A Robotic Device to Enhance Nursing Home Provider Telepresence During and After the COVID-19 Pandemic.

The COVID-19 pandemic presented significant challenges to face-to-face communication with people residing in post-acute and long-term care (PALTC) settings. Telemedicine is an alternative, but facility staff may be overburdened with the management of the equipment. Here we introduce the use of a mobile HIPPA-compliant telepresence robot (MTR) to bridge this barrier, which may be beneficial to reimagine options for PALTC in the future.

Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee.

The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.

Characteristics and Survival Outcomes of Children With Hodgkin Lymphoma Treated Primarily With Chemotherapy.

BACKGROUND: Hodgkin disease is a malignant tumor of the lymphatic system that comprises ∼6% of childhood cancers. In developing countries, efforts are made to ensure adherence to standard protocol/regimens, study patients' outcomes, and compare with that in developed world. MATERIALS AND METHODS: We conducted a retrospective medical records' review of 212 children younger than 20 years presenting to The Indus Hospital in Pakistan with previously untreated Hodgkin lymphoma between August 2000 and December 2012. We collected demographic and other epidemiologic variables such as age, sex, stage, subtype of disease, and survival outcomes. RESULTS: The mean±SD age of patients at time of diagnosis was 9.0±3.8 years with a male to female ratio of ∼4.7:1. In total, 44 (20.8%) patients were 5 years of age or above at presentation. Overall, 131 (61.8%) patients presented with B-symptoms and mixed cellularity was the most frequently diagnosed subtype in 65.1% of cases. In total, 170 (80.2%) achieved full remission after completion of chemotherapy. Patients were treated with alternating cycles of ABVD (Adriamycin, Bleomycin, Vincristine, and Dacarbazine) and COPDAC (Cyclophosphamide, Vincristine, Prednisolone, and Dacarbazine). The majority (n=114, 59.1%) received 6 cycles of chemotherapy, 44 (22.8%) received ≤4 cycles followed by 24 (12.4%) receiving 8 cycles. Radiotherapy was administered only to those patients with significant residual disease at the end of chemotherapy (n=20, 10%). The 5-year overall survival and event-free survival in our cohort was 89.6% and 82.1%, respectively. CONCLUSION: Our findings suggest that treatment with 4 to 8 alternating cycles of ABVD/COPDAC has an excellent outcome in childhood Hodgkin disease.

Evaluation of Baseline Cardiac Function by Echocardiography and its Association With Nutritional Status in Pediatric Cancer Patients at The Indus Hospital in Karachi, Pakistan.

INTRODUCTION: Evidence on conducting baseline echocardiogram before starting chemotherapy in pediatric cancer patients is limited from developing countries where malnutrition and infections are common and which may result in cardiac dysfunction. MATERIALS AND METHODS: A prospective, observational study was conducted from October 2016 to May 2017 at The Indus Hospital, Karachi, Pakistan, among children 1 to 16 years of age suffering from cancer. Echocardiography was performed before starting chemotherapy. Associations between body mass index and cardiac abnormalities were studied. RESULTS: A total of 384 children met the inclusion criteria. The median (interquartile range) age was 8.0 (5.0 to 12.0) years and 62.0% (n=238) were male individuals. Twenty-two of 384 (5.7%) children had systolic dysfunction. Four of 22 had moderate-systolic and one of 22 had mild systolic dysfunction, for whom the therapy was altered, and they were treated without anthracyclines. Four of these 5 patients died, and only 1 of 5 survived through high-risk protocol. Seventeen of 22 children had low-normal systolic dysfunction. We found no evidence of an association between body mass index for age and abnormal left ventricular ejection fraction and abnormal fractional shortening (P-trend=0.587; 0.487, respectively). No associations were found of weight-for-age and height-for-age with these outcomes. CONCLUSIONS: In developing countries, echocardiograms should be expeditiously performed and technology made more accessible to rule out cardiac dysfunction and avoid delay in chemotherapy. Malnutrition was not associated with cardiac dysfunction.

Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings.

In response to a rising concern for multidrug resistance and Clostridium difficile infections, the Centers for Medicare and Medicaid services (CMS) will require all long-term care (LTC) facilities to establish an antibiotic stewardship program by November 2017. Thus far, limited evidence describes implementation of antibiotic stewardship in LTC facilities, mostly in academic- or hospital-affiliated settings. To support compliance with CMS requirements and aid facilities in establishing a stewardship program, the Infection Advisory Committee at AMDA-The Society for Post-Acute and Long-Term Care Medicine, has developed an antibiotic stewardship policy template tailored to the LTC setting. The intent of this policy, which can be adapted by individual facilities, is to help LTC facilities implement an antibiotic stewardship policy that will meet or exceed CMS requirements. We also briefly discuss implementation of an antibiotic stewardship program in LTC settings, including a list of free resources to support those efforts.

Pneumococcal Vaccination Guidance for Post-Acute and Long-Term Care Settings: Recommendations From AMDA's Infection Advisory Committee.

Efforts at preventing pneumococcal disease are a national health priority, particularly in older adults and especially in post-acute and long-term care settings The Advisory Committee on Immunization Practices recommends that all adults ≥65 years of age, as well as adults 18-64 years of age with specific risk factors, receive both the recently introduced polysaccharide-protein conjugate vaccine against 13 pneumococcal serotypes as well as the polysaccharide vaccine against 23 pneumococcal serotypes. Nursing facility licensure regulations require facilities to assess the pneumococcal vaccination status of each resident, provide education regarding pneumococcal vaccination, and administer the appropriate pneumococcal vaccine when indicated. Sorting out the indications and timing for 13 pneumococcal serotypes and 23 pneumococcal serotypes administration is complex and presents a significant challenge to healthcare providers. Here, we discuss the importance of pneumococcal vaccination for older adults, detail AMDA-The Society for Post-Acute and Long-Term Care Medicine (The Society)'s recommendations for pneumococcal vaccination practice and procedures, and offer guidance to postacute and long-term care providers supporting the development and effective implementation of pneumococcal vaccine policies.

Osteomyelitis Infection of Mycobacterium marinum: A Case Report and Literature Review.

Mycobacterium marinum (M. marinum) is a ubiquitous waterborne organism that grows optimally at temperatures around 30°C. It is a nontuberculous Mycobacterium found in nonchlorinated water with worldwide prevalence. It is the most common atypical Mycobacterium that causes opportunistic infection in humans. M. marinum can cause superficial infections and localized invasive infections in humans, with the hands being the sites most frequently affected. It can cause skin lesions, which are either single, papulonodular lesions, confined to an extremity, or may resemble cutaneous sporotrichosis. This infection can also cause deeper infections including tenosynovitis, bursitis, arthritis, and osteomyelitis. Disseminated infections and visceral involvements have been reported in immunocompromised patients. We here report a case of severe deep soft tissue infection with necrotizing fasciitis and osteomyelitis of the left upper extremity (LUE) caused by M. marinum in an immunocompromised patient.

The impact of penicillin skin testing on clinical practice and antimicrobial stewardship.

BACKGROUND: Penicillin skin testing (PST) is a simple and reliable way of diagnosing penicillin allergy. After being off the market for 4 years, penicilloyl-polylysine was reintroduced in 2009 as PRE-PEN. We describe the negative predictive value (NPV) of PST and the impact on antibiotic selection in a sample of hospitalized patients with a reported history of penicillin allergy. METHODS: We introduced a quality improvement process at our 861-bed tertiary care hospital that used PST to guide antibiotic usage in patients with a history consistent with an immunoglobulin E (IgE)-mediated reaction to penicillin. Subjects with a negative PST were then transitioned to a ß-lactam agent for the remainder of their therapy. NPV of skin testing was established at 24-hour follow-up. We are reporting the result of 146 patients tested between March 2012 and July 2012. RESULTS: A total of 146 patients with a history of penicillin allergy and negative PST were treated with ß-lactam antibiotics. Of these, only 1 subject experienced an allergic reaction to the PST. The remaining 145 patients tolerated a full course of ß-lactam therapy without an allergic response, giving the PST a 100% NPV. We estimated that PST-guided antibiotic alteration for these patients resulted in an estimated annual savings of $82,000. CONCLUSION: Patients with a history of penicillin allergy who have a negative PST result are at a low risk of developing an immediate-type hypersensitivity reaction to ß-lactam antibiotics. The increased use of PST may help improve antibiotic stewardship in the hospital setting.

Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria.

(See the commentary by Moro, on pages 978-980 .) Infection surveillance definitions for long-term care facilities (ie, the McGeer Criteria) have not been updated since 1991. An expert consensus panel modified these definitions on the basis of a structured review of the literature. Significant changes were made to the criteria defining urinary tract and respiratory tract infections. New definitions were added for norovirus gastroenteritis and Clostridum difficile infections.

Factors influencing older adults to complete advance directives.

OBJECTIVE: The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults. METHOD: Direct interviews of hospitalized and community-dwelling cognitively intact patients > 65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables. RESULTS: Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3, p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2, p < 0.0001), having undergone major surgery (OR 6.3, p < 0.0017), female gender (OR 11.1, p < 0.0001) and increasing age (76-85 vs. 59-75: OR 3.4, p < 0.0543; < 85 vs. 59-75: OR 6.3, p < 0.0263). SIGNIFICANCE OF RESULTS: This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Estrogen and hypertension.

Menopause is accompanied by a dramatic rise in the prevalence of hypertension in women, suggesting a protective role of endogenous estradiol on blood pressure (BP). Both animal experimental and human clinical investigations suggest that estrogen engages several mechanisms that protect against hypertension, such as activation of the vasodilator pathway mediated by nitric oxide and prostacyclin and inhibition of the vasoconstrictor pathway mediated by the sympathetic nervous system and angiotensin. However, emerging evidence from recent clinical trials indicates a small increase, rather than decrease, in systolic BP with oral estrogen administration in postmenopausal women, without any detectable effect on diastolic BP. Mechanisms underlying this selective rise in systolic BP in postmenopausal women and oral contraceptive-induced hypertension in premenopausal women remain unknown, but the rise may be related to supraphysiologic concentration of estrogen in the liver. To date, transdermal delivery of estrogen, which avoids the first-pass hepatic metabolism of estradiol, appears to have a small BP-lowering effect in postmenopausal women and may be a safer alternative in hypertensive women.

One-hour postload plasma glucose in middle age and Medicare expenditures in older age among nondiabetic men and women: the Chicago Heart Association Detection Project in Industry.

OBJECTIVE: To examine associations in nondiabetic individuals of 1-h postload plasma glucose measured in young adulthood and middle age with subsequent Medicare expenditures for cardiovascular disease (CVD), diabetes, cancer, and all health care at age 65 years or older using data from the Chicago Heart Association Detection Project in Industry (CHA). RESEARCH DESIGN AND METHODS: Medicare data (1984-2000) were linked with CHA baseline records (1967-1973) for 8,580 men and 6,723 women ages 33-64 years who were free of coronary heart disease, diabetes, and major electrocardiogram (ECG) abnormalities and who were Medicare eligible (65+ years) for at least 2 years. Participants were classified based on 1-h postload plasma glucose levels <120, 120-199, or > or =200 mg/dl. RESULTS: With adjustment for baseline age, cigarette smoking, serum cholesterol, systolic blood pressure, BMI, ethnicity, education, and minor ECG abnormalities, the average annual and cumulative Medicare, total, and diabetes- and CVD-related charges were significantly higher with higher baseline plasma glucose in women, while only diabetes-related charges were significantly higher in men. For example, in women, multivariate-adjusted CVD-related cumulative charges were, respectively, USD 14,260, 18,909, and 21,183 for the three postload plasma glucose categories (P value for trend = 0.035). CONCLUSIONS: These findings suggest that maintaining low glucose levels early in life has the potential to reduce health care costs in older age.