Exploring Perceptions of Health Care Providers' Use of Electronic Advance Directive Forms in Electronic Health Records.

The current study explored the perceptions of health care providers' use of electronic advance directive (AD) forms in the electronic health record (EHR). The Technology Acceptance Model (TAM) was used to guide the study. Of 165 surveys distributed, 151 participants (92%) responded. A moderately strong positive correlation was noted between perceived usefulness and actual system usage (r = 0.70, p < 0.0001). Perceived ease of use and actual system usage also had a moderately strong positive correlation (r = 0.70, p < 0.0001). In contrast, the strength of the relationship between behavioral intention to use and actual system usage was more modest (r = 0.22, p < 0.004). There was a statistically significant difference in actual system usage of electronic ADs across six departments (χ2[5] = 79.325, p < 0.001). The relationships among primary TAM constructs found in this research are largely consistent with previous TAM studies, with the exception of behavioral intention to use, which is slightly lower. These data suggest that health care providers' perceptions have great influence on the use of electronic ADs. [Journal of Gerontological Nursing, 45(1), 17-21.].

Effects of platelet dysfunction and platelet transfusion on outcomes in traumatic brain injury patients.

OBJECTIVE: Platelet inhibition in traumatic brain injury (TBI) may be due to injury or antiplatelet medication use pre-injury. This study aims to identify factors associated with increased platelet arachidonic acid (AA) and adenosine diphosphate (ADP) inhibition and determine if platelet transfusion reduces platelet dysfunction and affects outcome. METHODS: Prospective thromboelastography (TEG) assays were collected on adult patients with TBI with intracranial injuries detected by computed tomography (CT). Outcomes included in-hospital mortality, and CT lesion expansion. RESULTS: Of 153 patients, ADP inhibition was increased in moderate and severe TBI compared to mild TBI (p = 0.0011). P2Y12 inhibiting medications had increased ADP inhibition (p = 0.0077). Admission ADP inhibition was not associated with in-hospital mortality (p = 0.24) or CT lesion expansion (p = 0.94). Mean reduction of ADP inhibition from platelet transfusion (-15.1%) relative to no transfusion (+ 11.7%) was not statistically different (p = 0.0472). CONCLUSIONS: Mild TBI results in less ADP inhibition compared to moderate and severe TBI, suggesting a dose response relationship between TBI severity and degree of platelet dysfunction. Further, study is warranted to determine efficacy and parameters for platelet transfusion in patients with TBI.

Corrigendum: 2016 ACG Abstracts- Outcomes Research.

This corrects the article DOI: 10.1038/ajg.2016.360.

Corneal anesthetic effect and ocular tolerance of 3.5% lidocaine gel in comparison with 0.5% aqueous proparacaine and 0.5% viscous tetracaine in normal canines.

OBJECTIVE: To compare the degree and duration of corneal anesthesia of a novel viscous ophthalmic lidocaine hydrochloride preparation vs. two commonly used ophthalmic anesthetic preparations. METHODS: Each subject was randomly selected to receive 2 of 4 treatments at 2 different time periods separated by a 1 week washout: 3.5% lidocaine hydrochloride gel (Akten® ; Akorn Inc., Lake Forest, Illinois, USA), 0.5% aqueous proparacaine hydrochloride (Akorn Inc.), 0.5% viscous tetracaine hydrochloride (TetraVisc™; Ocusoft Inc., Richmond, Texas, USA), or 0.9% saline eyewash as a negative control. Corneal sensitivity was determined using a Cochet-Bonnet aesthesiometer (Luneau® , Chartres Cedex, France) prior to instillation of each treatment; at 1 and 5 min post treatment; and at 5-min intervals thereafter for 90 min total. Ocular side effects were recorded on a scale of 0-3. RESULTS: Twenty-four normal dogs (48 eyes) were entered into the study. Mean duration of maximal anesthesia was significantly greater at 34.2 min with tetracaine compared to 21.5 min and 19 min with proparacaine and lidocaine respectively. Corneal sensitivity was significantly decreased from baseline for up to 70 min with tetracaine and 55 min with both proparacaine and lidocaine. All lidocaine-treated eyes had transient blepharospasm and conjunctival hyperemia. Ten out of 24 tetracaine-treated eyes had conjunctival hyperemia with 4 of these having concurrent chemosis. CONCLUSIONS: Tetracaine provided a significantly longer duration of corneal anesthesia than proparacaine or lidocaine. Tetracaine and lidocaine were associated with more ocular side effects than proparacaine, although these were mild and transient. None.

Effect of bandage contact lens wear and postoperative medical therapies on corneal healing rate after diamond burr debridement in dogs.

PURPOSE: To determine the effect of bandage contact lens wear and type of post-operative medical treatment on corneal healing rates in dogs after diamond burr debridement. ANIMALS STUDIED: 237 client-owned dogs. PROCEDURES: Canine patients having undergone diamond burr debridement (DBD) for treatment of spontaneous chronic corneal epithelial defects (SCCEDs) were included. Patients were put into 1 of 12 different groups based on type of postoperative medical regimen and whether a bandage contact lens (BCL) was utilized. Each dog was examined on a routine basis until the cornea was fluorescein negative. Data points collected included age, sex, breed, diabetic status, eye affected, Schirmer tear test 1, rebound tonometry, type and frequency of topical antibiotic, use of topical sodium chloride, use and retention of BCL, and days until healed. RESULTS: A total of 237 dogs, each contributing one eye to the study, underwent DBD for SCCEDs. All eyes treated had estimated median ± standard error (SE) days to heal of 9.37 ± 0.42 days. When sodium chloride and BCL were utilized, ofloxacin had a significantly shorter median healing time when compared to oxytetracycline (adjusted P = 0.0158) and tobramycin (adjusted P = 0.0261). BCL use significantly improved healing times (P = 0.0002). Overall BCL retention rate was 62.02% (80 of 129). PureVision lenses were retained more often compared to Acrivet lenses (P < 0.0001). Overall, BCL retention significantly improved healing rates (P = <0.0001). CONCLUSIONS: Postdebridement antibiotic type or use of sodium chloride ointment had minor effects on healing rates. Bandage contact lens use and retention significantly improves healing times.

Effect of prophylactic topical hypotensive medications in reducing the incidence of postoperative ocular hypertension after phacoemulsification in dogs.

OBJECTIVE: To determine whether topical hypotensive medications prevent postoperative ocular hypertension (POH) after phacoemulsification. ANIMALS STUDIED: 52 client-owned dogs (88 eyes). PROCEDURES: Diabetic and nondiabetic dogs having undergone phacoemulsification were included in this retrospective study. The control group received no ocular hypotensive medications. The treatment groups received latanoprost, dorzolamide, or dorzolamide/timolol, beginning immediately after surgery, for 2-week duration. IOPs were obtained at initial examination followed by 4 h, 24 h, 7 days, and 14 days postoperatively. POH was defined as an IOP above 20 mmHg (POH20) or 25 mmHg (POH25). RESULTS: POH20 occurred in 33 of 87 eyes (37.93%), including 11 of 21 eyes (52.38%) in the control group, three of 23 eyes (13.04%) in the latanoprost group, eight of 15 eyes (53.33%) in the dorzolamide group, and 11 of 28 eyes (39.29%) in the dorzolamide/timolol group. Active treatment groups were compared to the control group, and the overall group effect was not significant (P = 0.11). POH25 occurred in 22 of 86 eyes (25.58%), including seven of 21 eyes (33.33%) in the control group, two of 23 eyes (8.70%) in the latanoprost group, five of 15 eyes (33.33%) in the dorzolamide group, and eight of 27 eyes (29.63%) in the dorzolamide/timolol group. Active treatment groups were compared to the control group, and the overall group effect was not significant (P = 0.31). Intraoperative use of intracameral tissue plasminogen activator significantly decreased the chances of POH25 (P = 0.0063). CONCLUSIONS AND CLINICAL RELEVANCE: The latanoprost group had a substantially lower percentage of POH 20 and POH25 compared to the control and other active treatment groups, although statistical significance was not achieved. Intraoperative intracameral tissue plasminogen activator decreased the incidence of POH25.

Analyzing Change in Nursing Home Information Technology Sophistication: A 2-Year Survey.

Nursing home (NH) health information technology (IT) is becoming more prevalent across the country. Currently, a national sample of NHs is being surveyed for 3 consecutive years to determine trends in NH IT sophistication (e.g., measures of IT capabilities, extent of IT use, IT integration with internal and external stakeholders). IT sophistication is measured in resident care, clinical support, and administrative activities. The current article provides details of the differences in NH IT sophistication reported by administrators completing Year 1 and Year 2 surveys. IT in clinical support (i.e., laboratory, pharmacy, and radiology) had the greatest differences. This difference is expected because these areas typically require external contracts, making it dificult to fit IT with existing workflows, which is important for sustained adoption. [Journal of Gerontological Nursing, 43(1), 17-21.].

Levodopa as a possible treatment of visual loss in nonarteritic anterior ischemic optic neuropathy.

PURPOSE: To determine the clinical effectiveness and potential neuroprotection of levodopa in improving visual acuity, visual field, and retinal nerve fiber layer (RNFL) thickness in eyes affected by NAION. METHOD: Retrospective cohort study involving 59 eyes of 59 participants with NAION who were evaluated within 15 days of NAION onset. Participants received 25 mg carbidopa/100 mg levodopa three times daily with meals for 12 weeks (levodopa group) or were untreated (control group). Best-corrected visual acuity converted to logMAR, mean deviation (MD) threshold sensitivity on automated perimetry, and mean RNFL thickness on optical coherence tomography (OCT) were assessed. The primary outcome was the categorization of eyes into improved visual acuity (by 0.3 logMAR difference), worsened visual acuity (by 0.3 logMAR difference), or no change in visual acuity. The proportions in each category were compared between the levodopa and control groups. RESULTS: Among participants with 20/60 or worse initial visual acuity, levodopa-treated participants had significant improvement (P < 0.0001) in the mean change from initial to final logMAR visual acuity of -0.74 ± 0.56 (95 % CI, -0.98 to -0.50), while the mean change for the control group at -0.37 ± 1.09 (95 % confidence interval estimate, -1.00 to +0.26) was not significant (P = 0.23). A significant difference between groups was observed (P = 0.0086) such that 19/23 (83 %) in the levodopa group improved and none got worse, as compared with 6/14 (43 %) in the control group improving while four (29 %) worsened. The change in visual field MD and RNFL thickness on OCT showed no significant difference at P = 0.23 and P = 0.75 respectively. No levodopa-treated participant had any adverse event from the levodopa. CONCLUSIONS: Treatment within 15 days of onset of NAION with levodopa improved central visual acuity by an average of 6 lines on Snellen acuity chart. Levodopa may promote neuroprotection of the maculopapular retinal ganglion cell fibers in NAION.

Pancreatic Cancer Survival Outcomes at a Tertiary Medical Center Based on Sex and Geographic Location.

OBJECTIVES: To describe the survival outcomes of patients with histologically proven primary pancreatic cancer based on geographic location and sex. METHODS: We conducted a retrospective review of medical records from 2009 through 2013 of patients with pancreatic cancer using International Classification of Diseases, Ninth Revision code 157.9 and International Statistical Classification of Diseases, 10th Revision code C 25.9. The variables extracted included demographics, date of diagnosis, mode of diagnosis, duration, treatment methods, family history, history of chronic pancreatitis, and diabetes mellitus. ZIP codes were used to identify the geographic location of each subject, and rural urban commuting area codes were used to further classify the areas as metropolitan, micropolitan, small town, and rural. Population sizes were classified as metropolitan >50,000, micropolitan 10,000 to 49,999, small town 2500 to 9999, and rural <2500. Descriptive analysis and Kaplan-Meier survival for survival outcomes were performed with statistical significance identified as P < 0.05. RESULTS: A total of 400 medical charts were extracted for review, 301 of which belonged to patients with primary pancreatic cancer. Of the 301 cases, we identified 175 men (58%), 125 women (41%), and 1 missing sex data. There were 280 whites (95%), 8 African Americans (2%), 2 Asian Americans (0.64%), 1 Hispanic American (0.34%) and 1 Native American (0.34%), with a mean age of 63.2 ± 12.6 years. Based on geography, there were 34%, 27%, 20%, and 19% in rural areas, metropolitans, small towns, and micropolitans, respectively. No statistically significant difference was noted in sex on survival outcomes (P = 0.85) or geography (P = 0.62). Additional analysis revealed no statistical significant difference between sexes when stratifying by location (P = 0.96). CONCLUSIONS: There is no difference in survival outcomes of patients with primary pancreatic cancer based on sex or geographic location. Our survival outcomes differ from the national survival outcomes, which reveal that mortality in men is higher than it is in women.

Effects of Staffing and Regional Location on Influenza and Pneumococcal Vaccination Rates in Nursing Home Residents.

Vaccinations reduce the risk of hospitalizations and adverse health outcomes in older adult populations, which has led to initiatives such as the Healthy People 2010 goal to vaccinate 90% of all nursing home residents. The current analysis looked at the percentage of residents who received vaccinations in 15,653 nursing homes in the United States and relationships of vaccination to staffing intensity and regional location. Overall, approximately 75% of facilities reached the optimum 90% vaccination levels for long-term residents, but less than 50% reached this goal for short-term residents. Further analyses revealed a consistently lower median rate of vaccination for metropolitan areas and indicated a weak relationship between staffing levels of RNs and short-term resident vaccination. Factors influencing staffing levels, and the possible connection between vaccination and technology, are discussed, as well as suggestions for future research aimed at better understanding mechanisms involved in suboptimal influenza and pneumococcal vaccination in nursing homes. [Journal of Gerontological Nursing, 42(2), 38-44.].

Complications associated with tibial plateau leveling osteotomy: a retrospective of 1519 procedures.

This retrospective study identified complications associated with tibial plateau leveling osteotomy (TPLO) and predisposing factors for these complications in a large population of dogs from a metropolitan area with cruciate ligament deficiency. There were 943 dogs that underwent unilateral TPLO and 288 with staged bilateral TPLO for a total of 1519 procedures. There were 47 cases with at least 1 major complication and 126 cases with at least 1 minor complication but no major complications. The total complication rate (major or minor) was 11.4% [95% confidence interval (CI) estimate: 9.8%, 13.2%]; the major complication rate was 3.1% (95% CI: 2.3%, 4.1%); and the minor complication rate was 8.3% (95% CI: 7.0%, 9.8%). Factors associated with development of complications included being a German shepherd dog [odds ratio (OR): 3.2], tibial plateau angle > 30° (OR: 1.6), and heavier weights (for every 4.5 kg increase in body weight the OR increased by 1.10). Tibial plateau leveling osteotomy is a common treatment for dogs with cruciate ligament deficiency and has a low complication rate.

Complications associées à l'ostéotomie de nivellement du plateau tibial : rétrospective de 1519 interventions. Cette étude rétrospective a identifié les complications associées à l'ostéotomie de nivellement du plateau tibial (ONPT) et les facteurs de prédisposition pour ces complications dans une grande population de chiens atteinte d'une déficience du ligament croisé provenant d'une région métropolitaine. Il y avait 943 chiens qui avaient subi une ONPT unilatérale et en plusieurs temps pour un total de 1519 interventions. Il y a eu 47 cas avec au moins 1 complication majeure et 126 cas avec au moins 1 complication mineure mais aucune complication majeure. Le taux des complications totales (majeures ou mineures) était de 11,4 % [estimation de l'intervalle de confiance de 95 % (IC) : 9,8 %, 13,2 %]; le taux des complications majeures était de 3,1 % (IC de 95 % : 2,3 %, 4,1 %); et le taux des complications mineures était de 8,3 % (IC de 95 % : 7,0 %, 9,8 %). Les facteurs associés au développement des complications incluaient être un chien Berger allemand [rapport des cotes (RC) : 3,2], un angle du plateau tibial de > 30° (RC : 1,6) et des poids supérieurs (pour chaque hausse de 4,5 kg du poids corporel, le RC augmentait de 1,10). L'ostéotomie de nivellement du plateau tibial est un traitement commun chez les chiens avec une déficience du ligament croisé et elle présente un faible taux de complications.(Traduit par Isabelle Vallières).

From socialist ideology to cultural heritage: the changing basis of legitimacy in the People's Republic of China.

There has been a shift over the past generation in the moral basis for legitimacy of the Chinese state. The socialist state was legitimated by a sinified version of Marxism-Leninism, watered with the blood of revolutionary martyrs who fought on behalf of the Communist Party to defend the nation from external aggressors. However, at many levels of society, the Marxist legitimation is dead. Instead of claiming to represent the values of Communist revolutionary struggle in the twentieth century, the state is now presenting itself as the carrier and the defender of 5000 years of national cultural heritage. This undoubtedly arises partly from changes in moral attitude arising from the grass roots and partly from government initiatives descending from the top down. There is wide variation across China in the intermingling between the bottom-up and top-down moral impulses, and this is partially connected with different moral ecologies constituted by configurations of state and local political and economic institutions throughout China. In this paper, based on case studies from fieldwork carried out in several different locations in 2009, the author draws a broad map of these variations.

Time-in-a-bottle (TIAB): a longitudinal, correlational study of patterns, potential predictors, and outcomes of immunosuppressive medication adherence in adult kidney transplant recipients.

This study examined patterns, potential predictors, and outcomes of immunosuppressive medication adherence in a convenience sample of 121 kidney transplant recipients aged 21 yr or older from three kidney transplant centers using a theory-based, descriptive, correlational, longitudinal design. Electronic monitoring was conducted for 12 months using electronic monitoring. Participants were persistent in taking their immunosuppressive medications, but execution, which includes both taking and timing, was poor. Older age was the only demographic variable associated with medication adherence (r = 0.25; p = 0.005). Of the potential predictors examined, only medication self-efficacy was associated with medication non-adherence, explaining about 9% of the variance (r = 0.31, p = 0.0006). The few poor outcomes that occurred were not significantly associated with medication non-adherence, although the small number of poor outcomes may have limited our ability to detect a link. Future research should test fully powered, theory-based, experimental interventions that include a medication self-efficacy component.

Comparison of two portable lactate meters in dogs.

The objective of this study was to compare two portable lactate analyzers for testing canine patients in a clinical setting with a previously accepted methodology for measuring plasma lactate. Between Jan 1, 2005 and Jun 1, 2006, all samples were analyzed using two different portable analyzers (devices A and B), and 86 of those samples were also analyzed by a reference laboratory (REF). The concordance correlation coefficient (CCC) for device A and the REF was 0.949 (95% confidence interval [95% CI], 0.923-0.966). For device B and REF, the CCC was 0.990 (95% CI, 0.985-0.993). Only 8 of 85 samples (9.4%) exceeded a relative difference of 20% for device B (note that 1 of the 86 samples was not included because the lactate level fell below the detectable limit of device B), but 48 of 85 samples (56.5%) exceeded a relative difference of 20% for device A. Both portable lactate analyzers appeared to be effective in detecting clinically significant elevations in plasma lactate compared with the REF but device B had better agreement. A positive correlation among all three analyzers existed; however, the analyzers do not yield directly interchangeable results.

Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients.

BACKGROUND: Immunosuppressive medication non-adherence is one of the most prevalent but preventable causes of poor outcomes in adult renal transplant recipients, yet there is a paucity of studies testing interventions in this area. METHODS: Using a randomized controlled trial design, 30 adult renal transplant recipients were screened for medication non-adherence using electronic monitoring. Fifteen non-adherent participants were randomized to receive either a continuous self-improvement intervention or attention control management. The six-month continuous self-improvement intervention involved the participant and clinical nurse specialist collaboratively identifying the person's life routines, important people, and possible solutions to enhance medication taking. The participant then received individual monthly medication taking feedback delivered via a graphic printout of daily medication taking generated from electronic monitoring. RESULTS: The mean medication adherence score for the continuous self-improvement intervention group (n = 8) was statistically significantly higher than the attention control group's (n = 5) mean medication adherence score (p = 0.03). The continuous self-improvement intervention effect size (Cohen's d) was large at 1.4. Participants' perceptions of the intervention were highly favorable. CONCLUSIONS: The continuous self-improvement intervention shows promise as an effective and feasible approach to improve medication adherence in adult renal transplant recipients. A fully-powered study with a diverse sample is needed to confirm these preliminary findings.

Postoperative glaucoma in the Labrador Retriever: incidence, risk factors, and visual outcome following routine phacoemulsification.

OBJECTIVE: To evaluate the incidence and risk factors associated with development of postoperative glaucoma in the Labrador Retriever following routine phacoemulsification. METHODS: Medical records from Labradors and a randomly selected population of non-Labradors were retrospectively evaluated. Signalment, diabetic status, cataract stage, gonioscopic findings, presence of preoperative lens-induced uveitis, development of postoperative hypertension (POH), postoperative glaucoma and postoperative visual status were recorded for each patient. Survival curves were developed using the Cox proportional hazards model. RESULTS: Forty-two Labradors (66 eyes) and 199 non-Labradors (314 eyes) were included. The incidence of POH was significantly higher in Labradors (33%) than non-Labradors (18%). Labradors were at significantly increased risk of postoperative glaucoma and blindness compared to non-Labradors. Estimated probabilities of postoperative glaucoma in Labradors were 23%, 25%, 30% and 35% at weeks 4, 26, 52 and 104, respectively, compared with 5%, 6%, 7% and 9% at weeks 4, 26, 52 and 104, respectively, in non-Labradors. Estimated probabilities of postoperative blindness in Labradors were 5%, 9%, 15% and 27% at weeks 4, 26, 52 and 104, respectively, compared with 2%, 3%, 5% and 10% at weeks 4, 26, 52 and 104, respectively, in non-Labradors. Risk factors for the development of glaucoma in Labradors included increasing age and development of POH. No statistically significant risk factors for the development of glaucoma were identified in non-Labradors. CONCLUSIONS: Labradors are at increased risk of glaucoma and blindness following phacoemulsification compared with non-Labradors. POH and increasing age represent risk factors for the development of postoperative glaucoma in Labradors.

A Report of Information Technology and Health Deficiencies in U.S. Nursing Homes.

OBJECTIVE: The aim of the study was to investigate the impact of nursing home (NH) information technology (IT) sophistication on publically reported health safety deficiency scores documented during standard inspections. METHODS: The sample included 807 NHs from every U.S. state. A total of 2187 health inspections were documented in these facilities. A national IT sophistication survey describing IT capabilities, extent of IT use, and degree of IT integration in resident care, clinical support, and administrative activities in U.S. NHs was used. The relationship between NH health deficiencies and IT sophistication survey scores was examined, using weighted regression. RESULTS: Controlling for registered nurse hours per resident day, deficiency scores decreased as total IT sophistication increased. Controlling for total IT sophistication score, deficiency scores decreased as registered nurse hours per resident day increased. Ownership status significantly influenced health deficiency scores. CONCLUSIONS: These results highlight the necessity to understand benefits of implementing NH IT and demonstrating its impact on patient safety.

Pain management in nursing homes: what do quality measure scores tell us?

Pain management for older adults residing in nursing homes continues to present multifaceted challenges to health care practitioners and researchers. This study, which focuses on improvement in pain assessment and management, is a secondary analysis of data from a larger study, which used an intervention simultaneously directed at all levels of staff with change in quality measure (QM)/quality indicator (QI) scores to determine improvement in resident outcomes. We anticipated that focused improvement efforts in resident care regarding pain management would be reflected by correspondingly lower QM/QI scores over time. Findings of increased QM/QI scores may be positive in that they may point to increased attention by staff regarding pain management for residents.