Potentially inappropriate prescriptions for poly-treated patients in long-term care facilities: retrospective pharmacoutilization analysis.

BACKGROUND This study aimed to investigate, among elderly patients in long-term care (LTC) facilities, potentially inappropriate drug prescriptions, potentially interactions and verify whether they can be traced back to hospitalisations or accesses to the Emergency Department (ED). The study data were acquired by means of a case report form investigating the medication management process in LTCs. MATERIAL AND METHODS Analysis of pharmacutilisation in LTCFs patients aged ≥65 years on polypharmacy or excessive polypharmacy, January-July 2023. Data was extracted from a database (DB) containing the monthly prescriptions of medicines supplied by direct distribution (DD) to LTCs. The prevalence of PIMs was evaluated by applying the Beers and STOPP criteria to the medication profile of each patient. RESULTS The overall prevalence of polypharmacy and hyperpolypharmacy was 83% and 17%, respectively. PIMs were defined using Beers and STOPP criteria. The most frequent PIMs were proton pump inhibitors (19% e 15%), antiplatelets agent (17% e 13%) and non-associated sulfonamides (14% e 12%). Of the 1,921 PIMs, 121 were contraindicated or very serious (6%) and 1,800 were major (94%).The most common medicaments involved in drug-drug interaction are furosemide (21%), sertraline (19%), pantoprazole (16%) e trazodone (15%). LTCs participating in the study (56%) excluded polypharmacy as a cause of access to the ED and ADRs. Therefore no case was ever reported (100%). CONCLUSIONS Polypharmacy or excessive polypharmacy among elderly patients may increase PIMs and ADRs. A constant review of the therapeutic regimens and deprescribing decrease inappropriate use of medications and interactions, ADRs, and accesses to the ED with consequent reduction of pharmaceutical spending.

Association Between Changes in Postoperative Opioid Utilization and Long-Term Health Care Spending Among Surgical Patients With Chronic Opioid Utilization.

BACKGROUND: There is growing interest in identifying and developing interventions aimed at reducing the risk of increased, long-term opioid use among surgical patients. While understanding how these interventions impact health care spending has important policy implications and may facilitate the widespread adoption of these interventions, the extent to which they may impact health care spending among surgical patients who utilize opioids chronically is unknown. METHODS: This study was a retrospective analysis of administrative health care claims data for privately insured patients. We identified 53,847 patients undergoing 1 of 10 procedures between January 1, 2004, and September 30, 2018 (total knee arthroplasty, total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery, transurethral resection of the prostate, or simple mastectomy) who had chronic opioid utilization (≥10 prescriptions or ≥120-day supply in the year before surgery). Patients were classified into 3 groups based on differences in opioid utilization, measured in average daily oral morphine milligram equivalents (MMEs), between the first postoperative year and the year before surgery: "stable" (<20% change), "increasing" (≥20% increase), or "decreasing" (≥20% decrease). We then examined the association between these 3 groups and health care spending during the first postoperative year, using a multivariable regression to adjust for observable confounders, such as patient demographics, medical comorbidities, and preoperative health care utilization. RESULTS: The average age of the sample was 62.0 (standard deviation [SD] 13.1) years, and there were 35,715 (66.3%) women. Based on the change in average daily MME between the first postoperative year and the year before surgery, 16,961 (31.5%) patients were classified as "stable," 15,463 (28.7%) were classified as "increasing," and 21,423 (39.8%) patients were classified as "decreasing." After adjusting for potential confounders, "increasing" patients had higher health care spending ($37,437) than "stable" patients ($31,061), a difference that was statistically significant ($6377; 95% confidence interval [CI], $5669-$7084; P < .001), while "decreasing" patients had lower health care spending ($29,990), a difference (-$1070) that was also statistically significant (95% CI, -$1679 to -$462; P = .001). These results were generally consistent across an array of subgroup and sensitivity analyses. CONCLUSIONS: Among patients with chronic opioid utilization before surgery, subsequent increases in opioid utilization during the first postoperative year were associated with increased health care spending during that timeframe, while subsequent decreases in opioid utilization were associated with decreased health care spending.

Wound Care Consultation in Postacute/Long-term Care: Characteristics and Practice Implications.

OBJECTIVE: To study the characteristics of residents in postacute (PA)/long-term care (LTC) facilities with wounds and prevalence of wound types other than pressure injuries (PIs). METHODS: The authors conducted a retrospective review of all wound care consultations over 1 year at The New Jewish Home, a 514-bed academically affiliated facility in an urban setting. Investigators analyzed residents by age, sex, type of wound, presence of infection, and whether the resident was PA or LTC. Authors designated PIs as facility acquired or present on admission. RESULTS: During the study period, 190 wound care consultations were requested; 74.7% of consults were for those in PA care. The average patient age was 76.3 years, and there were 1.7 wounds per resident receiving consultation. Of studied wounds, 53.2% were PIs, 15.8% surgical, 6.8% arterial, 6.3% soft tissue injury, 5.8% venous, 2.6% malignant wounds, and 2.1% diabetic ulcers; however, 11.6% of residents receiving consults had more than one wound type. In this sample, 13.2% of residents had infected wounds, and 76.2% of PIs were present on admission. CONCLUSIONS: The wide variety of wounds in this sample reflects the medical complexity of this population. The transformation of LTC into a PA environment has altered the epidemiology of chronic wounds and increased demand for wound care expertise. These results challenge traditional perceptions of wound care centered on PIs. Given its importance, a wound care skill set should be required of all PA/LTC providers.

Improvement in the long-term care burden after surgical treatment of patients with idiopathic normal pressure hydrocephalus: a supplementary study.

Idiopathic normal pressure hydrocephalus (iNPH) is a surgically treatable syndrome commonly observed in older adults. However, it is unclear whether clinical improvements after surgery can effectively reduce the long-term care burden (LTCB). In this study, we determined whether shunt surgery was effective in decreasing LTCB. We also investigated the degree of variability in patients and hospitals, using data from the iNPH multicenter study. This study involved 69 participants who underwent lumboperitoneal shunt surgery with follow-up for 12 months. A generalized linear mixed model was applied to analyze the fixed and random effects simultaneously. Regarding LTCB, the disability grades improved significantly. Although the dementia grades also improved, it was not statistically significant. The differences in the LTCB grades in most patients were within the range of the 95% confidence intervals, while in the case of hospitals, some were often out of the range. Further studies are needed to improve dementia in patients with iNPH. The incorporation of random variables, such as hospitals, is important for the analysis of data from multicenter studies.

Disability-free survival after major cardiac surgery: a population-based retrospective cohort study.

BACKGROUND: Cardiovascular research has traditionally been dedicated to "tombstone" outcomes, with little attention dedicated to the patient's perspective. We evaluated disability-free survival as a patient-defined outcome after cardiac surgery. METHODS: We conducted a retrospective cohort study of patients aged 40 years and older who underwent coronary artery bypass grafting (CABG) or single or multiple valve (aortic, mitral, tricuspid) surgery in Ontario between Oct. 1, 2008, and Dec. 31, 2016. The primary outcome was disability (a composite of stroke, 3 or more nonelective hospital admissions and admission to a long-term care facility) within 1 year after surgery. We assessed the procedure-specific risk of disability using cumulative incidence functions, and the relative effect of covariates on the subdistribution hazard using Fine and Gray models. RESULTS: The study included 72 824 patients. The 1-year incidence of disability and death was 2431 (4.6%) and 1839 (3.5%) for CABG, 677 (6.5%) and 539 (5.2%) for single valve, 118 (9.0%) and 140 (10.7%) for multiple valve, 718 (9.0%) and 730 (9.2%) for CABG and single valve, and 87 (13.1%) and 94 (14.1%) for CABG and multiple valve surgery, respectively. With CABG as the reference group, the adjusted hazard ratios for disability were 1.34 (95% confidence interval [CI] 1.21-1.48) after single valve, 1.43 (95% CI 1.18-1.75) after multiple valve, 1.38 (95% CI 1.26-1.51) after CABG and single valve, and 1.78 (95% CI 1.43-2.23) after CABG and multiple valve surgery. Combined CABG and multiple valve surgery, heart failure, creatinine 180 µmol/L or greater, alcohol use disorder, dementia and depression were independent risk factors for disability. INTERPRETATION: The cumulative incidence of disability was lowest after CABG and highest after combined CABG and multiple valve surgery. Our findings point to a need for models that predict personalized disability risk to enable better patient-centred care.

[Changes in trends of diseases requiring long-term care in an aging community].

Objectives　The purpose of this study was to identify the changes in trends of leading diseases that require long-term care within a 5-year period in an area with a rapidly growing aging population.Methods　Data were obtained from newly registered primary insured individuals for long-term care insurance in Sapporo Minami Ward. There were 2,538 participants in FY2018 and 4,089 in FY2013 and FY2014.　Disorders diagnosed by a primary doctor were categorized into groups using a long-term care questionnaire survey from the Comprehensive Survey of Living Conditions. The difference in the frequency of diseases between the survey years was examined using a chi-square test.Results　In men, there was no significant change in the frequency of diseases that require long-term care within the 5-year period. In women, the frequency of cerebrovascular diseases significantly reduced (7.8% for FY2013 and 2014 vs. 5.6% for FY2018; P=0.008) and fractures and falls significantly increased (9.5% vs. 13.8%; P=0.001).　Regarding the diseases in the severe-level category of long-term care insurance, malignancy was the most frequent disorder in men, followed by stroke. In women, the frequency of fractures and falls increased (10.5% vs. 17.7%; P=0.002) and subsequently became the most frequently occurring disorder. Similarly, the frequency of fractures and falls increased significantly (9.2% vs. 12.5%; P=0.004) in the mild-level long-term care insurance category.Conclusion　For women, fractures and falls increased within the 5-year period, indicating the need to introduce a prompt preventive program. Lifestyle-related diseases such as malignancy and cerebrovascular diseases have become the main reason for shortening a healthy lifespan. This finding highlights the importance of preventing lifestyle-related diseases.

Clinical characteristics and predictors of mortality associated with COVID-19 in elderly patients from a long-term care facility.

Since December 2019, coronavirus disease 2019 (COVID-19) pandemic has spread from China all over the world and many COVID-19 outbreaks have been reported in long-term care facilities (LCTF). However, data on clinical characteristics and prognostic factors in such settings are scarce. We conducted a retrospective, observational cohort study to assess clinical characteristics and baseline predictors of mortality of COVID-19 patients hospitalized after an outbreak of SARS-CoV-2 infection in a LTCF. A total of 50 patients were included. Mean age was 80 years (SD, 12 years), and 24/50 (57.1%) patients were males. The overall in-hospital mortality rate was 32%. At Cox regression analysis, significant predictors of in-hospital mortality were: hypernatremia (HR 9.12), lymphocyte count < 1000 cells/µL (HR 7.45), cardiovascular diseases other than hypertension (HR 6.41), and higher levels of serum interleukin-6 (IL-6, pg/mL) (HR 1.005). Our study shows a high in-hospital mortality rate in a cohort of elderly patients with COVID-19 and hypernatremia, lymphopenia, CVD other than hypertension, and higher IL-6 serum levels were identified as independent predictors of in-hospital mortality. Given the small population size as major limitation of our study, further investigations are necessary to better understand and confirm our findings in elderly patients.

Not All Discharge Settings Are Created Equal: Thirty-Day Readmission Risk after Elective Colorectal Surgery.

BACKGROUND: Discharge to nonhome settings after colorectal resection may increase risk of hospital readmission. OBJECTIVE: The purpose of this study was to determine the impact of various discharge dispositions on 30-day readmission after adjusting for confounding demographic and clinical factors. DESIGN: This was a retrospective cohort study. SETTINGS: Data were obtained from the University HealthSystem Consortium (2011-2015). PATIENTS: Adults who underwent elective colorectal resection were included. MAIN OUTCOME MEASURES: Thirty-day hospital readmission risk was measured. RESULTS: The mean age of the study population (n = 97,455) was 58 years; half were men and 78% were white. Seventy percent were discharged home routinely (home without service), 24% to home with organized health services, 5% to skilled nursing facility, 1% to rehabilitation facility, and <1% to long-term care hospital. Overall rate of readmission was 12%; 9% from home without service, 16% from home with organized home health services, 19% from skilled nursing facility, 34% from rehabilitation facility, and 22% from long-term care hospital (p < 0.001). Patients with an intensive care unit stay, more postoperative complications, and longer hospitalization stay were more likely to be discharged to home with organized home health services or to a facility (p < 0.001). Discharge to home with organized home health services, skilled nursing facility, or rehabilitation facility increased multivariable-adjusted readmission risk by 30% (OR = 1.3 (95% CI, 1.3-1.6)), 60% (OR = 1.6 (95% CI, 1.5-1.8)), or 200% (OR = 3.0 (95% CI, 2.5-3.6)). Discharge to long-term care hospital was not associated with higher adjusted readmission risk (OR = 1.2 (95% CI, 0.9-1.6)), despite this group having the highest comorbidity and postoperative complications. Among patients readmitted within 30 days, median time to readmission was significantly different among home without service (n = 7), home with organized home health services (n = 8), skilled nursing facility (n = 8), rehabilitation facility (n = 9), and long-term care hospital (n = 12; p < 0.001). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Discharge to home with organized home health services, skilled nursing facility, or rehabilitation facility, but not long-term care hospital, is associated with increased adjusted risk of readmission compared with routine home discharge. Potential targets to decrease readmission include improving transition of care at discharge, improving quality of care after discharge, and improving facility resources. See Video Abstract at http://links.lww.com/DCR/B272. NO TODAS LAS CONFIGURACIONES DE ALTA SON IGUALES: RIESGOS DE READMISIÓN A 30 DÍAS DESPUÉS DE CIRUGÍA COLORRECTAL ELECTIVA: El alta hospitalaria hacia el domicilio luego de una resección colorrectal puede aumentar el riesgo de readmisión.Determinar el impacto de varias configuraciones diferentes de alta en la readmisión a 30 días luego de ajustar factores demográficos y clínicos.Estudio de cohortes retrospectivo.Los datos se obtuvieron del Consorcio del Sistema de Salud Universitaria (2011-2015).Todos aquellos adultos que se sometieron a una resección colorrectal electiva.Los riesgos de readmisión hospitalaria a 30 días.La edad media de la población estudiada (n = 97,455) fué de 58 años; la mitad eran hombres y un 78% eran blancos. El 70% fueron dados de alta de manera rutinaria (a domicilio sin servicios complementarios), 24% alta a domicilio con servicios de salud organizados, 5% alta hacia un centro con cuidados de enfermería especializada, 1% alta hacia un centro de rehabilitación y <1% alta hacia un hospital con atención a largo plazo. La tasa global de readmisión fué del 12%; nueve por ciento desde domicilios sin servicios complementarios, 16% desde domicilios con servicios de salud organizados, 19% desde un centro de enfermería especializada, 34% desde el centro de rehabilitación y 22% desde un hospital con atención a largo plazo (p <0.001). Los pacientes con estadías en Unidad de Cuidados Intensivos, con más complicaciones postoperatorias y con una hospitalización prolongada tenían más probabilidades de ser dados de alta hacia un domicilio con servicios de salud organizados o hacia un centro de rehabilitación (p <0,001). El alta hospitalaria con servicios organizados de atención médica domiciliaria, centros de enfermería especializada o centros de rehabilitación aumentaron el riesgo de readmisión ajustada de múltiples variables en un 30% (OR 1.3, IC 95% 1.3-1.6), 60% (OR 1.6, IC 95% 1.5-1.8), o 200% (OR 3.0, IC 95% 2.5-3.6), respectivamente. El alta hospitalaria a largo plazo no fué asociada con un mayor riesgo de readmisión ajustada (OR 1.2, IC 95% 0.9-1.6), no obstante que este grupo fué el que tuvo las mayores comorbilidades y complicaciones postoperatorias. Entre los pacientes readmitidos dentro de los 30 días, la mediana del tiempo hasta el reingreso fue significativamente diferente entre el domicilio sin servicios complementarios (7), domicilio con servicios de salud organizados (8), el centro de cuidados de enfermería especializada (8), centros de rehabilitación (9) y hospitales con atención a largo plazo (12) (p <0,001).Naturaleza retrospectiva del presente estudio.El alta hospitalaria con servicios de salud domiciliarios organizados, hacia centros de enfermería especializada o hacia centros de rehabilitación se asocian con un mayor riesgo ajustado de readmisión en comparación con el alta domiciliaria de rutina y los hospitales con atención a largo plazo. Los objetivos potenciales para disminuir la readmisión incluyen mejorar la transición de la atención al momento del alta, mejorar la calidad de la atención después del alta y mejorar las diferentes facilidades para los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B272.

Characteristics of Long-Term Care Residents That Predict Adverse Events after Hospitalization.

BACKGROUND/OBJECTIVES: Adverse events (AEs) occur frequently in long-term care (LTC) residents transitioning from the hospital back to an LTC facility. Measuring the association between resident characteristics and AEs can inform AE risk reduction strategies. DESIGN: Prospective cohort analysis. SETTING: A total of 32 nursing homes from six New England states. PARTICIPANTS: A total of 555 LTC residents contributing 762 transitions from the hospital back to LTC. MEASUREMENTS: We measured the association between all AEs and preventable AEs developing in the 45 days following discharge back to LTC and demographic variables, hospital length of stay (LOS), Charlson Comorbidity Index (CCI) (0-1, 2-3, 4-5 and ≥6), dependency in activities of daily living (ADLs) using the Minimum Data Set Long Form Scale (in quintiles 0-12, 13-15, 16, 17-18, and ≥19), and number of regularly scheduled medications (0-9, 10-13, 14-17, and ≥18). To understand the independent association of each resident characteristic with AEs and preventable AEs, we constructed multiple Cox proportional hazards models. RESULTS: There were 283 discharges with one or more AEs and 212 with preventable AEs. Characteristics independently associated with higher risk of an AE included hospital LOS 9 or more days (hazard ratio [HR] = 1.49; 95% confidence interval [CI] = 1.02-2.17); CCI of 4 to 5 (HR = 1.74; 95% CI = 1.13-2.67) or 6 or higher (HR = 1.58; 95% CI = 1.01-2.46); 18 or more regularly scheduled medications (HR = 1.53; 95% CI = 1.07-2.18); and 19 and above on ADL dependency (HR = 1.78; 95% CI = 1.21-2.62). Results from models with preventable AEs were similar to those with all AEs. CONCLUSION: Increased LOS, higher comorbidity burden, greater dependency in ADLs, and polypharmacy were the resident characteristics most strongly associated with risk of AEs and preventable AEs. We recommend heightened vigilance in the care of LTC residents with these characteristics transitioning back to LTC. We also recommend research to assess strategies to reduce the risk of AEs.

Cardiopulmonary responses to exercise in an individual with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome during long-term treatment with intravenous saline: A case study.

BACKGROUND: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) causes significant impairment in daily activities, including the ability to pursue daily activities. Chronotropic intolerance is becoming better characterized in ME/CFS and may be the target of supportive treatment. OBJECTIVE: To document the effect of repeated intravenous (IV) saline administration on cardiovascular functioning and symptoms in a 38-year old female with ME/CFS. METHODS: The patient received 1 L of 0.9% IV saline through a central line for a total of 675 days. Single CPETs were completed periodically to assess the effect of treatment on cardiopulmonary function at peak exertion and ventilatory anaerobic threshold (VAT). An open-ended symptom questionnaire was used to assess subjective responses to CPET and self-reported recovery time. RESULTS: Improvements were noted in volume of oxygen consumed (VO2), heart rate (HR), and systolic blood pressure (SBP) at peak and VAT. Self-reported recovery time from CPET reduced from 5 days to 1-2 days by the end of treatment. The patient reported improved quality of life related, improved capacity for activities of daily living, and reduced symptoms. CONCLUSIONS: IV saline may promote beneficial effects for cardiopulmonary function and symptoms in people with ME/CFS, which should be the focus of formal study.

Statin use and fall-related hospitalizations among residents of long-term care facilities: A case-control study.

BACKGROUND: Statins are associated with muscle-related adverse events, but few studies have investigated the association with fall-related hospitalizations among residents of long-term care facilities (LTCFs). OBJECTIVE: The objective of the study is to investigate whether statin use is associated with fall-related hospitalizations from LTCFs. METHODS: A case-control study was conducted among residents aged ≥65 years admitted to hospital from 2013 to 2015. Cases (n = 332) were residents admitted for falls and fall-related injuries. Controls (n = 332) were selected from patients admitted for reasons other than cardiovascular and diabetes. Cases and controls were matched 1:1 by age (±2 years), index date of admission (±6 months), and sex. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression, after considering for history of falls, hypertension, dementia, functional comorbidity index, polypharmacy (≥9 regular preadmission medications), and fall-risk medications. Subanalyses were performed for individual statins, dementia, and statin intensity. RESULTS: Overall, 43.1% of cases and 27.1% of controls used statins. Statins were associated with fall-related hospitalizations (aOR = 2.24, 95% CI 1.56-3.23), in particular simvastatin (aOR = 2.26, 95% CI 1.22-4.20) and atorvastatin (aOR = 2.08, 95% CI 1.33-3.24). Statins were associated with fall-related hospitalizations in residents with (aOR = 2.34, 95% CI 1.33-4.11) and without dementia (aOR = 2.30, 95% CI 1.46-3.63). There was no association between statin intensity and fall-related hospitalizations (aOR = 0.78, 95% CI 0.43-1.40). CONCLUSION: This study suggests a possible association between statin use and fall-related hospitalizations among residents living in LTCFs. However, there was minimal evidence for a relationship between statin intensity and fall-related hospitalizations. Further research is required to substantiate these hypothesis-generating findings.

Diagnose, indicate, and treat severe mental illness (DITSMI) as appropriate care: A three-year follow-up study in long-term residential psychiatric patients on the effects of re-diagnosis on medication prescription, patient functioning, and hospital bed utilization.

BACKGROUND: While polypharmacy is common in long-term residential psychiatric patients, prescription combinations may, from an evidence-based perspective, be irrational. Potentially, many psychiatric patients are treated on the basis of a poor diagnosis. We therefore evaluated the DITSMI model (i.e., Diagnose, Indicate, and Treat Severe Mental Illness), an intervention that involves diagnosis (or re-diagnosis) and appropriate treatment for severely mentally ill long-term residential psychiatric patients. Our main objective was to determine whether DITSMI affected changes over time regarding diagnoses, pharmacological treatment, psychosocial functioning, and bed utilization. METHODS: DITSMI was implemented in a consecutive patient sample of 94 long-term residential psychiatric patients during a longitudinal cohort study without a control group. The cohort was followed for three calendar years. Data were extracted from electronic medical charts. As well as diagnoses, medication use and current mental status, we assessed psychosocial functioning using the Health of the Nations Outcome Scale (HoNOS). Bed utilization was assessed according to length of stay (LOS). Change was analyzed by comparing proportions of these data and testing them with chi-square calculations. We compared the numbers of diagnoses and medication changes, the proportions of HoNOS scores below cut-off, and the proportions of LOS before and after provision of the protocol. RESULTS: Implementation of the DITSMI model was followed by different diagnoses in 49% of patients, different medication in 67%, some improvement in psychosocial functioning, and a 40% decrease in bed utilization. CONCLUSIONS: Our results suggest that DITSMI can be recommended as an appropriate care for all long-term residential psychiatric patients.

Does body mass index affect the rate of adverse outcomes in total hip and knee arthroplasty? A retrospective review of a total joint replacement database

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are reliable surgical options to treat pain and disability resulting from degenerative conditions around the hip and knee. Obesity is a modifiable risk factor that contributes to significant morbidity. The purpose of this study was to retrospectively compare outcomes in primary hip and knee arthroplasty for patients with increased body mass index (BMI) and those with normal BMI, using data from the registry of the Alberta Bone and Joint Health Institute (ABJHI). Methods: We retrospectively reviewed the data compiled in the ABJHI registry between March 2010 and July 2016. We reviewed outcomes with respect to length of stay, discharge destination, 30-day readmission, postoperative infection, postoperative transfusion requirements, postoperative adverse events and in-hospital postoperative mechanical complications. Results: A total of 10 902 patients (6076 women, 4826 men) who underwent THA and 16 485 patients (10 057 women, 6428 men) who underwent TKA were included in the study. For both THA and TKA, patients with increased BMI had an increased number of in-hospital medical events, had an increased rate of deep infection, were less likely to be discharged home (p < 0.001) and had decreased transfusion requirements (p < 0.001) than patients whose weight was in the normal range. Increased BMI increased the rate of 30-day readmission and length of stay in the THA cohort but not in the TKA cohort. Increased BMI had no effect on acute postoperative dislocation or periprosthetic fractures. Patients with a BMI of 30 kg/m2 or greater required a THA 1.7 years earlier than patients of normal weight, patients whose BMI was 35 kg/m2 or greater required a THA 3.4 years earlier, and patients whose BMI was 40 kg/m2 or greater required a THA 5.8 years earlier. In the TKA cohort, patients with a BMI of 30 kg/m2 or greater required a TKA 2.7 years earlier than patients whose weight was in the normal range, patients with a BMI of 35 kg/m2 or greater required a TKA 4.6 years earlier, and patients whose BMI was 40 kg/m2 or greater required a TKA 7.6 years earlier. Conclusion: Our study quantifies the effects of obesity in primary hip and knee arthroplasty. It provides a greater understanding of the risks in the obese population when contemplating joint arthroplasty.

Contexte: La prothèse totale de la hanche (PTH) et la prothèse totale du genou (PTG) sont des options chirurgicales fiables pour traiter la douleur et l'invalidité résultant de maladies dégénératives de la hanche et du genou. L'obésité est un facteur de risque modifiable qui contribue significativement à la morbidité. Le but de cette étude était de comparer de manière rétrospective le résultat des interventions primaires pour prothèses de la hanche et du genou selon que les patients avaient un indice de masse corporelle (IMC) normal ou élevé à partir des données du registre de l'Alberta Bone and Joint Health Institute (ABJHI). Méthodes: Nous avons analysé de manière rétrospective les données compilées par le registre de l'ABJHI entre mars 2010 et juillet 2016. Nous avons passé en revue les paramètres suivants : durée du séjour hospitalier, destination post-congé, réadmissions dans les 30 jours, infections postopératoires, besoins transfusionnels postopératoires, complications postopératoires et complications mécaniques postopératoires perhospitalières. Résultats: En tout, 10 902 patients (6076 femmes, 4826 hommes) ayant subi une PTH et 16 485 patients (10 057 femmes, 6428 hommes) ayant subi une PTG ont été inclus dans l'étude. Tant pour la PTH que pour la PTG, les patients ayant un IMC élevé ont présenté un plus grand nombre de complications médicales en cours d'hospitalisation; ils ont aussi présenté un nombre plus élevé d'infections profondes, étaient moins susceptibles de pouvoir retourner chez eux au moment de leur congé (p < 0,001) et ont eu moins besoin de transfusions (p < 0,001) comparativement aux patients dont le poids se situait dans l'éventail des valeurs normales. L'IMC élevé a été en corrélation avec une augmentation du taux de réadmission à 30 jours et de la durée du séjour dans la cohorte soumise à une PTH, mais non dans la cohorte soumise à une PTG. L'IMC élevé n'a exercé aucun effet sur la dislocation postopératoire aiguë ou les fractures périprothétiques. Les patients ayant un IMC de 30 kg/m2 ou plus ont eu besoin d'une PTH 1,7 an plus tôt que les patients de poids normal, les patients ayant un IMC de 35 kg/m2 ou plus ont eu besoin d'une PTH 3,4 ans plus tôt, et les patients ayant un IMC de 40 kg/m2 ou plus ont eu besoin d'une PTH 5,8 ans plus tôt. Dans la cohorte soumise à la PTG, les patients ayant un IMC de 30 kg/m2 ou plus ont eu besoin d'une PTG 2,7 ans plus tôt que les patients de poids normal, les patients ayant un IMC de 35 kg/m2 ou plus ont eu besoin d'une PTG 4,6 ans plus tôt, et les patients ayant un IMC de 40 kg/m2 ou plus ont eu besoin d'une PTG 7,6 ans plus tôt. Conclusion: Notre étude quantifie les effets de l'obésité sur le recours aux interventions primaires pour prothèse de la hanche et du genou. Elle permet de mieux comprendre les risques auxquels est exposée la population obèse lorsqu'une intervention pour prothèse articulaire est envisagée.

Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care.

OBJECTIVE: To examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use. DESIGN: Cross-sectional claims data study. SETTING: The Netherlands. PARTICIPANTS: Patients deceased in 2013-2015 with lung cancer (N = 25 553). MAIN OUTCOME MEASURES: We calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization. RESULTS: The utilization of hospital services in high-using regions is 2.3-3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level. CONCLUSIONS: Hospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.

Carbapenem-resistant Enterobacteriaceae: A retrospective review of treatment and outcomes in a long-term acute care hospital.

BACKGROUND: Long-term acute care hospitals (LTACHs) have a unique patient population, with multiple risk factors for carbapenem-resistant Enterobacteriaceae (CRE) colonization and infection. METHODS: We performed a retrospective analysis of patients in LTACHs who were diagnosed with and treated for CRE infections. Baseline data, antimicrobial treatment, and outcomes were collected in patients with bacteremia, health care-associated pneumonia, and complicated urinary tract infection/acute pyelonephritis due to CRE diagnosed between January 2017 and December 2017. RESULTS: A total of 57 cases of CRE infection were identified over the study period, including 12 cases of bacteremia, 20 cases of health care-associated pneumonia, and 25 cases of complicated urinary tract infection/acute pyelonephritis. Patient had significant comorbidities: 31.5% with diabetes, 40.4% with heart failure, 29.8% with kidney disease, and 10% with solid tumors. The majority (56) of 57 patients received empiric antibiotics known to have activity against gram-negative bacteria, but only 38.6% had in vitro activity against the CRE organism in cultured specimens. A total of 78.9% of patients received monotherapy. Overall outcome was poor, with 28-day mortality across all infection sites of 17.5% in patients but up to 25% in patients with bacteremia. CONCLUSIONS: In this retrospective analysis of our clinical experience treating CRE infections in an LTACH setting, we documented that CRE infections occur in patients with substantial comorbidities. Although clinical outcome remains of great concern, the 28-day mortality and rate of eradication of CRE in this study were comparatively better than other national estimates. Inappropriate empiric treatment may be one of many factors leading to overall poor treatment outcomes.

Recurrence rate and long-term course of cats with feline lower urinary tract disease.

OBJECTIVES: Feline lower urinary tract disease (FLUTD) causes clinical signs such as stranguria, pollakiuria, haematuria, vocalisation and periuria, and is often associated with recurring episodes. The primary objective of this study was to survey the long-term course of cats presenting with FLUTD in terms of recurrence rate and mortality. METHODS: Data from cats that were presented with lower urinary tract signs from 2010 to 2013 were collected by telephone interview with cat owners, using a questionnaire. The observation period ranged from the first presentation due to FLUTD to the telephone interview or the cat's death. Data on diagnoses, recurrence of clinical signs and disease-free intervals, as well as implementation and impact of prophylactic measures (PMs), were collected and compared between groups with different aetiologies. RESULTS: The study included 101 cats. Fifty-two cats were diagnosed with feline idiopathic cystitis, 21 with urolithiasis and 13 with bacterial urinary tract infection; 15 had no definitive diagnosis. Of the 86 cats with a known diagnosis, the recurrence rate was 58.1%, with no significant difference between groups. Twenty-one cats had one relapse, 12 had two relapses, 10 had three and seven had four to eight relapses within a median observation period of 38 months (range 0.5-138 months). Fourteen cats suffered from different causes of FLUTD at different episodes. Mortality due to FLUTD among all 101 cats was 5.0%. The recurrence rate in cats with urolithiasis receiving at least two PMs was significantly lower than the recurrence rate in those without PMs (P = 0.029). CONCLUSIONS AND RELEVANCE: More than half of the cats with FLUTD presented with two or more recurrent episodes irrespective of the identified aetiology. Cats should be thoroughly investigated at each presentation as it cannot be presumed that the cause of FLUTD is the same at different episodes. The mortality due to FLUTD is lower than previously reported.

Factors influencing patient's perception of long-term treatment with low-molecular-weight heparins for cancer-associated thrombosis: an updated analysis of TROPIQUE, a prospective observational study.

PURPOSE: Our objective was to compare patient's expectations to their experience and to identify factors predictive of patient's perception of long-term LMWH for the treatment of cancer-associated thrombosis (CAT). METHODS: Results from the validated Perception Anticoagulant Treatment Questionnaires (PACTQ) completed before inclusion (PACTQ1 for expectations) and at the end (PACTQ2 for convenience and satisfaction) of the 6-month TROPIQUE study were studied with principal component analysis. Possible predictive factors of improved perception of LMWH treatment were analyzed with the Kruskall-Wallis test. RESULTS: Among 409 included patients treated with LMWH, 269 PACT-Q1 and 139 PACT-Q2 were evaluable for treatment perception. Patients had high expectations (A1-A7 score of 26.7 ± 3.5, max = 35). Treatment cost (A7 = 1.90 ± 1.31) and concern about a mistake in anticoagulation (A5 = 1.93 ± 1.12) had little importance while LMWH treatment was considered easy to use (A4 = 4.20 ± 0.93). Six-month treatment with LMWH was associated with a high rate of convenience (B1-B11, C1-C2 = 55.1 ± 8.38, max = 65) and a high satisfaction score (D1-D7 = 25.1 ± 4.32, max = 35). Patients' confidence in treatment and perception of possible LMWH side effects were moderate while perception of autonomy and independence significantly improved at the end of the study compared to inclusion. PACT-Q2 satisfaction score was low in patients who experienced bleeding (PACT-Q2 24.1 ± 3.3 vs. 25.1 ± 4.3). LMWH twice daily tended to be found less convenient compared than once daily (53.3 ± 7.2 vs. 55.0 ± 8.3). CONCLUSION: CAT patients had a good perception of the 6-month LMWH treatment when comparing expectations and experience. Using a quantitative scale validated in the general population for VTE and subcutaneous injection and including a large number of patients, bleeding complications and LMWH twice daily were associated with a nonsignificant trend towards a worsen perception.

Framework for Patient and Informal Caregiver Participation in Research (PAICPAIR): Part 1.

The term user involvement is frequently applied in research. Frameworks for patient and informal caregiver participation as coresearchers in studies concerning patients with life-threatening illness are however sparse. The PhD project Dying With Dignity-Dignity-Preserving Care for Older Women Living at Home With Incurable Cancer has implemented a thorough cooperation with patients and informal caregivers from the early stages of the research process. A framework for Patient and Informal Caregiver Participation In Research (PAICPAIR) is suggested-creating a stronger foundation for democracy, equality, and research quality by also promoting active participation among vulnerable people experiencing incurable, life-threatening illness, as coresearchers.

Proton Pump Inhibitors and Infection-Related Hospitalizations Among Residents of Long-Term Care Facilities: A Case-Control Study.

OBJECTIVE: Our objective was to investigate associations between proton pump inhibitor (PPIs) use and infection-related hospitalizations among residents of long-term care facilities (LTCFs). METHODS: This was a case-control study of residents aged ≥ 65 years admitted to hospital between July 2013 and June 2015. Residents admitted for infections (cases) and falls or fall-related injuries (controls) were matched for age (± 2 years), sex, and index date of admission (± 6 months). Conditional logistic regression was used to estimate crude and adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between PPI use and infection-related hospitalizations. Analyses were adjusted for age, sex, polypharmacy, diabetes, heart failure, chronic obstructive pulmonary disease, myocardial infarction, cerebrovascular accident, and concomitant use of cancer and immunosuppressant medications. Subgroup analyses were performed for high- and low/moderate-intensity PPIs and for respiratory and non-respiratory infections. Logistic regression was used to compare the odds of infection-related hospitalizations among users of high- and low/moderate-intensity PPIs. RESULTS: Overall, 181 cases were matched to 354 controls. Preadmission PPI use was associated with infection-related hospitalizations (aOR 1.66; 95% CI 1.11-2.48). In subgroup analyses, the association was apparent only for respiratory infections (aOR 2.26; 95% CI 1.37-3.73) and high-intensity PPIs (aOR 1.93; 95% CI 1.23-3.04). However, the risk of infection-related hospitalization was not significantly higher among users of high- versus low/moderate-intensity PPIs (aOR 1.25; 95% CI 0.74-2.13). CONCLUSION: Residents who use PPIs may be at increased risk of infection-related hospitalizations, particularly respiratory infections. Study findings provide further support for initiatives to minimize unnecessary PPI use in the LTCF setting.

Preferences for cancer survivorship care among adolescents and young adults who experienced healthcare transitions and their parents.

PURPOSE: This study aimed to elucidate experiences and preferences for survivorship care delivery among adolescent and young adult (AYA) childhood cancer survivors who experienced healthcare transitions. METHODS: Eight focus groups were conducted with two groups of AYA survivors and their parents: (1) those who recently completed cancer treatment and are beginning follow-up care and (2) those who disengaged in follow-up care after the transition from pediatric to adult survivorship clinics. Interviewers used a structured interview guide that contained questions about perceptions and preferences for survivorship care models, resources, and tools (e.g., a survivorship care plan). We employed directed content analysis techniques to identify and organize relevant themes. RESULTS: Results of this study support six primary themes for optimizing survivorship care models for AYA: (1) improve knowledge of late effects and need for LTFU; (2) provide supportive services that help to address fear and uncertainty about health; (3) adapt survivorship care to be consistent with AYA developmental factors; (4) increase support surrounding healthcare transitions; (5) improve survivorship care communication and coordination between patients and families, and between providers; and (6) incorporate digital health tools. CONCLUSIONS: These groups represent vulnerable patient populations in AYA survivorship care and their perspectives highlight potential clinical and research priorities for enhancing long-term care models. IMPLICATIONS FOR CANCER SURVIVORS: Elucidating AYA and parent recommendations for survivorship care delivery can help to promote continuous engagement in care, target unmet needs, and promote health through survivorship models that are deemed acceptable to both patients and families.