors was demonstrated because higher scores were noted during movement, and scores before movement were significantly higher than those obtained after movement. For movement over time, there was a significant difference in the PATCIE score, regardless of ethnicity or time (p < .0001). There were no significant differences found between ethnic groups, either overall or in change over time between movements or between the categories of cognitive function. African Americans were more likely to display frowning, and Caucasians to display irritability. The PATCIE demonstrates preliminary reliability and validity in assessing pain in African American and Caucasian nursing home residents with dementia.

A Multiple Behavior Self-Monitoring Intervention for African- American Veterans with Type 2 Diabetes: A Feasibility Implementation Study.

The purpose of this study was to determine the feasibility of implementing a multiple-behavior self-monitoring intervention within a diabetes education program. This study was a 3-month pre- post-design, conducted with African-Americans (N = 20), who attended diabetes education classes at a large Veteran's Affairs (VA) hospital in Southwest Texas. Participants selfmonitored their blood glucose, diet, exercise, and weight on either a smart phone application or paper diaries. Paired t tests showed strong evidence that patient self-monitoring of healthy lifestyle behaviors improved blood glucose (t = -3.858, p = .001) and HbAlc (t = -4.428, p <.001), respectively. Moreover Spearman's correlation coefficient showed significant correlations between blood glucose and exercise (rs = -.68, p = .008) and HbAlc and exercise (rs = -.56, p = .036). This feasibility study showed that multiple-behavior self-monitoring was effective in lowering blood glucose and HbA1c levels among African-American Veterans; however, a randomized controlled trial with a larger sample is needed to validate these preliminary findings.

Suicide Within 72 Hours After Discharge From Health Care Settings: Decedent Characteristics.

Health care providers have the challenge of identifying patients at risk of committing suicide after discharge from their care. The aim of this study was to identify and describe the population committing suicide less than 72 hours after discharge from medical care. Between 2006 and 2014 in Harris County, Texas, 30 individuals were identified who met these criteria. The decedents included 27 men and 3 women with a mean age of 43.5 years. The cause of death in most cases was gunshot wound of the head. Five of the decedents had requested discharge or left against medical advice and 24 committed suicide within 24 hours. Although the sample size is small, it is one of the largest cohorts of its type.

Influence of light source, polarization, education, and training on shade matching quality.

STATEMENT OF PROBLEM: Many factors influence the quality of shade selection, and isolating how significantly each of these factors influences results is difficult. PURPOSE: The purpose of this in vitro study was to compare results of shade matching using handheld lights with or without a polarizing filter with results obtained using a professional viewing booth and to analyze the influence of education and training on shade selection outcome. MATERIAL AND METHODS: A total of 96 third-year dental students (evaluators) were randomly separated into 4 groups. Each group was assigned 1 of 2 handheld shade-matching devices (lights) with or without a polarizing filter. Each group performed a shade matching exercise using the handheld light or a professional viewing booth. The exercise consisted of matching shade tabs placed in a typodont to a commercial shade guide. Each group repeated this procedure 4 times over a 9-week period. A lecture on shade matching was presented at the fifth week of the study, between "before" and "after" shade matching procedures. RESULTS: Shade matching scores with handheld lights (7.8) were higher than scores of shade matching with the viewing booth (7.2). The mean scores for before (7.2) and after (7.8) shade matching (with education and training in between) were significantly different. The combined effect of light and education and training improved the shade matching score by 1.2, from 6.8 in the before sessions using the viewing booth to 8.0 in the after sessions using handheld lights. A 21% increase in the number of evaluators who selected 1 of 4 best matches was recorded, 10% for handheld lights versus viewing booth after education and training versus before sessions and 11% between after sessions using handheld lights versus before sessions using viewing booth. CONCLUSIONS: Within the limits of the study, the shade matching scores with handheld lights were significantly better than the results obtained using a viewing booth (P<.01). Using a handheld light with or without a polarizing filter did not influence shade matching results. Mean shade matching scores were significantly better after education and training (P<.01). Light combined with education and training resulted in the greatest increase in shade matching quality.

Evaluation of a calcium silicate-based cement as a root reinforcement material for endodontically treated maxillary anterior teeth.

STATEMENT OF PROBLEM: Fractures of endodontically treated teeth have been attributed to weakened tooth structure caused by root canal enlargement and post preparation. PURPOSE: The purpose of this in vitro study was to evaluate the fracture resistance of roots filled with either gutta percha, composite resin (LuxaCore Dual), or calcium silicate-based cement (Biodentine). MATERIAL AND METHODS: One hundred twenty freshly extracted, human, permanent maxillary anterior teeth were sorted by type and assigned to 1 of 4 groups (n=30). The teeth in group NT were not endodontically treated and served as the control. The teeth in groups GP, LC, and, BD were accessed and instrumented to size 40/06. In group GP, the root canals were completely filled with gutta percha. In groups LC and BD, only the apical 5-mm portion of the root canals was filled with gutta percha, and the remaining portion of the root canals was filled with (LuxaCore Dual) in group LC and with (Biodentine) in group BD. Fracture resistance (kN) was assessed at the middle portion of each root, using a 3-point bending test with a universal testing machine exerting a compressive load on a loading pin at a crosshead speed of 0.5 mm/min until fracture occurred. One-way ANOVA was used to compare the mean root fracture resistance among the 4 groups (α=.05). RESULTS: The mean ± SD fracture loads were 2.13 ±0.53 kN for group NT, 1.97 ±0.60 kN for group GP, 2.18 ±0.71 kN for group LC, and 2.22 ±0.54 kN for group BD. No statistically significant differences were found among the 4 groups (P>.05). CONCLUSIONS: The roots of endodontically treated maxillary anterior permanent incisors filled with gutta percha, Biodentine, or LuxaCore Dual had resistance to fracture similar to that of teeth that were not endodontically treated.

Utilizing online tools to increase volunteer ombudsmen presence in long-term care.

In this descriptive study, former and current volunteer ombudsmen (n = 65) completed an online survey and Chi-square analyses were used to determine group differences in order to examine the impact of internet-based communication on the recruitment and retention of volunteer long-term care ombudsmen. The results showed that the program's shift to internet-based recruitment and communication methods helped increase the number of volunteers by 50% and contributed to a positive shift in role perception and satisfaction. Consequently, the proliferation of internet and social media usage permits greater volunteer management opportunities than previously were available. These tools also allow for consistency of message, extended training opportunities, and recourse to resources at need which permit ombudsmen volunteers to identify more readily with the role of resident advocate and receive greater performance satisfaction as it relates to that role.

Comparison Study of Braden Scale and Time-to-Erythema Measures in Long-term Care.

PURPOSE: The Braden Scale for Predicting Pressure Sore Risk is used to assess risk, and the Centers for Medicare & Medicaid guidelines suggest the use of a tissue tolerance procedure that detects time-to-erythema (TTE) to further refine tissue tolerance, a component of the Braden Scale. The aim of this study was to compare the Braden Scale and TTE as risk classification methods and their utility in identifying care planning interventions. DESIGN: Descriptive study using retrospective chart review. SUBJECTS AND SETTING: Participants were a convenience sample of 89 adults 65 years or older residing in a long-term care facility in the Midwestern United States. The sample was drawn from a facility-generated list of 90 residents who had both Braden Scale and tissue tolerance testing performed within 24 hours of admission from any setting, readmission after a hospital stay, or performed as part of a routine annual reassessment. METHODS: Results of staff performance on the Braden Scale and TTE were compared as risk classification methods and based on their utility for identifying care planning interventions. Data were collected during 1 session when TTE and the Braden Scale were completed. Agreement between the 5 risk categories from the Braden Scale and 5 TTE risk categories was analyzed via the kappa statistic and Kendall tau-c statistic. Spearman or Pearson correlation coefficients were calculated as appropriate for ordinal and continuous risk, intervention, and severity measures. RESULTS: The mean Braden Scale score was 17.5 ± 3 (mean ± SD); the mean TTE-Bed was 2.35 ± 0.57 hours and the mean TTE-Chair was 2.18 ± 0.52. Using a Braden Scale score of 18 or less as a cut point for identifying clinically relevant risk for pressure ulcer development, 55 participants were deemed at risk, 62 had mobility subscale scores less than 4, 76 had activity subscale scores less than 4, and 73 were incontinent. The weighted kappa statistic demonstrated weak agreement between TTE-Bed and the Braden Scale Total Score (κ = 0.04; 95% CI: 0.002-0.07). Agreement was not significant for TTE-Chair and the Braden Scale Total Score (κ = 0.01; 95% CI: -0.01 to 0.04), TTE-Bed and Braden Scale-Mobility (κ = 0.09; 95% CI: -0.05 to 0.23) and between TTE-Chair and Braden Scale-Activity (κ = 0.07; 95% CI: -0.05 to 0.19). The TTE-Chair and TTE-Bed assessment demonstrated fair agreement (κ = 0.37; 95% CI: 0.19-0.55). The Braden Scale cumulative score where a lower score equates to higher risk was found to be correlated with the total number of interventions observed in the care plan (r = -0.62; P < .0001). Correlation between the Braden Scale-Mobility subscale score and in-bed mobility specific interventions was r = -0.64 (P < .0001), whereas correlation for TTE-Bed category and specific in-bed mobility interventions was r = 0.21 (P = .05). CONCLUSION: Study findings provide little support for tissue tolerance testing versus assessment using the validated Braden Scale for assessment of pressure ulcer risk. Study findings support the use of the Braden Scale to develop an individualized care plan based on the areas of risk.

Using a single screening question for depressive symptoms in patients with acute coronary syndrome.

BACKGROUND: Despite the prevalence of depressive symptoms and increased risk for future cardiovascular events, depressive symptoms frequently go underrecognized in patients hospitalized for acute coronary syndrome (ACS). Identifying an effective approach to depressive symptom screening is imperative in this population. OBJECTIVE: The purpose of this cross-sectional study was to explore the agreement between Beck Depression Inventory-II (BDI-II) scores and a single screening question for depressive symptoms in 1122 patients hospitalized for ACS. METHODS: Independent-samples t tests and χ tests were used to compare the groups with BDI-II scores of 14 or higher and lower than 14. Three separate agreement analyses were conducted using categorized BDI-II scores (≥14, ≥20, and ≥29). Agreement of the BDI-II categories with the responses to the single screening question was assessed with the simple κ statistic. Sensitivity and specificity were calculated using the BDI-II categories as the criterion standards for depressive symptom screening. RESULTS: The agreement analysis revealed a moderate level of agreement (κ coefficient = 0.42) between the BDI-II scores of 14 or higher and the single screening question. Of the participants who reported a BDI-II score of 14 or higher, 61.65% answered yes to the single screening question (sensitivity, 0.62). For those who had BDI-II scores of lower than 14, a total of 82% responded no to the single screening question (specificity, 0.82). When using higher BDI-II scores to define depressive symptoms (≥20 and ≥29), the level of agreement decreased, whereas sensitivity increased to 0.76 and 0.90, with a trade-off in specificity (0.79 and 0.74, respectively). CONCLUSIONS: These results suggest that the single screening question for depressive symptoms correctly identifies depressive symptoms 62% of the time but inappropriately identifies depressive symptoms 18% of the time in patients hospitalized for ACS. This suggests that the single screening question for depressive symptoms may be used with caution to initially screen patients with ACS, who can then undergo a more thorough assessment for clinical depression.

Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation.

PURPOSE: To identify the incidence of adverse events (AE) that occurred in stroke survivors during the first year following discharge from inpatient rehabilitation and to determine the type and patterns of AE. METHODS: Data were collected for 12 months on events resulting in admissions to the emergency department, hospital, long-term care facility, or death. Descriptive statistics were used to depict the patterns of AE and univariate comparisons were made of the differences between survivors who did or did not experience one or more AE. RESULTS: Of the 159 participants, 50% reported a total of 163 AE. Most AE (82.2%) were unexpected and the majority occurred during the first 6 months; 12 recurrent strokes and 6 transient ischemic attacks occcurred. CONCLUSIONS: Education on prevention and treatment of common AE is important prior to discharge. Anticipatory guidance may help survivors and caregivers modify their lifestyle and prevent common AE.

Linguistic analysis to assess the effect of a mindfulness intervention on self-change for adults in substance use recovery.

Substance use is a pervasive health problem. Therapeutic community (TC) is an established substance abuse treatment but TC environments are stressful and dropout rates are high. Mindfulness-based TC (MBTC) intervention was developed to address TC stress and support self-change that could impact treatment retention. Self-change was assessed through feeling and thinking word-use in written stories of stress from 140 TC residents in a historical control group and 253 TC residents in a MBTC intervention group. Data were collected 5 times over a 9-month period. Linguistic analysis showed no differences between the groups over time; however, over all time points, the MBTC intervention group used fewer negative emotion words than the TC control group. Also, negative emotion (P < .01) and anxiety (P < .01) word-use decreased whereas positive emotion word-use increased (P < .05) over time in both groups. Descriptive data from linguistic analyses indicated that sustained self-change demands participation in mindfulness behaviors beyond the instructor-guided MBTC intervention.

Practices and outcomes: pressure ulcer management in nursing facilities.

INTRODUCTION: The objective of this study was to compare reported pressure ulcer prevention and treatment practices in nursing facilities with high prevalence of pressure ulcers versus nursing facilities with low prevalence of pressure ulcers. METHODS: A 26-item survey on implementation of nationally accepted standards for pressure ulcer prevention and treatment was mailed to directors of nursing in all 68 nursing facilities in an urban county. RESULTS: There were no statistically significant differences on reported pressure ulcer prevention interventions based on pressure ulcer prevalence. When treating pressure ulcers, respondents of facilities with high prevalence of pressure ulcers reported more frequent pain assessments, more frequent use of low air-loss beds, and daily wound assessments. DISCUSSION: The study failed to support the hypothesis that nursing facilities with low prevalence of pressure ulcers report using more guideline-recommended pressure ulcer prevention and treatment interventions than facilities with high prevalence of pressure ulcers. Reported adherence to recommended interventions for repositioning and pressure relief measures, moisture management, and attention to nutrition exceeded 60% in all facilities. CONCLUSION: The disparity between reported interventions and pressure ulcer prevalence rates offers an opportunity for future collaborative quality improvement projects, research, and the need for leadership to develop systems of care to ensure the use of pressure ulcer prevention guidelines.

The Effects of Meditation, Race, and Anxiety on Stroke Survivor Resilience.

BACKGROUND: Significant gaps exist in the identification and management of psychological effects of stroke on survivors. Interventions to enhance resilience, the ability to rebound from stress or adversity, could positively impact stroke recovery. The purpose of this study was to test the effect of meditation on resilience of community-dwelling stroke survivors and to identify resilience predictor variables in these survivors. METHODS: This was a substudy with secondary analysis of existing data from the parent study, MEditatioN for post stroke Depression. The effect of meditation on stroke survivor resilience in the intervention group (n = 20) was evaluated with a paired samples t test, with measures at baseline and immediately after the 4-week intervention. Baseline resilience predictor variables for all stroke survivors (n = 35) were evaluated with univariable analysis and multiple linear regression modeling. RESULTS: The increase in stroke survivor resilience scores from baseline (mean [SD], 3.46 [0.81]) to intervention completion (mean [SD], 3.58 [1.02]) was not statistically significant (t = 0.60, df = 19, P = .56). One-way analysis of variance with Tukey post hoc analysis revealed that baseline resilience was significantly lower (P = .02) for non-Hispanic black participants than for non-Hispanic white participants. Multiple linear regression with resilience as the dependent variable, race as a fixed factor, and trait anxiety as a covariate was significant (F3,33 = 6.32, P = .002) and accounted for nearly 33% of the variance in baseline resilience. CONCLUSION: The effects of meditation on stroke survivor resilience should be tested in larger clinical trials that would explore the influence of social determinants of health, perceived stress, race-related stress, and anxiety subtypes on resilience.

Caregiver Burden and Associated Factors Among Informal Caregivers of Stroke Survivors.

BACKGROUND: Informal caregiving of stroke survivors often begins with intensity compared with the linear caregiving trajectories in progressive conditions. Informal caregivers of stroke survivors are often inadequately prepared for their caregiving role, which can have detrimental effects on their well-being. A greater depth of understanding about caregiving burden is needed to identify caregivers in most need of intervention. The purpose of this study was to examine caregiver burden and associated factors among a cohort of informal caregivers of stroke survivors. METHODS: A cross-sectional study of 88 informal caregivers of stroke survivors was completed. Caregiver burden was determined with the Zarit Burden Interview, caregiver depressive symptoms were measured with the Patient Health Questionnaire-9, and stroke survivor functional disability was assessed with the Barthel Index. Ordinal logistic regression was used to identify independent factors associated with caregiver burden. RESULTS: Forty-three informal caregivers (49%) reported minimal or no caregiver burden, 30 (34%) reported mild to moderate caregiver burden, and 15 (17%) reported moderate to severe caregiver burden. Stroke survivor functional disability was associated with informal caregiver burden (P = .0387). The odds of having mild to moderate caregiver burden were 3.7 times higher for informal caregivers of stroke survivors with moderate to severe functional disability than for caregivers of stroke survivors with no functional disability. The presence of caregiver depressive symptoms was highly correlated with caregiver burden (P < .001). CONCLUSION: Caregivers of stroke survivors with functional disabilities and caregivers experiencing depressive symptoms may have severer caregiver burden. Trials of interventions aimed at decreasing informal caregiver burden should consider the potential impact of stroke survivors' functional disability and the presence of depressive symptoms.

Substance abuser impulsivity decreases with a nine-month stay in a therapeutic community.

BACKGROUND: Substance abuse continues to be a major public health problem. Keeping substance abusers in treatment is a challenge, and researchers continue to investigate ways to increase retention. OBJECTIVE: The aim of this study was to investigate the relationship between impulsivity in substance abusers and length of stay in the context of therapeutic community. METHODS: The Barratt Impulsiveness Scale- 11 (BIS-11) was used to assess impulsivity in 138 substance abusers at admission and at nine months in a therapeutic community. RESULTS: Impulsivity significantly decreased in subjects who completed nine months in the therapeutic community. Legal stipulation increased length of stay, on average, by three months. On admission, female participants were on average more impulsive than their male counterparts. CONCLUSION: Impulsivity decreased in subjects who remained in therapeutic community for nine months although self-reported impulsivity at baseline did not seem to be associated with retention. SCIENTIFIC SIGNIFICANCE: Therapeutic community factors contribute to a decrease in self-reported impulsivity and these factors might be enhanced to increase retention in therapeutic community.

Mindfulness-based stress reduction in therapeutic community treatment: a stage 1 trial.

OBJECTIVE: This trial compared Mindfulness-Based Stress Reduction, adapted for therapeutic community treatment (MBTC), with treatment as usual (TAU) for reducing stress and increasing retention in a residential facility for substance use disorders. METHOD: Four-hundred and fifty-nine participants, who met DSM-IV criteria for substance dependence were recruited (TAU = 164, MBTC = 295). RESULTS: A survival analysis of time to dropout did not show a significant difference between groups, however level of participation in MBTC was associated with decreased likelihood of dropout (p = < .01), and higher Symptoms of Stress Inventory (SOSI) scores at baseline were associated with increased likelihood of dropout (p = .03). CONCLUSION: The association between retention and level of stress on intake as well as level of participation in MBTC provides support for further research on integrating MBTC into therapeutic community treatment.

Randomization for clinical research: an easy-to-use spreadsheet method.

In this article, we illustrate a new method for random selection and random assignment that we developed in a pilot study for a randomized clinical trial. The randomization database is supported by a commonly available spreadsheet. Formulas were written for randomizing participants and for creating a "shadow" system to verify integrity of the randomization. Advantages of this method are that it is easy to use, effective, and portable, allowing it to be shared among multiple investigators at multiple study sites. Clinical researchers may find the method useful for research projects that are pilot studies or conducted with limited funding.

Predictors of resuming therapy within four weeks after discharge from inpatient rehabilitation.

PURPOSE: To identify the percentage of persons with stroke resuming therapy within 4 weeks of inpatient rehabilitation discharge, to compare the characteristics of those who did and did not resume therapy, and to determine the predictors of resuming physical (PT), occupational (OT), and speech (ST) therapy. METHOD: Sociodemographic, stroke-related, and therapy data for persons with stroke (N = 131) were abstracted from inpatient rehabilitation charts. FIM, Stroke Impact Scale, Geriatric Depression Scale, and data on therapy received after discharge were also collected. RESULTS: Logistic regression models demonstrated that minorities were less likely to resume PT (odds ratio [OR] = 0.30) and OT (OR = 0.25). Survivors with neglect/visual-field cut/spatial-perceptual loss were 2-3 times more likely to resume PT, OT, and ST. Survivors with higher scores on the SIS Physical domain subscale were less likely to resume PT (OR = 0.98) and OT (OR = 0.97). Men were 3.3 times more likely to have OT than women. Those with comprehensive health insurance were 11.2 times more likely to receive ST. CONCLUSIONS: The benefits of outpatient therapy are not universally available to all persons with stroke. Further research needs to explore the factors that hinder the prompt resumption of therapy for minority and female persons with stroke and to test appropriate interventions.

Stress experienced by stroke survivors and spousal caregivers during the first year after discharge from inpatient rehabilitation.

PURPOSE: This study describes levels of stress in stroke survivors and spousal caregivers and identifies predictors of stress in couples during their first year at home. METHOD: The Perceived Stress Scale (PSS) was administered to 159 stroke survivors and caregivers at discharge and at 3, 6, 9, and 12 months. Other variables tested included stroke survivor function (FIM), health status, mutuality, stroke impact (SIS), caregiver coping (F-COPES), support (MOS Social Support Survey), and preparedness. Repeated measures analyses of PSS scores were conducted with linear mixed models for stroke survivors and caregivers. RESULTS: PSS scores for stroke survivors and caregivers were positively correlated (p<.01). Scores decreased significantly over the year, but caregivers had higher scores initially and decreased less. Stroke survivor function was a significant predictor of stress for both survivors and caregivers. Preparation was the most powerful predictor of stress in caregivers, whereas mutuality was the strongest predictor for stroke survivors. Good health, social support, and coping were associated with less stress. CONCLUSIONS: Stress is increased by poor function and mediated by internal and external buffers including health, the dyadic relationship, coping ability, and social support. More research using a dyadic research approach is needed to better understand stress within couples.