The effect of discharge planning on length of stay and readmission rates of older adults in acute hospitals: A systematic review and meta-analysis of systematic reviews.

AIM: To examine the effectiveness of discharge planning on length of stay and readmission rates among older adults in acute hospitals. BACKGROUND: Discharge planning takes place in all acute hospital settings in many forms. However, it is unclear how it contributes to reducing patient length of stay in hospital and readmission rates. METHODS: Seven systematic reviews were identified and examined. All of the systematic reviews explored the impact of discharge planning on length of stay and readmission rates. RESULTS: A limited meta-analysis of the results in relation to length of stay indicates positive finding for discharge planning as an intervention (MD = -0.71(95% CI -1.05,-0.37; p = .0001)). However, further analysis of the broader findings in relation to length of stay indicates inconclusive or mixed results. In relation to readmission rates both meta-analysis and narrative analysis point to a reduced risk for older people where discharge planning has taken place (RR = 0.78 (95% CI: 0.72, 0.84; p = .00001)). The ability to synthesize results however is severely hampered by the diversity of approaches to research in this area. IMPLICATIONS FOR NURSING MANAGEMENT: It is unclear what impact discharge planning has on length of stay of older people. Indeed, while nurse mangers will be interested in gauging this impact on throughput and patient flow, it is questionable if length of stay is the correct outcome to measure when studying discharge planning as good discharge planning may increase length of stay. Readmission rates may be a more appropriate outcome measure but standardization of approach needs to be considered in this regard. This would assist nurse managers in assessing the impact of discharge planning processes.

CONTINUOUS REPOPULATION OF LYMPHOCYTE SUBSETS IN TRANSPLANTED MYCOBACTERIAL GRANULOMAS.

Granulomas are the interface between host and mycobacteria, and are crucial for the surivival of both species. While macrophages are the main cellular component of these lesions, different lymphocyte subpopulations within the lesions also play important roles. Lymphocytes are continuously recruited into these inflammatory lesions via local vessels to replace cells that are either dying or leaving; however, their rate of replacement is not known. Using a model of granuloma transplantation and fluorescently labeled cellular compartments we report that, depending on the subpopulation, 10-80%, of cells in the granuloma are replaced within one week after transplantation. CD4(+) T cells specific for Mycobacterium antigen entered transplanted granulomas at a higher frequency than Foxp3(+) CD4(+) T cells by one week. Interestingly, a small number of T lymphocytes migrated out of the granuloma to secondary lymphoid organs. The mechanisms that define the differences in recruitment and efflux behind each subpopulation requires further studies. Ultimately, a better understanding of lymphoid traffic may provide new ways to modulate, regulate, and treat granulomatous diseases.

Patient anxiety and IV sedation in Northern Ireland.

BACKGROUND: In recent years there has been an increase in the provision of conscious sedation, which is said to be a safe and effective means of managing the anxious patient. However, there are no guidelines to aid the dental practitioner in assessing the patient's need for sedation based on their level of anxiety. AIMS AND METHODS: The present study investigated the importance of patient anxiety as an indicator for IV sedation, using focus groups to inform the development of narrative vignettes. Ninety-nine practitioners responded to a series of scenarios to determine whether the level of patient anxiety and the patient's demand for IV sedation influenced their decision making. RESULTS: Level of dental anxiety had a stronger influence on the clinician's decision making than patient demand, with increasing levels of dental anxiety being positively associated with the likelihood of clinicians indicating a need for IV patient sedation and also, the likelihood of clinicians providing IV sedation to these patients. Only 14% (n = 14) of respondents reported formally assessing dental anxiety. CONCLUSIONS: While dental anxiety is considered to be a key factor in determining the need for IV sedation, there is a lack of guidance regarding the assessment of anxiety among patients.

Broadband Mie scattering from optically levitated aerosol droplets using a white LED.

We describe a simple and efficient means of using a white LED source to illuminate an optically levitated aerosol droplet to enable study of broadband Mie scattering. The backscattered resonances are imaged through a spectrograph and CCD which show high resolution Mie scattering intensity distributions across a spectral range of 480 to 700 nm. The wide spectral range allows assignment of resonance mode numbers and mode orders using conventional Mie theory calculations. Accurate droplet sizing, within +/- 2 nm, is possible for water-based droplets with radii between 2 microm and 8 microm. We additionally demonstrate that the refractive index dispersion can be determined from a single refractive index value at known wavelength. Finally, morphological droplet dynamics are presented showing non-linear droplet evaporation behaviour at a temporal resolution of 100 milliseconds.

Subjective and objective performance of the Lenstec KH-3500 "accommodative" intraocular lens.

AIM: To determine whether eyes implanted with the Lenstec KH-3500 "accommodative" intraocular lenses (IOLs) have improved subjective and objective focusing performance compared to a standard monofocal IOLs. METHODS: 28 participants were implanted monocularly with a KH-3500 "accommodative" IOL and 20 controls with a Softec1 IOL. Outcome measures of refraction, visual acuity, subjective amplitude of accommodation, objective accommodative stimulus response curve, aberrometry, and Scheimpflug imaging were taken at approximately 3 weeks and repeated after 6 months. RESULTS: Best corrected acuity with the KH-3500 was 0.06 (SD 0.13) logMAR at distance and 0.58 (0.20) logMAR at near. Accommodation was 0.39 (0.53) D measured objectively and 3.1 (1.6) D subjectively. Higher order aberrations were 0.87 (0.85) microm and lower order were 0.24 (0.39) microm. Posterior subcapsular light scatter was 0.95% (1.37%) greater than IOL clarity. In comparison, all control group measures were similar except objective (0.17 (0.13) D; p = 0.032) and subjective (2.0 (0.9) D; p = 0.009) amplitude of accommodation. Six months following surgery, posterior subcapsular scatter had increased (p<0.01) in the KH-3500 implanted subjects and near word acuity had decreased (p<0.05). CONCLUSIONS: The objective accommodating effects of the KH-3500 IOL appear to be limited, although the subjective and objective accommodative range is significantly increased compared to control subjects implanted with conventional IOLs. However, this "accommodative" ability of the lens appears to have decreased by 6 months post-surgery.

The influence of lower face vertical proportion on facial attractiveness.

This study investigated the influence of changing lower face vertical proportion on the attractiveness ratings scored by lay people.Ninety-two social science students rated the attractiveness of a series of silhouettes with normal, reduced or increased lower face proportions. The random sequences of 10 images included an image with the Eastman normal lower face height relative to total face height [lower anterior face height/total anterior face height (LAFH/TAFH) of 55 per cent], and images with LAFH/TAFH increased or decreased by up to four standard deviations (SD) from the Eastman norm. All the images had a skeletal Class I antero-posterior (AP) relationship. A duplicate image in each sequence assessed repeatability. The participants scored each image using a 10 point numerical scale and also indicated whether they would seek treatment if the image was their own profile. The profile image with normal vertical facial proportions was rated by the lay people as the most attractive. Attractiveness scores reduced as the vertical facial proportions diverged from the normal value. Images with a reduced lower face proportion were rated as significantly more attractive than the corresponding images with an increased lower face proportion. Images with a reduced lower face proportion were also significantly less likely to be judged as needing treatment than the corresponding images with an increased lower face proportion.

Evaluation of the measurement of refractive error by the PowerRefractor: a remote, continuous and binocular measurement system of oculomotor function.

BACKGROUND/AIM: The technique of photoretinoscopy is unique in being able to measure the dynamics of the oculomotor system (ocular accommodation, vergence, and pupil size) remotely (working distance typically 1 metre) and objectively in both eyes simultaneously. The aim of this study was to evaluate clinically the measurement of refractive error by a recent commercial photoretinoscopic device, the PowerRefractor (PlusOptiX, Germany). METHOD: The validity and repeatability of the PowerRefractor was compared to: subjective (non-cycloplegic) refraction on 100 adult subjects (mean age 23.8 (SD 5.7) years) and objective autorefraction (Shin-Nippon SRW-5000, Japan) on 150 subjects (20.1 (4.2) years). Repeatability was assessed by examining the differences between autorefractor readings taken from each eye and by re-measuring the objective prescription of 100 eyes at a subsequent session. RESULTS: On average the PowerRefractor prescription was not significantly different from the subjective refraction, although quite variable (difference +0.05 (0.63) D, p=0.41) and more negative than the SRW-5000 prescription (by -0.20 (0.72) D, p<0.001). There was no significant bias in the accuracy of the instrument with regard to the type or magnitude of refractive error. The PowerRefractor was found to be repeatable over the prescription range of -8.75D to +4.00D (mean spherical equivalent) examined. CONCLUSION: The PowerRefractor is a useful objective screening instrument and because of its remote and rapid measurement of both eyes simultaneously is able to assess the oculomotor response in a variety of unrestricted viewing conditions and patient types.

Continuous measurement of accommodation in human factor applications.

It has long been sought to measure ocular accommodation continuously in human factor applications such as driving or flying. Open-field autorefractors such as the Canon R-1 could be converted to allow continuous, objective recording, but steady eye fixation and head immobilisation were essential for the measurements to be valid. Image analysis techniques utilised by newer open-view autorefractors such as the Shin-Nippon SRW-5000 are more tolerant to head and eye movements, but perhaps the technique with the greatest potential for the measurement of accommodation in human factor applications is photoretinoscopy. This paper examines the development of techniques for high temporal measurements of accommodation and reports on the tolerance of one such recent commercial instrument, the PowerRefractor (PlusOptiX). The instrument was found to be tolerant to eye movements from the optical axis of the instrument (approximately 0.50 DS change in apparent accommodation with gaze 25 degrees eccentric to the optical axis), longitudinal head movement (<0.25 DS from 8 cm towards and 20 cm away from the correct photorefractor to eye distance) and changes in background illuminance (<0.25 DS from 0.5 to 20 cd m(-2) target luminance). The PowerRefractor also quantifies the direction of gaze and pupil size, but is unable to take measurements with small pupils <3.7 +/- 1.0 mm.

The psychosocial impact of orthognathic surgery: a systematic review.

The aim of this study was to review the reported psychosocial benefits of orthognathic surgery. A systematic review of the literature was conducted using MEDLINE (1966 to December 2000), Web of Science (1981 to December 2000), and reference sections of identified articles. We also hand searched key orthodontic, oral surgery, and psychology journals. No language limitations were imposed. Randomized controlled trials, other controlled clinical trials, prospective studies (with or without controls), and retrospective studies (with or without controls) were considered for inclusion. Two reviewers extracted the data and independently assessed the quality of the studies. In all, 29 studies, including a number of prospective and retrospective studies, were identified as relevant. The results of the review indicated that orthognathic patients experience psychosocial benefits as a result of orthognathic surgery, including improved self-confidence, body and facial image, and social adjustment. However, there were wide variations in the study designs and a lack of uniformity in measuring the psychosocial constructs. This made it difficult to quantify the extent and the duration of the psychosocial benefits.

Professional perceptions of the benefits of orthodontic treatment.

The aim of this study was to assess general dental practitioners' and orthodontists' perceptions of the benefits of orthodontic treatment. A specially designed questionnaire was sent to a random sample of 150 general dental practitioners (GDPs) and all orthodontists in Northern Ireland (excluding hospital practitioners) with a postgraduate qualification (n = 29). There was a 93 per cent response rate by the general dental practitioners and all but one specialist practitioner returned the questionnaire. The questionnaire comprised 14 visual analogue scales (VAS) whereby participants were asked to rate the importance of various possible dental health and psychosocial benefits of orthodontic treatment. In addition to the VAS, the influence of dentist variables such as number of years since qualification, orthodontic cases completed, referral rates and attendance at postgraduate lectures were examined. When ratings on the 14 dental health and psychosocial scales were examined overall, GDPs rated an improvement in self-esteem while orthodontists considered an improvement in physical attractiveness as the most important benefit of orthodontic treatment. Even though psychosocial variables received the highest ratings, examination of the mean ratings (and 95 per cent confidence intervals) revealed that some dental health factors were also rated highly by both groups. While the results do indicate an encouraging awareness of the psychosocial benefits of orthodontic treatment, they also suggest that both GDPs and orthodontists have an unrealistic expectation of the dental health gain likely to result from orthodontic treatment.

Effect of Plant Age on Resistance of Alfalfa to Meloidogyne hapla.

Meloidogyne hapla-resistant plants grown from cuttings and inoculated with M. hapla larvae were free of galls. However, 35 to 48% of the seedling intercross progeny of resistant genotypes that were inoculated in the germinated seed stage were galled. There was an inverse relationship between the age of plants grown from seed and the percentage of plants galled by M. hapla; the older the plants at inoculation, the greater the percentage of gall-free plants. The per cent of galled plants was significantly reduced when galled roots were removed and plants reinoculated. Reproduction of M. hapla on galled progeny of resistant plants was significantly less than that on susceptible plants. There were no differences in nematode reproduction on galled progeny of resistant plants, regardless of age at time of inoculation. An in,ease in inoculum levels from 100 to 10,000 M. hapla larvae did not affect resistance or susceptility. There was a direct correlation between galling of inoculated seedlings of resistant progeny and temperature; inoculated 8-week-old cuttings of resistant plants were galled only at 32 C.