Modeling the resiliency of energy-efficient retrofits in low-income multifamily housing.

Residential energy efficiency and ventilation retrofits (eg, building weatherization, local exhaust ventilation, HVAC filtration) can influence indoor air quality (IAQ) and occupant health, but these measures' impact varies by occupant activity. In this study, we used the multizone airflow and IAQ analysis program CONTAM to simulate the impacts of energy retrofits on indoor concentrations of PM2.5 and NO2 in a low-income multifamily housing complex in Boston, Massachusetts (USA). We evaluated the differential impact of residential activities, such as low- and high-emission cooking, cigarette smoking, and window opening, on IAQ across two seasons. We found that a comprehensive package of energy and ventilation retrofits was resilient to a range of occupant activities, while less holistic approaches without ventilation improvements led to increases in indoor PM2.5 or NO2 for some populations. In general, homes with simulated concentration increases included those with heavy cooking and no local exhaust ventilation, and smoking homes without HVAC filtration. Our analytical framework can be used to identify energy-efficient home interventions with indoor retrofit resiliency (ie, those that provide IAQ benefits regardless of occupant activity), as well as less resilient retrofits that can be coupled with behavioral interventions (eg, smoking cessation) to provide cost-effective, widespread benefits.

Telephone follow-up by nurse practitioners of geriatric patients discharged from the emergency department after traumatic injury.

INTRODUCTION: Geriatric patients discharged from the emergency department (ED) after an injury are at risk for adverse outcomes. Older patients are at a higher risk for sensory impairments and cognitive problems which can make comprehension of discharge instructions more difficult. Moreover, geriatric patients often have limited skills with or access to alternative sources of information, such as hospital web pages or phone applications, which could put them at a higher risk of undertreatment. Implementing telephone follow-up after discharge presents a potential solution to enhance information transfer and address problems related to the injury. METHODS: An exploratory cohort study was conducted in the ED of an inner-city hospital in the Netherlands between 2019-2020. Patients ≥70 years were included if they presented with an injury and were discharged home from the ED. Telephone follow-up was performed by an ED nurse practitioner within 48 hours after discharge to address any problems or questions relating to the injury. Feasibility was assessed by determining whether the intervention could be performed within the allotted time period during normal work hours (1 h per day). The frequency and type of additional advice given, as well as patient satisfaction with the intervention, were documented. RESULTS: 635 patients were eligible for inclusion, and 266 completed the intervention (median age 77 years; 32 % male). Nurse practitioners were able to complete the intervention on over 90 % of days. A total of 64 % of patients received additional advice during the telephone call, mostly related to pain medication adjustments and instructions to contact their GP. Patient satisfaction with the intervention was high (median score 8/10). CONCLUSION: Telephone follow-up is a feasible intervention that may be able to enhance older patients' comprehension of discharge instructions and help identify new problems after discharge. During the follow-up call, the majority of patients received additional advice, indicating a potential demand for this intervention. The main limitation was that not all eligible patients were approached or did not want to participate in the intervention. Future studies should investigate whether telephone follow-up can effectively reduce adverse events and improve the quality of life for these patients.

Formaldehyde concentrations in household air of asthma patients determined using colorimetric detector tubes.

Formaldehyde is a colorless, pungent gas commonly found in homes and is a respiratory irritant, sensitizer, carcinogen, and asthma trigger. Typical household sources include plywood and particleboard, cleaners, cosmetics, pesticides, and others. Development of a fast and simple measurement technique could facilitate continued research on this important chemical. The goal of this research is to apply an inexpensive short-term measurement method to find correlations between formaldehyde sources and concentration, and formaldehyde concentration and asthma control. Formaldehyde was measured using 30-min grab samples in length-of-stain detector tubes in homes (n = 70) of asthmatics in the Boston, MA area. Clinical status and potential formaldehyde sources were determined. The geometric mean formaldehyde level was 35.1 ppb and ranged from 5 to 132 ppb. Based on one-way ANOVA, t-tests, and linear regression, predictors of log-transformed formaldehyde concentration included absolute humidity, season, and the presence of decorative laminates, fiberglass, or permanent press fabrics (P < 0.05), as well as temperature and household cleaner use (P < 0.10). The geometric mean formaldehyde concentration was 57% higher in homes of children with very poorly controlled asthma compared to homes of other asthmatic children (P = 0.078). This study provides a simple method for measuring household formaldehyde and suggests that exposure is related to poorly controlled asthma.

Does postacute care site matter? A longitudinal study assessing functional recovery after a stroke.

OBJECTIVE: To determine the impact of postacute care site on stroke outcomes. DESIGN: Prospective cohort study. SETTING: Four northern California hospitals that are part of a single health maintenance organization. PARTICIPANTS: Patients with stroke (N=222) enrolled between February 2008 and July 2010. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Baseline and 6-month assessments were performed using the Activity Measure for Post Acute Care (AM-PAC), a test of self-reported function in 3 domains: Basic Mobility, Daily Activities, and Applied Cognition. RESULTS: Of the 222 patients analyzed, 36% went home with no treatment, 22% received home health/outpatient care, 30% included an inpatient rehabilitation facility (IRF) in their care trajectory, and 13% included a skilled nursing facility (but not IRF) in their care trajectory. At 6 months, after controlling for important variables such as age, functional status at acute care discharge, and total hours of rehabilitation, patients who went to an IRF had functional scores that were at least 8 points higher (twice the minimally detectable change for the AM-PAC) than those who went to a skilled nursing facility in all 3 domains and in 2 of 3 functional domains compared with those who received home health/outpatient care. CONCLUSIONS: Patients with stroke may make more functional gains if their postacute care includes an IRF. This finding may have important implications as postacute care delivery is reshaped through health care reform.

[Validation of the German version of the Singing Voice Handicap Index]. / Validierung des Singing Voice Handicap Index in der deutschen Fassung.

The Singing Voice Handicap Index (SVHI) was developed in the United States for the self-assessment of patients with singing problems. It has been translated into German and its reliability and validity have been assessed. In total, 54 (35 female, 19 male) dysphonic singers and 130 (74 female, 56 male) non-dysphonic professional singers were included in the study. Reliability rested on high test-retest reliability (r = 0.960, p ≤ 0.001, Pearson correlation) and a Cronbach's α of 0.975. A principal component analysis using the Varimax method and the results of the screeplot suggest the SVHI scored as a single scale. Validity rested on a highly significant correlation between the severity of the self-rated voice impairment by the patient and the total SVHI score. Dysphonic singers have significantly higher SVHI scores than healthy singers. The SVHI is thus suited to implementation as a diagnostic tool in German-speaking countries.

Evaluation of patient and proxy responses on the activity measure for postacute care.

BACKGROUND AND PURPOSE: Our objective was to examine the agreement between adult patients with stroke and family member or clinician proxies in activity measure for postacute care (AM-PAC) summary scores for daily activity, basic mobility, and applied cognitive function. METHODS: This study involved 67 patients with stroke admitted to a hospital within the Kaiser Permanente of Northern California system and were participants in a parent study on stroke outcomes. Each participant and proxy respondent completed the AM-PAC by personal or telephone interview at the point of hospital discharge or during ≥1 transitions to different postacute care settings. RESULTS: The results suggest that for patients with a stroke proxy, AM-PAC data are robust for family or clinician proxy assessment of basic mobility function and clinician proxy assessment of daily activity function, but less robust for family proxy assessment of daily activity function and for all proxy groups' assessments of applied cognitive function. The pattern of disagreement between patient and proxy was, on average, relatively small and random. There was little evidence of systematic bias between proxy and patient reports of their functional status. The degree of concordance between patient and proxy was similar for those with moderate to severe strokes compared with mild strokes. CONCLUSIONS: Patient and proxy ratings on the AM-PAC achieved adequate agreement for use in stroke research when using proxy respondents could reduce sample selection bias. The AM-PAC data can be implemented across institutional as well as community care settings while achieving precision and reducing respondent burden.

Prevalence of depression and anxiety disorders following mild traumatic brain injury.

BACKGROUND: Previous studies have identified an association between traumatic brain injuries and the development of psychiatric disorders in general. However, these studies were subject to limitations that demonstrate the need for a study of a large, clearly defined mild traumatic brain injury (mTBI) population within an integrated healthcare system. OBJECTIVE: To determine the prevalence and relative risk of postinjury affective disorders over 4 years following mTBI. DESIGN: Cohort study of mTBI cases and matched controls, over a 4-year period. SETTING: An integrated healthcare delivery system in California. PATIENTS: A total of 9428 adult health plan members diagnosed with mTBI from 2000-2007 and enrolled in the year before injury, during which no TBI was ascertained. Control participants included 18,856 individuals selected based on the following criteria: Two unexposed health plan members per each mTBI-exposed patient were randomly selected and individually matched for age, gender, race/ethnicity, and medical comorbidities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A diagnosis of affective disorder (depressive, anxiety, and adjustment disorders) in the 4 years after mTBI or the reference date, determined according to the International Classification of Diseases, Ninth Revision, Clinical Modification as well as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS: Affective disorders were most prominent during the first 12 months with 23% following mTBI and 14% in the control group. Four-year aggregate adjusted odds ratios for having an affective disorder following mTBI were 1.2 (95% CI: 1.1, 1.2; p < .001) and 1.5 (95% CI: 1.5, 1.6; p < .001) for patients with and without prior affective disorders, respectively. CONCLUSION: mTBI was associated with a significantly increased risk of having subsequent affective disorders. Screening for and addressing affective disorders at earlier stages following the injury is an important step to avoid persisting conditions that may pose a barrier to full recovery.

Stroke, disability, and unconscious bias: interrelationships and over-determination in medical decisions.

Many factors influence what and how we communicate with patients after stroke. As physicians, we have a responsibility to examine our medical decisions and prognostication regarding each stroke patient. We must understand how many factors come into play in decisions regarding care, including perspectives that reflect the specific training of physicians in various specialties. How the physician responds to the patient with a stroke is highly individual. The more familiar the physician is with stroke recovery and the more time he or she has for individualized and less automatic approaches, the less likely decisions will be reflexive, based on bias. By examining our unconscious biases, we can provide individualized care that gives patients more latitude to create their own stories of recovery.

The impact of hypopituitarism on function and performance in subjects with recent history of traumatic brain injury and aneurysmal subarachnoid haemorrhage.

PRIMARY OBJECTIVE: To correlate deficient pituitary function with life satisfaction and functional performance in subjects with a recent history of traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH). RESEARCH DESIGN: Cross-sectional study. METHODS AND PROCEDURES: Eighteen subjects with TBI and 16 subjects with SAH underwent pituitary hormonal and functional assessments 5-12 months following the event. Adrenal reserve was assessed with a 1 mcg cosyntropin stimulation test and growth hormone deficiency (GHD) was diagnosed by insufficient GH response to GHRH-Arginine stimulation. Assessments of life satisfaction and performance-function included the Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART) and the Mayo Portland Adaptability Inventory-4 (MPAI-4). RESULTS: Hypopituitarism was present in 20 (58.8%) subjects, including 50% with adrenal insufficiency. Hypothyroidism correlated with worse performance on SWLS and CHART measures. GHD was associated with poorer performance on CHART and MPAI-4 scale. CONCLUSIONS: In this series of subjects with history of TBI and SAH, hypothyroidism and GHD were associated with diminished life satisfaction and performance-function on multiple assessments. Further studies are necessary to determine the appropriate testing of adrenal reserve in this population and to determine the benefit of pituitary hormone replacement therapy on function following brain injury.

Development of phosphorylated glucomannan-coated chitosan nanoparticles as nanocarriers for protein delivery.

The aim of the present work was to develop a new nanoparticle carrier, adapted for the oral administration of proteins and their delivery to the immune system. Chitosan and phosphorylated glucomannan were chosen as major constituents of the nanoparticles. Chitosan nanoparticles were formed by ionic gelation and then coated with glucomannan. Two different protocols were adopted for the formation of the glucomannan coating: protocol I, in which chitosan nanoparticles were isolated before their coating; protocol II, in which chitosan nanoparticles were not isolated, but coated with glucomannan in the presence of free chitosan. The results showed that, under the selected formulation conditions, the sizes of the nanoparticles ranged between 170 and 300 nm and their zeta potential values were inverted from positive to negative by the glucomannan coating. The nanoparticles prepared by the two protocols could be freeze-dried, in the presence or absence of cryoprotective agents, preserving their original characteristics. The results of the stability study evidenced the positive role of the glucomannan coating in preventing the aggregation of the nanoparticles in buffered media. Finally, the association of the inmunomodulatory protein complex P1 to the chitosan-glucomannan nanoparticles was investigated. The results showed that the association was not dependent on the chitosan: sodium tripoliphosphate ratio, but it was significantly affected by the presence of sodium phosphate in the protein structure.

Natural killer cells infiltrating colorectal cancer and MHC class I expression.

A majority of colorectal adenocarcinomas displays diminished MHC class I expression, making them particularly vulnerable for NK cell-mediated killing. Generally, these tumors also show a substantial inflammatory infiltrate. Most inflammatory cells, however, reside in the tumor stroma, where they do not have direct contact with tumor cells in the tumor epithelium. In this study, we investigated the correlation between colorectal tumor MHC class I aberrations and infiltration of NK cells. We studied 88 tumor specimens obtained from 88 colorectal cancer patients for locus-specific HLA aberrations and correlated these data to infiltration of CD4, CD8+ and CD56+ lymphocytes. The lymphocyte markers were individually combined with laminin as a second marker to facilitate quantification in the different tumor compartments, i.e. tumor epithelium and tumor stroma. Locus-specific partial or total HLA class I loss was detected in 72% of the tumors studied. Twenty-eight percent had no HLA loss at all. Mean overall intra-epithelial infiltration of CD56+ lymphocytes was 7 cells/mm(2) compared to 76 cells/mm(2) for CD8 and 19 cells/mm(2) for CD4+ lymphocytes. Locus-specific partial or total loss of tumor cell MHC class I expression was positively correlated with the intra-epithelial infiltration of CD8+ cells (P = 0.01), but not with CD4+ or CD56+ lymphocytes. Triple immunofluorescence staining showed that these cells were CD8 and granzyme-B positive T-lymphocytes. Our data showed that colorectal tumors are sparsely infiltrated by CD56+ cells compared to CD8+ T-cells and that loss of MHC is associated with T-cell infiltration instead of NK cell infiltration. Considering the fact that MHC loss is quite common in colorectal cancer and that, due to local absence of NK cells, it is unlikely that there has been selection for NK-escape variants, improvement of the intra-epithelial infiltration/migration of NK cells may be an important basis for the development of an effective adjuvant NK-based immunotherapy of colorectal cancer.

Evidence of covert recognition in a prosopagnosic patient.

This is a case-study of a patient (ET) who suffers from prosopagnosia, in the context of impairment to cognitive functions, following traumatic brain injury. Despite severe perceptual difficulties in tests involving non-face stimuli and matching unfamiliar faces, ET showed evidence of "covert" recognition of familiar faces in a number of tasks. Although densely prosopagnosic, she performed at normal levels in word and object recognition tasks, and is unimpaired in her ability to recognise names of celebrities. She performed at the same level as controls in her ability to make a forced-choice of the correct name for a famous face, even though it evoked no feeling of familiarity for her. She performed at chance in a forced-choice face familiarity decision task, but showed evidence of covert recognition in a "true" versus "untrue" face-name learning task. ET showed overt recognition of some famous faces using a procedure based on Sergent and Poncet's (1990) semantic activation task. The pattern of impairment of ET's face processing abilities is interpreted in terms of an interactive activation model of face processing.

Proton magnetic resonance spectroscopy for detection of axonal injury in the splenium of the corpus callosum of brain-injured patients.

OBJECT: This study was conducted to determine whether proton magnetic resonance spectroscopy (MRS) is a sensitive method for detecting diffuse axonal injury, which is a primary sequela of traumatic brain injury (TBI). Diffuse axonal injury is characterized by selective damage to white matter tracts that is caused in part by the severe inertial strain created by rotational acceleration and deceleration, which is often associated with motor vehicle accidents. This axonal injury is typically difficult to detect by using conventional imaging techniques because it is microscopic in nature. The splenium was selected because it is a site vulnerable to shearing forces that produce diffuse axonal injury. METHODS: The authors used proton MRS to evaluate the splenium, the posterior commissure of the corpus callosum, in normal control volunteers and in patients with TBI. Proton MRS provided an index of neuronal and axonal viability by measuring levels of N-acetyl aspartate (NAA). CONCLUSIONS: A majority of mildly brain injured patients, as well as those more severely injured, showed diminished NAA/creatine (Cr) levels in the splenium compared with normal control volunteers. The patients displaying lowered NAA/Cr in the splenium were also likely to exhibit lowered NAA/Cr in lobar white matter. Also, the levels of NAA/Cr in the splenium of normal volunteers were higher compared with those found in lobar white matter. Decreases in NAA/Cr levels in the splenium may be a marker for diffuse injury. A proton MRS examination may be particularly useful in evaluating mildly injured patients with unexplained neurological and cognitive deficits. It is concluded that MRS is a sensitive tool in detecting axonal injury.

Medical management of the comatose, vegetative, or minimally responsive patient.

This review outlines the range of medical problems occurring in brain injured patients in coma or emerging from coma, including the population of vegetative and minimally responsive patients. This range of medical problems includes those associated with the original brain injury or associated injuries, those representing complications of bedrest, and those caused by the use of medications that may retard recovery or contribute to an obtunded or comatose state. The review is organized by organ systems, each section including a brief discussion with reference to more indepth discussions in other sources. A number of algorithms are included to define approaches to evaluation of common clinical presentations which may be helpful to clinicians treating this population in acute or subacute settings.

An interdisciplinary perspective on the agitated brain injured patient.

The Special Interest Group on Brain Injury of the American Academy of Physical Medicine and Rehabilitation is developing a practice parameter for the agitated patient following traumatic brain injury (TBI). The eventual goal of the project is to create an interdisciplinary practice guideline for classifying and treating these patients using a common nosology, based on contributions from the literatures of neurosurgery, psychology, psychiatry and rehabilitation medicine. It is envisioned that a uniform classification system would ultimately promote interdisciplinary research and serve to advance our understanding and treatment of this patient population. In the acute post-injury period, many TBI patients can be characterized by confusion, agitation, post-traumatic amnesia and delirium. In various acute care settings, psychiatrists, psychologists or rehabilitation medicine physicians (physiatrists) are asked to evaluate and treat this population of patients. Each of these disciplines employ specialty-based diagnostic criteria and rating instruments, with little or no consensus across disciplines concerning the appropriateness of these tools. This article reviews the classification and rating systems utilized within the fields of neurosurgery, rehabilitation medicine, psychology and psychiatry, to describe patients displaying agitated behaviors. The authors review the literature establishing the definitions, measurement and possible neuroanatomic and neurophysiologic substrate for delirium and brain-injury agitation, with its characteristic cognitive and behavioral manifestations. Pharmacologic treatment is briefly reviewed to emphasize the significantly different viewpoints from the fields of rehabilitation medicine and psychiatry. The authors explore support from the literature for an interdisciplinary definition for agitation following TBI which includes criteria for delirium, post-traumatic amnesia, and associated behavioral excesses such as disinhibition, aggression, or emotional lability. Wide acceptance of this definition by medical and research professionals may potentially lead to a greater understanding of this clinical state and its neuropathogenesis through promotion of intra- and inter-disciplinary research.

Daily treatment time and functional gains of stroke patients during inpatient rehabilitation.

OBJECTIVE: To study the effects of daily treatment time on functional gain of patients who have had a stroke. DESIGN: A retrospective cohort study. SETTING: An inpatient rehabilitation hospital (IRH) in northern California. PARTICIPANTS: Three hundred sixty patients who had a stroke and were discharged from the IRH in 2007. INTERVENTIONS: Average minutes of rehabilitation therapy per day, including physical therapy, occupation therapy, speech and language therapy, and total treatment. MAIN OUTCOME MEASURES: Functional gain measured by the Functional Independence Measure, including activities of daily living, mobility, cognition, and the total of the Functional Independence Measure (FIM) scores. RESULTS: The study sample had a mean age of 64.8 years; 57.4% were men and 61.4% were white. The mean total daily therapy time was 190.3 minutes, and the mean total functional gain was 26.0. A longer daily therapeutic duration was significantly associated with total functional gain (r = .23, P = .0094). Patients who received a total therapy time of <3.0 hours per day had significantly lower total functional gain than did those treated ≥3.0 hours. No significant difference in total functional gain was found between patients treated ≥3.0 but <3.5 hours and ≥3.5 hours per day. The daily treatment time of physical therapy, occupational therapy, and speech and language therapy also was significantly associated with corresponding subscale functional gains. In addition, hemorrhagic stroke, left brain injury, earlier IRH admission, and a longer IRH stay were associated with total functional improvement. CONCLUSIONS: The study demonstrated a significant relationship between daily therapeutic duration and functional gain during IRH stay and showed treatment time thresholds for optimal functional outcomes for patients in inpatient rehabilitation who had a stroke.

Designing and implementing a system for tracking functional status after stroke: a feasibility study.

OBJECTIVE: To determine the feasibility of tracking stroke patients' functional outcomes in an integrated health system across a care continuum using the computer version of the Activity Measure of Post-Acute Care (AM-PAC). SETTING: A large integrated health care system in northern California. PARTICIPANTS: A total of 222 stroke patients (aged ≥18 years) who were hospitalized after an acute cerebrovascular accident. METHODS: An AM-PAC assessment was made at discharge from sites of care, including acute hospital, inpatient rehabilitation hospital, skilled nursing facility, home during home care, and outpatient settings. Assessments also were completed in the patient's home at 6 months. Data from the AM-PAC program were integrated with the health care system's databases. MAIN OUTCOME MEASUREMENTS: (1) AM-PAC administration time at the various sites of care; (2) assessment of a floor or a ceiling effect; and (3) administrative burden of tracking participants. RESULTS: AM-PAC assessment sessions averaged 7.9 minutes for data acquisition in 3 domains: Basic Mobility, Activities of Daily Living, and Applied Cognition. Participants answered, on average, 27 AM-PAC questions per session. A small ceiling effect was observed at 6 months, and there was a larger ceiling effect when the instrument was administered in an institution, ie, when the AM-PAC institutional item bank was used rather than the community item bank. It was feasible to track patients and to assess their function using the AM-PAC instrument from institutional to community settings. Implementation of the AM-PAC in clinical environments, and the success of the project, were influenced by instrumental, technological, operational, resource, and cultural factors. CONCLUSIONS: This study demonstrates the feasibility of implementing a single functional outcome instrument in clinical and community settings to measure rehabilitation functional outcomes of stroke patients. Integrating the AM-PAC measurement system into clinical workflows and the electronic medical record could provide assistance to clinicians for medical decision making, functional prognostication, and discharge planning.