Prospective Association of Daily Steps With Cardiovascular Disease: A Harmonized Meta-Analysis.

BACKGROUND: Taking fewer than the widely promoted "10 000 steps per day" has recently been associated with lower risk of all-cause mortality. The relationship of steps and cardiovascular disease (CVD) risk remains poorly described. A meta-analysis examining the dose-response relationship between steps per day and CVD can help inform clinical and public health guidelines. METHODS: Eight prospective studies (20 152 adults [ie, ≥18 years of age]) were included with device-measured steps and participants followed for CVD events. Studies quantified steps per day and CVD events were defined as fatal and nonfatal coronary heart disease, stroke, and heart failure. Cox proportional hazards regression analyses were completed using study-specific quartiles and hazard ratios (HR) and 95% CI were meta-analyzed with inverse-variance-weighted random effects models. RESULTS: The mean age of participants was 63.2±12.4 years and 52% were women. The mean follow-up was 6.2 years (123 209 person-years), with a total of 1523 CVD events (12.4 per 1000 participant-years) reported. There was a significant difference in the association of steps per day and CVD between older (ie, ≥60 years of age) and younger adults (ie, <60 years of age). For older adults, the HR for quartile 2 was 0.80 (95% CI, 0.69 to 0.93), 0.62 for quartile 3 (95% CI, 0.52 to 0.74), and 0.51 for quartile 4 (95% CI, 0.41 to 0.63) compared with the lowest quartile. For younger adults, the HR for quartile 2 was 0.79 (95% CI, 0.46 to 1.35), 0.90 for quartile 3 (95% CI, 0.64 to 1.25), and 0.95 for quartile 4 (95% CI, 0.61 to 1.48) compared with the lowest quartile. Restricted cubic splines demonstrated a nonlinear association whereby more steps were associated with decreased risk of CVD among older adults. CONCLUSIONS: For older adults, taking more daily steps was associated with a progressively decreased risk of CVD. Monitoring and promoting steps per day is a simple metric for clinician-patient communication and population health to reduce the risk of CVD.

A Pragmatic Clinical Trial of Hearing Screening in Primary Care Clinics: Effect of Setting and Provider Encouragement.

OBJECTIVES: The prevalence of hearing loss increases with age. Untreated hearing loss is associated with poorer communication abilities and negative health consequences, such as increased risk of dementia, increased odds of falling, and depression. Nonetheless, evidence is insufficient to support the benefits of universal hearing screening in asymptomatic older adults. The primary goal of the present study was to compare three hearing screening protocols that differed in their level of support by the primary care (PC) clinic and provider. The protocols varied in setting (in-clinic versus at-home screening) and in primary care provider (PCP) encouragement for hearing screening (yes versus no). DESIGN: We conducted a multisite, pragmatic clinical trial. A total of 660 adults aged 65 to 75 years; 64.1% female; 35.3% African American/Black completed the trial. Three hearing screening protocols were studied, with 220 patients enrolled in each protocol. All protocols included written educational materials about hearing loss and instructions on how to complete the self-administered telephone-based hearing screening but varied in the level of support provided in the clinic setting and by the provider. The protocols were as follows: (1) no provider encouragement to complete the hearing screening at home, (2) provider encouragement to complete the hearing screening at home, and (3) provider encouragement and clinical support to complete the hearing screening after the provider visit while in the clinic. Our primary outcome was the percentage of patients who completed the hearing screening within 60 days of a routine PC visit. Secondary outcomes following patient access of hearing healthcare were also considered and consisted of the percentage of patients who completed and failed the screening and who (1) scheduled, and (2) completed a diagnostic evaluation. For patients who completed the diagnostic evaluation, we also examined the percentage of those who received a hearing loss intervention plan by a hearing healthcare provider. RESULTS: All patients who had provider encouragement and support to complete the screening in the clinic completed the screening (100%) versus 26.8% with encouragement to complete the screening at home. For patients who were offered hearing screening at home, completion rates were similar regardless of provider encouragement (26.8% with encouragement versus 22.7% without encouragement); adjusted odds ratio of 1.25 (95% confidence interval 0.80-1.94). Regarding the secondary outcomes, roughly half (38.9-57.1% depending on group) of all patients who failed the hearing screening scheduled and completed a formal diagnostic evaluation. The percentage of patients who completed a diagnostic evaluation and received a hearing loss intervention plan was 35.0% to 50.0% depending on the group. Rates of a hearing loss intervention plan by audiologists ranged from 28.6% to 47.5% and were higher compared with those by otolaryngology providers, which ranged from 15.0% to 20.8% among the groups. CONCLUSIONS: The results of the pragmatic clinical trial showed that offering provider encouragement and screening facilities in the PC clinic led to a significantly higher rate of adherence with hearing screening associated with a single encounter. However, provider encouragement did not improve the significantly lower rate of adherence with home-based hearing screening.

Self-Reported Dysphagia and Psychosocial Health Among Community-Dwelling Older Adults: Results of a National Study.

BACKGROUND: The risk of dysphagia increases with age, affecting up to 33% of adults over the age of 65. Older adults with dysphagia are at increased risk for negative physical health outcomes such as aspiration pneumonia and death. However, the relationship between dysphagia and psychosocial health is uncertain in this population. OBJECTIVE: We aimed to assess the associations between dysphagia and psychosocial health among older adults (≥ 65) with self-reported dysphagia. DESIGN: We performed a cross-sectional assessment of the National Health and Aging Trends Study (NHATS) conducted in 2019. MAIN MEASURES: Weighted logistic and linear regression models were used to assess the relationship between self-reported dysphagia and psychosocial health using established patient-reported outcome measures including those for depression, anxiety, and social isolation previously used in NHATS analyses, while adjusting for demographics, comorbid conditions, and risk factors for dysphagia identified by purposeful selection. KEY RESULTS: Among the 4041 adults in this cohort, almost half (40%) were between 70 and 74 years old, more than half were female (55%), and a significantly higher proportion were White, non-Hispanic respondents (78.1%, p < 0.01) compared with other races and ethnicities. There were 428 (10.5%) respondents reporting dysphagia symptoms within the previous month. In the multivariable model, dysphagia was associated with significantly increased odds of anxiety (OR 1.33 [1.06, 1.67]) and a significantly decreased sense of well-being (coefficient - 1.10 [- 1.66, - 0.54]), but no association was detected for social isolation. CONCLUSIONS: When accounting for factors associated with underlying physical health status, self-reported dysphagia is independently associated with negative psychosocial health and warrants attention by healthcare providers. Future studies should aim to identify causal factors and the extent to which interventions may mitigate these factors.

Exploration of model misspecification in latent class methods for longitudinal data: Correlation structure matters.

Modeling longitudinal trajectories and identifying latent classes of trajectories is of great interest in biomedical research, and software to identify latent classes of such is readily available for latent class trajectory analysis (LCTA), growth mixture modeling (GMM) and covariance pattern mixture models (CPMM). In biomedical applications, the level of within-person correlation is often non-negligible, which can impact the model choice and interpretation. LCTA does not incorporate this correlation. GMM does so through random effects, while CPMM specifies a model for within-class marginal covariance matrix. Previous work has investigated the impact of constraining covariance structures, both within and across classes, in GMMs-an approach often used to solve convergence problems. Using simulation, we focused specifically on how misspecification of the temporal correlation structure and strength, but correct variances, impacts class enumeration and parameter estimation under LCTA and CPMM. We found (1) even in the presence of weak correlation, LCTA often does not reproduce original classes, (2) CPMM performs well in class enumeration when the correct correlation structure is selected, and (3) regardless of misspecification of the correlation structure, both LCTA and CPMM give unbiased estimates of the class trajectory parameters when the within-individual correlation is weak and the number of classes is correctly specified. However, the bias increases markedly when the correlation is moderate for LCTA and when the incorrect correlation structure is used for CPMM. This work highlights the importance of correlation alone in obtaining appropriate model interpretations and provides insight into model choice.

A pragmatic clinical trial of hearing screening in primary care clinics: cost-effectiveness of hearing screening.

BACKGROUND: Hearing loss is a high prevalence condition among older adults, is associated with higher-than-average risk for poor health outcomes and quality of life, and is a public health concern to individuals, families, communities, professionals, governments, and policy makers. Although low-cost hearing screening (HS) is widely available, most older adults are not asked about hearing during health care visits. A promising approach to addressing unmet needs in hearing health care is HS in primary care (PC) clinics; most PC providers (PCPs) do not inquire about hearing loss. However, no cost assessment of HS in community PC settings has been conducted in the United States. Thus, this study conducted a cost-effectiveness analysis of HS using results from a pragmatic clinic trial that compared three HS protocols that differed in the level of support and encouragement provided by the PC office and the PCPs to older adults during their routine visits. Two protocols included HS at home (one with PCP encouragement and one without) and one protocol included HS in the PC office. METHODS: Direct costs of the HS included costs of: (1) educational materials about hearing loss, (2) PCP educational and encouragement time, and (3) access to the HS system. Indirect costs for in-office HS included cost of space and minimal staff time. Costs were tracked and modeled for each phase of care during and following the HS, including completion of a diagnostic assessment and follow-up with the recommended treatment plan. RESULTS: The cost-effectiveness analysis showed that the average cost per patient is highest in the patient group who completed the HS during their clinic visit, but the average cost per patient who failed the HS is by far the lowest in that group, due to the higher failure rate, that is, rate of identification of patients with suspected hearing loss. Estimated benefits of HS in terms of improvements in quality of life were also far greater when patients completed the HS during their clinic visit. CONCLUSIONS: Providing HS to older adults during their PC visit is cost-effective and accrues greater estimated benefits in terms of improved quality of life. TRIAL REGISTRATION: clinicaltrials.gov (Registration Identification Number: NCT02928107).

Evaluating the Association Between Hearing Loss and Falls in Adults With Vestibular Dysfunction or Nonvestibular Dizziness.

OBJECTIVES: Although emerging evidence suggests that hearing loss (HL) is an independent risk factor for falls, it is unclear how HL may impact falls risk in adults with vestibular dysfunction and nonvestibular dizziness. The purpose of this study was to characterize the impact of HL on falls in patients with vestibular dysfunction and nonvestibular dizziness relative to a group of patients without dizziness. In addition, this study aimed to evaluate whether there was an interactive effect between HL and vestibular dysfunction or nonvestibular dizziness on the odds of falling. DESIGN: The authors conducted a retrospective cross-sectional study of 2,750 adult patients with dizziness evaluated at a tertiary care center vestibular clinic between June 1, 2015, and October 7, 2020. Only patients with available self-reported falls status, as extracted from the electronic medical record, were included. Patients were classified into the following diagnostic groups based on rotary chair testing and videonystagmography: benign paroxysmal positional vertigo (BPPV, n = 255), unilateral vestibular hypofunction (UVH, n = 456), bilateral vestibular hypofunction (BVH, n = 38), central dysfunction (n = 208), multiple diagnoses (n = 109), and dizzy, nonvestibular (n = 1,389). A control group of patients without dizziness (n = 295) was identified by a random sample of audiology patients. Degree of HL was characterized by the 4-frequency pure tone average (PTA) (0.5, 1, 2, and 4 kHz) of the better hearing ear. Demographic variables, comorbidities, cognitive impairment status, and falls-associated medications were extracted from the electronic medical record and included as covariates during analysis. Potential associations between PTA and falls status and possible interactions between diagnostic group and PTA were explored using multivariate logistic regression. RESULTS: The BVH and central dysfunction groups had the highest rates of self-reported falls at 26.3% and 26.9%, respectively. The control group had the lowest rate of self-reported falls at 6.4%. With the exception of the multiple diagnoses group, all diagnostic groups had elevated odds of falling compared with the control group, when adjusting for demographics, comorbidities, cognitive impairment status, and falls-associated medications. There was no significant association between degree of HL and falls status (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 0.93, 1.11; p = 0.713) when adjusting for diagnostic group and all other covariates. Furthermore, there were no significant interactions between diagnostic group and degree of HL on the odds of falling. CONCLUSIONS: These results indicate that HL was not associated with falls in patients with vestibular dysfunction or nonvestibular dizziness, while adjusting for demographics, comorbidities, and falls-associated medications. There was no significant interactive effect observed between HL and vestibular dysfunction or nonvestibular dizziness on the odds of falling. As previously reported, vestibular dysfunction and nonvestibular dizziness were independently associated with falls relative to a group of patients without dizziness. A population-based study utilizing more robust falls data is needed to explore a potential association between HL and falls in those with vestibular dysfunction.

Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy.

OBJECTIVE: This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy. STUDY DESIGN: This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition. RESULTS: Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts. CONCLUSION: A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases. KEY POINTS: · An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..

Parenthood and Medical Training: Challenges and Experiences of Physician Moms in the US.

Phenomenon: Balancing the demands of medical training and parenthood is challenging. We explored perceptions of programmatic support, parental leave, breastfeeding, and self-reported biggest challenges among a large cohort of physician mothers in a variety of medical specialties and across the stage of training when they had their first child. Our goal was to inform strategies to help improve the physician parent experience. Approach: This cross-sectional, observational survey study was performed using a convenience sample from an online physician-mom support group from January to February 2018. Descriptive statistics and bivariate analyses were used to report results and examine relationships between career stage at first child and outcome variables. Responses to the open-ended question, "What is your biggest challenge as a physician mom?" were qualitatively analyzed. Findings: The survey received 896 complete responses. The most common specialties were obstetrics and gynecology (25.3%), pediatrics (19.9%), internal medicine or medicine/pediatrics (17.1%), and family medicine (10.2%). The majority of participants (63.9%) had their first child during medical training, including medical school (14.3%), residency (35.8%) or fellowship (13.6%). Medical students were less likely to perceive programmatic support than residents or fellows (44.1% vs. 63.1% vs. 62.3%, respectively), and only 19.9% of participants who became parents during medical training reported having a clear and adequate parental leave policy. Nearly 70% of participants breastfed for six months or more, with no statistical differences across career stage. Most participants (57.6%) delayed child-bearing for one or more reasons, with 32.3% delaying to complete training. The most common codes applied to responses for 'biggest challenges as a physician mom' were insufficient time, lack of work-life balance, missing out, and over-expectation. Insights: Physician mothers, particularly those who had their first child during training, continue to struggle with support from training programs, finding work-life balance, and feelings of inadequacy. Interventions such as clear and adequate leave policies, program-sponsored or onsite childcare and improved programmatic support of breastfeeding and pumping may help to ameliorate the challenges described by our participants.

Traumatic brain injury and dementia risk in male veteran older twins-Controlling for genetic and early life non-genetic factors.

INTRODUCTION: This study leveraged the twin study design, which controls for shared genetic and early life exposures, to investigate the association between traumatic brain injury (TBI) and dementia. METHODS: Members of the National Academy of Sciences-National Research Council's Twins Registry of World War II male veterans were assigned a cognitive outcome based on a multi-step assessment protocol. History of TBI was obtained via interviews. RESULTS: Among 8302 individuals, risk of non-Alzheimer's disease (non-AD) dementia was higher in those with TBI (hazard ratio [HR] = 2.00, 95% confidence interval [CI], 0.97-4.12), than for AD (HR = 1.23, 95% CI, 0.76-2.00). To add more control of genetic and shared environmental factors, we analyzed 100 twin pairs discordant for both TBI and dementia onset, and found TBI-associated risk for non-AD dementia increased further (McNemar odds ratio = 2.70; 95% CI, 1.27-6.25). DISCUSSION: These findings suggest that non-AD mechanisms may underlie the association between TBI and dementia, potentially providing insight into inconsistent results from prior studies.

Impact of a Novel Training Approach on Hemodynamic and Vascular Profiles in Older Adults.

Exercise training beneficially moderates the effects of vascular aging. This study compared the efficacy of Peripheral Remodeling through Intermittent Muscular Exercise (PRIME), a novel training regimen, versus aerobic training on hemodynamic profiles in participants ≥70 years at risk for losing functional independence. Seventy-five participants (52 females, age: 76 ± 5 years) were assessed for hemodynamic and vascular function at baseline, after 4 weeks of either PRIME or aerobic training (Phase 1) and again after a further 8 weeks of aerobic and resistance training (Phase 2). Data were analyzed using 2 × 2 repeated-measures analysis of variance models on the change in each dependent variable. PRIME demonstrated reductions in brachial and aortic mean arterial pressure and diastolic blood pressure (p < .05) from baseline after Phase 1, which were sustained throughout Phase 2. Earlier and greater reductions in blood pressure following PRIME support the proposal that peripheral muscular training could beneficial for older individuals commencing an exercise program.

Assessing patient perceptions of cytomegalovirus infection in pregnancy.

Pregnant women impacted by cytomegalovirus (CMV) make clinical decisions despite uncertain outcomes. Intolerance of uncertainty score (IUS) is a validated measure of tendency for individuals to find unacceptable that a negative event might occur. We investigated patient perceptions of CMV infection during pregnancy and correlated IUS and knowledge with decision-making. Electronic questionnaire was sent to women from July to August 2017. The questionnaire evaluated knowledge of CMV, IUS, and responses regarding management to three clinical scenarios with escalating risk of CMV including choices for no further testing, ultrasound, amniocentesis, or abortion. For each scenario, logistic regression was used to model IUS on responses. A total of 815 women were included. The majority of participants was white (63.1%) and 42% had a postgraduate degree. Over 70% reported that they had not previously heard of CMV. In the scenario with only CMV exposure, participants with increasing IUS were more likely to choose abortion (odds ratio [OR] = 1.04; 95% confidence interval [CI]: 1.01, 1.06) and no further testing (OR = 0.97; 95% CI: 0.95, 0.99). In the scenario with mild ultrasound findings in setting of CMV exposure, increasing IUS was associated with higher odds of choosing no further testing (OR = 0.97; 95% CI, 0.94, 0.99). No significant association was observed between IUS and responses in the scenario with severe ultrasound abnormalities in setting of CMV exposure. The majority of patients had no knowledge of CMV. Higher IUS was associated more intervention in low severity scenarios, but in severe scenarios, IUS was not associated with participants' choices.

Beet the Best?

RATIONALE: A primary goal of therapy for patients with peripheral artery disease (PAD) and intermittent claudication is increased ambulatory function. Supervised exercise rehabilitation was recently shown to confer superior walking benefits to pharmacological or surgical interventions. Increases in plasma inorganic nitrite, via oral nitrate, have been shown to increase exercise performance in both human and animal models, especially in hypoxic conditions. OBJECTIVE: To determine whether a 36-session exercise rehabilitation program while consuming oral inorganic nitrate (4.2 mmol concentrated beetroot juice) would produce superior benefits over exercise plus placebo in pain-free walking and markers of increased skeletal muscle perfusion in patients with PAD and intermittent claudication. METHODS AND RESULTS: This was a randomized, double-blind, per-protocol study design. After the 12-week protocol, claudication onset time on a maximal treadmill test increased by 59.2±57.3 s for the exercise plus placebo group (n=13) and by 180.3±46.6 s for the exercise plus beetroot juice group (n=11; P≤0.05). This produced a between treatment medium to large standardized effect size (Cohen d) of 0.62 (95% CI, -0.23 to +1.44). The data for 6-minute walk distance showed a similar pattern with increases of 24.6±12.1 and 53.3±19.6 m ( P≤0.05) in the exercise plus placebo and exercise plus beetroot juice groups, respectively. Measures of gastrocnemius perfusion, including ankle-brachial index, peak reactive hyperemic blood flow, and tissue deoxygenation characteristics, during exercise (assessed my near-infrared spectroscopy) all changed significantly for the exercise plus beetroot juice group with moderate-to-large effect sizes over exercise plus placebo changes. CONCLUSIONS: Although it is premature to speculate on overall clinical utility of a nitrate-based therapy for PAD, this early pilot study evidence is encouraging. Specifically, our data suggests that increasing plasma nitrite before exercise may allow PAD subjects to train with less pain, at higher workloads for longer durations at each training session, thereby maximizing the beneficial peripheral vascular and skeletal muscle adaptations. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01684930 and NCT01785524.

Age matters: older age as a risk factor for CMV reactivation in the CMV serostatus-positive kidney transplant recipient.

Evaluate risk factors for cytomegalovirus (CMV) reactivation during the first year after kidney transplantation in the CMV-seropositive older recipient. Retrospective single-center study. Between 2011 and 2015, 91 patients ≥ 65 years received a kidney transplant; these were matched with 91 controls, aged 40-60. Risk of CMV reactivation in the CMV-seropositive recipients was analyzed. Sixty-three older and 54 younger recipients were included; 50% had received CMV-directed prophylaxis. CMV reactivation was significantly more frequent in the older group (71.4% vs 44.4%, p = 0.003) and occurred earlier (p = 0.003). A multivariate model showed that only age was associated with CMV reactivation (OR 2.48, p = 0.03). After excluding patients that received thymoglobulin, older age group remained the only risk factor of CMV reactivation (OR 3.81, p = 0.014). Recurrent event analysis showed that the older cohort had an HR of 1.94 (p = 0.01) of CMV viremia; there was significant episode-cohort interaction (p < 0.01). While the older group had a higher risk of infection (HR = 2.43), after the initial episode the relative hazards were approximately equal (HR = 1.08, at period 2). This suggests that it is key to specifically avoid the first episode of reactivation. Universal prophylaxis or a hybrid prophylaxis model should be considered in the CMV-seropositive kidney transplant recipient aged ≥ 65 years.

Comparative implementation-effectiveness of three strategies to perform hearing screening among older adults in primary care clinics: study design and protocol.

BACKGROUND: The burden of hearing loss among older adults could be mitigated with appropriate care. This study compares implementation of three hearing screening strategies in primary care, and examines the reliability and validity of patient self-assessment, primary care providers (PCP) and diagnostic audiologists in the identification of 'red flag' conditions (those conditions that may require medical consultation and/or intervention). METHODS: Six primary care practices will implement one of three screening strategies (2 practices per strategy) with 660 patients (220 per strategy) ages 65-75 years with no history of hearing aid use or diagnosis of hearing loss. Strategies differ on the location and use of PCP encouragement to complete a telephone-based hearing screen (tele-HS). Group 1: instructions for tele-HS to complete at home and educational materials on warning signs and consequences of hearing loss. Group 2: PCP counseling/encouragement on importance of hearing screening, instructions to take the tele-HS from home, educational materials. Group 3: PCP counseling/encouragement, in-office tele-HS, and educational materials. Patients from all groups who fail the tele-HS will be referred for diagnostic audiological testing and medical evaluation, and complete a self-assessment of red flag conditions at this follow-up appointment. Due to the expected low incidence of ear disease in the PCP cohort, we will enroll a complementary population of patients (N = 500) from selected otolaryngology head and neck surgery clinics in a national practice-based research network to increase the likelihood of occurrence of medical conditions that might contraindicate hearing aid fitting. The primary outcome is the proportion of patients who complete the tele-HS within 2 months of the PCP appointment comparing Group 3 (PCP encouragement, in-office tele-HS, education) versus Groups 2 and 1 (education and tele-HS at home, with and without PCP encouragement, respectively). The several secondary outcomes include direct and indirect costs, patient, family and provider attitudes of hearing healthcare, and accuracy of red flag condition evaluations compared with expert medical assessment by an otolaryngology provider. DISCUSSION: Determining the relative effectiveness of three different strategies for hearing screening in primary care and the assessment accuracy of red flag conditions can each lead to practice and policy changes that will reduce individual, family and societal burden from hearing loss among older adults. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02928107; 10/10/2016 protocol version 1.

Pilot randomized controlled trial of exercise training for older veterans with PTSD.

Exercise training positively impacts mental health, yet remains untested in older adults with posttraumatic stress disorder (PTSD). We conducted a randomized controlled pilot trial to test the feasibility and acceptability of exercise training in older veterans with PTSD. Fifty-four veterans ≥ 60 years, with a DSM-V diagnosis of PTSD, were randomized to supervised exercise (n = 36) or wait-list (WL; n = 18). Primary outcomes included recruitment rates, attendance, satisfaction, and retention. Secondary outcomes included changes in PTSD symptoms, depression, health-related quality of life, and sleep quality; assessed at baseline and 12 weeks. There were no adverse events. Attrition was minimal (14%), and adherence to the exercise intervention was high (82%). Clinically significant improvements in PTSD and related conditions were observed following exercise (Cohen's d = 0.36-0.81). Exercise training is safe and acceptable in older adults with PTSD, may improve PTSD symptoms, and broadly impacts PTSD-related conditions. Future definitive trials are warranted.

Cost trajectories as a measure of functional resilience after hospitalization in older adults.

BACKGROUND: Administrative data sets lack functional measures. AIM: We examined whether trajectories of cost can be used as a marker of functional recovery after hospitalization. METHODS: Secondary analysis of the National Health and Aging Trends Study merged with Centers for Medicare and Medicaid Services data. Community-dwelling participants with a first hospitalization occurring after any annual survey were included (N = 937). Monthly total cost trajectories were constructed for the 3 months before and 3 months following hospitalization. Growth mixture models identified groups of patients with similar trajectories. The association of cost classes with five functional outcomes was examined using multivariate models, controlling for pre-hospitalization function and lead time. RESULTS: Four cost trajectory classes describing common recovery patterns were identified-persistently high, persistently moderate, low-spike-recover, and low variable. Cost class membership was significantly associated with change in Activities of Daily Living (ADL), instrumental ADL, Short Physical Performance Battery, and grip strength (p < 0.005), but not gait speed (p = 0.08). The proportion of patients who maintained or improved SPPB score was 46.8% in the persistently high, 49.2% in the persistently moderate, 52.7% in the low-spike-recover, and 57.2% in the low-variable groups. In models adjusted for known predictors of functional outcome, the magnitude and direction of association was maintained but significance was lost, indicating that cost trajectories' mirror is mediated by predictors of recovery not available in administrative data. CONCLUSION: Cost trajectories and total costs are associated with functional recovery following hospitalization in older adults. Cost may be useful as a measure of recovery in administrative data.

Physical Activity in the Hospital: Documentation and Influence on Venous Thromboembolism Prophylaxis.

This study describes the availability of physical activity information in the electronic health record, explores how electronic health record documentation correlates with accelerometer-derived physical activity data, and examines whether measured physical activity relates to venous thromboembolism (VTE) prophylaxis use. Prospective observational data comes from community-dwelling older adults admitted to general medicine (n = 65). Spearman correlations were used to examine association of accelerometer-based daily step count with documented walking distance and with duration of VTE prophylaxis. Only 52% of patients had documented walking in nursing and/or physical therapy/occupational therapy notes during the first three hospital days. Median daily steps recorded via accelerometer was 1,370 (interquartile range = 854, 2,387) and correlated poorly with walking distance recorded in physical therapy/occupational therapy notes (median 33 feet/day [interquartile range = 12, 100]; r = .24; p = .27). Activity measures were not associated with use or duration of VTE prophylaxis. VTE prophylaxis use does not appear to be directed by patient activity, for which there is limited documentation.

A study of decompression sickness using recorded depth-time profiles.

Introduction: 122,129 dives by 10,358 recreational divers were recorded by dive computers from 11 manufacturers in an exploratory study of how dive profile, breathing gas (air or nitrox [N2/O2] mixes), repetitive diving, gender, age, and dive site conditions influenced observed decompression sickness (DCSobs). Thirty-eight reports were judged as DCS. Overall DCSobs was 3.1 cases/104 dives. Methods: Three dive groups were studied: Basic (live-aboard and shore/dayboat), Cozumel Dive Guides, and Scapa Flow wreck divers. A probabilistic decompression model, BVM(3), controlled dive profile variability. Chi-squared test, t-test, logistic regression, and log-rank tests evaluated statistical associations. Results: (a) DCSobs was 0.7/104 (Basic), 7.6/104 (Guides), and 17.3/104 (Scapa) and differed after control for dive variability (p ≺ 0.001). (b) DCSobs was greater for 22%-29% nitrox (12.6/104) than for 30%-50% nitrox (2.04/104) (p ≤ 0.0064) which did not differ from air (2.97/10104). (c) For daily repetitive dives (≺12-hour surface intervals (SI)), DCS occurred only following one or two dives (4.3/10104 DCSobs; p ≺ 0.001) where SIs were shorter than after three or more dives. (d) For multiday repetitive dives (SIs ≺ 48 hours), DCS was associated with high multiday repetitive dive counts only for Guides (p = 0.0018). (e) DCSobs decreased with age at 3%/year (p ≤ 0.0144). (f) Males dived deeper (p ≺ 0.001) but for less time than females (p ≺ 0.001). Conclusion: Collecting dive profiles with dive computers and controlling for profile variability by probabilistic modeling was feasible, but analytical results require independent confirmation due to limited observed DCS. Future studies appear promising if more DCS cases are gathered, stakeholders cooperate, and identified data collection problems are corrected.

Impact of a documentation intervention on health-assessment metrics on an inpatient gynecologic oncology service.

OBJECTIVE: Accurate documentation is critical for patient care and hospital reimbursement. We sought to improve the accuracy of severity of illness (SOI) and risk of mortality (ROM) scores through implementation of documentation initiatives. METHODS: We performed a pre- versus post-implementation analysis to assess the impact of a documentation intervention bundle on calculated admission/discharge SOI/ROM scores on an inpatient gynecologic oncology service. Introduced in January 2017, the bundle included educational in-service, introduction of problem-based progress notes, a documentation tip ID badge and video, and weekly chart audits. Admission/discharge SOI/ROM scores (range 1-4) were obtained from hospital performance services. Demographics and 30-day mortality were collected from electronic medical records for all inpatients in historic (calendar year 2015) and intervention (2017) cohorts. Primary outcomes (discharge SOI/ROM) were modelled using ordinal and multinomial logistic regressions, controlling for confounders. 30-day observed/expected mortality ratios were reported for each cohort. RESULTS: 629 patients were included: 378 (60%) in 2015, 251 (40%) in 2017. Increased odds of having higher SOI score were observed in the intervention cohort for medical (OR = 2.22; 95% CI 1.38, 3.58) and surgical admissions (OR = 2.63; 95% CI 1.47, 4.40). Surgical (OR = 5.54; 95% CI 1.29, 23.96), but not medical (OR = 1.45; 95% CI 0.46, 4.57), admissions in the intervention cohort had higher odds of having the worst ROM score. Observed/expected mortality was 0.24 in the intervention compared to 0.37 in historic cohort (p = 0.58, NS). CONCLUSION: An intervention bundle to improve physician documentation accuracy resulted in higher discharge SOI scores for medical and surgical admissions.

Intraoperative Renal Resistive Index as an Acute Kidney Injury Biomarker: Development and Validation of an Automated Analysis Algorithm.

OBJECTIVE: Intraoperative Doppler-determined renal resistive index (RRI) is a promising early acute kidney injury (AKI) biomarker. As RRI continues to be studied, its clinical usefulness and robustness in research settings will be linked to the ease, efficiency, and precision with which it can be interpreted. Therefore, the authors assessed the usefulness of computer vision technology as an approach to developing an automated RRI-estimating algorithm with equivalent reliability and reproducibility to human experts. DESIGN: Retrospective. SETTING: Single-center, university hospital. PARTICIPANTS: Adult cardiac surgery patients from 7/1/2013 to 7/10/2014 with intraoperative transesophageal echocardiography-determined renal blood flow measurements. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Renal Doppler waveforms were obtained retrospectively and assessed by blinded human expert raters. Images (430) were divided evenly into development and validation cohorts. An algorithm for automated RRI analysis was built using computer vision techniques and tuned for alignment with experts using bootstrap resampling in the development cohort. This algorithm then was applied to the validation cohort for an unbiased assessment of agreement with human experts. Waveform analysis time per image averaged 0.144 seconds. Agreement was excellent by intraclass correlation coefficient (0.939; 95% confidence interval [CI] 0.921 to 0.953) and in Bland-Altman analysis (mean difference [human-algorithm] -0.0015; 95% CI -0.0054 to 0.0024), without evidence of systematic bias. CONCLUSION: The authors confirmed the value of computer vision technology to develop an algorithm for RRI estimation from automatically processed intraoperative renal Doppler waveforms. This simple-to-use and efficient tool further adds to the clinical and research value of RRI, already the "earliest" among several early AKI biomarkers being assessed.