The association of nursing home infection preventionists' training and credentialing with resident COVID 19 deaths.

BACKGROUND: Nursing home (NH) residents' vulnerability to COVID-19 underscores the importance of infection preventionists (IPs) within NHs. Our study aimed to determine whether training and credentialing of NH IPs were associated with resident COVID-19 deaths. METHODS: This retrospective observational study utilized data from the Centers for Disease Control and Prevention's National Healthcare Safety Network NH COVID-19 Module and USAFacts, from May 2020 to February 2021, linked to a 2018 national NH survey. We categorized IP personnel training and credentialing into four groups: (1) LPN without training; (2) RN/advanced clinician without training; (3) LPN with training; and (4) RN/advanced clinician with training. Multivariable linear regression models of facility-level weekly deaths per 1000 residents as a function of facility characteristics, and county-level COVID-19 burden (i.e., weekly cases or deaths per 10,000 population) were estimated. RESULTS: Our study included 857 NHs (weighted n = 14,840) across 489 counties and 50 states. Most NHs had over 100 beds, were for profit, part of chain organizations, and located in urban areas. Approximately 53% of NH IPs had infection control training and 82% were RNs/advanced clinicians. Compared with NHs employing IPs who were LPNs without training, NHs employing IPs who were RNs/advanced clinicians without training had lower weekly COVID-19 death rates (-1.04 deaths per 1000 residents; 95% CI -1.90, -0.18), and NHs employing IPs who were LPNs with training had lower COVID-19 death rates (-1.09 deaths per 1000 residents; 95% CI -2.07, -0.11) in adjusted models. CONCLUSIONS: NHs with LPN IPs without training in infection control had higher death rates than NHs with LPN IPs with training in infection control, or NHs with RN/advanced clinicians in the IP role, regardless of IP training. IP training of RN/advanced clinician IPs was not associated with death rates. These findings suggest that efforts to standardize and improve IP training may be warranted.

Timing of Goals of Care Discussions in Nursing Homes: A Systematic Review.

OBJECTIVES: Discussions between health professionals and nursing home (NH) residents or their families about the current or future goals of health care may be associated with better outcomes at the end of life (EOL), such as avoidance of unwanted interventions or death in hospital. The timing of these discussions varies, and it is possible that their influence on EOL outcomes depends on their timing. This study synthesized current evidence concerning the timing of goals of care (GOC) discussions in NHs and its impact on EOL outcomes. DESIGN: Systematic review. SETTING AND PARTICIPANTS: Adult populations in NH settings. METHODS: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Embase, and Cumulative Index of Nursing and Allied Health from January 2000 to September 2022. We included studies that examined timing of GOC discussions in NHs, were peer-reviewed, and published in English. Quality of the studies was assessed using the Newcastle-Ottawa Scale. RESULTS: Screening of 1930 abstracts yielded 149 papers that were evaluated for eligibility. Of the 18 articles, representing 16 distinct studies that met review criteria, 12 evaluated the timing of advance directives. There was variation in the timing of GOC discussions and compared with discussions that occurred within a month of death, earlier discussions (eg, at the time of facility admission) were associated with lower rates of hospitalization at the EOL and lower health care costs. CONCLUSIONS AND IMPLICATIONS: The timing of GOC discussions in NHs varies and evidence suggests that late discussions are associated with poorer EOL outcomes. The benefits of goal-concordant care may be enhanced by earlier and more frequent discussions. Future studies should examine the optimal timing for GOC discussions in the NH population.

A comparison of conceptual frameworks to examine health inequities in End-of-Life care.

AIMS: To discuss existing conceptual frameworks that can be applied to the examination of health inequities in end-of-life care and related health outcomes. We used the Fawcett and Desanto-Madeya evaluation technique modified by the National Institute on Minority Health and Health Disparities Research Framework to include individual, interpersonal, community, and societal levels of influence. DESIGN: Discussion paper. DATA SOURCES: We performed a systematic review of PubMed, CINAHL and Embase for conceptual frameworks of health inequities in end-of-life care and health outcomes published as of February 2022. IMPLICATIONS FOR NURSING: There is a strong need for research that can address multiple factors influencing end-of-life care inequities and health outcomes. To mitigate the complex nature of social determinants of health and structural inequities, researchers, clinicians, educators and administrators should have solid conceptualizations of these multi-level factors. Based on sound and comprehensive frameworks, nurses with interdisciplinary partnerships can promote health equity with a broader health care scope through addressing social determinants of health. CONCLUSION: We identified and reviewed three frameworks. We concluded all three frameworks have the potential for use in the examination of health inequities in end-of-life care and health outcomes. However, the Conceptual Framework of Minority Access to End-of-Life Care was more applicable to diverse studies and settings when adapted to include fundamental characteristics such as sex and gender. IMPACT: Despite the substantial rise in end-of-life care delivery, health inequities persist in end-of-life care access and utilization. Though some studies have been conducted to promote health equity by addressing social determinants of health, progress is hampered by their complex and multi-faceted nature. Through a concrete conceptual framework, researchers can comprehensively examine multi-level factors influencing health inequities in end-of-life care. NO PATIENT OR PUBLIC CONTRIBUTION: This discussion paper focused on reviewing existing evidence.

Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States.

OBJECTIVE: Home health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their urban counterparts in delivering care (eg, longer distances to travel to patient homes leading to higher fuel/travel costs and fewer number of visits in a day, impacting the quality of home health care for rural beneficiaries). We review evidence on differences in care outcomes provided by urban and rural HHAs. DESIGN: Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the Newcastle-Ottawa Scale (NOS) for quality appraisal. SETTING: Care provided by urban and rural HHAs. METHODS: We conducted a systematic search for English-language peer-reviewed articles after 2010 on differences in urban and rural care provided by U.S. HHAs. We screened 876 studies, conducted full-text abstraction and NOS quality review on 36 articles and excluded 2 for poor study quality. RESULTS: Twelve studies were included; 7 focused on patient-level analyses and 5 were HHA-level. Nine studies were cross-sectional and 3 used cohorts. Urban and rural differences were measured primarily using a binary variable. All studies controlled for agency-level characteristics, and two-thirds also controlled for patient characteristics. Rural beneficiaries, compared with urban, had lower home health care utilization (4 of 5 studies) and fewer visits for physical therapy and/or rehabilitation (3 of 5 studies). Rural agencies had lower quality of HHA services (3 of 4 studies). Rural patients, compared with urban, visited the emergency room more often (2 of 2 studies) and were more likely to be hospitalized (2 of 2 studies), whereas urban patients with heart failure were more likely to have 30-day preventable hospitalizations (1 study). CONCLUSION AND IMPLICATIONS: This review highlights similar urban/rural disparities in home health care quality and utilization as identified in previous decades. Variables used to measure the access to and quality of care by HHAs varied, so consensus was limited. Articles that used more granular measures of rurality (rather than binary measures) revealed additional differences. These findings point to the need for consistent and refined measures of rurality in studies examining urban and rural differences in care from HHAs.

Measuring Palliative Care-Related Knowledge, Attitudes, and Confidence in Home Health Care Clinicians, Patients, and Caregivers: A Systematic Review.

Background: Integrating palliative care services in the home health care (HHC) setting is an important strategy to provide care for seriously ill adults and improve symptom burden, quality of life, and caregiver burden. Routine palliative care in HHC is only possible if clinicians who provide this care are prepared and patients and caregivers are well equipped with the knowledge to receive this care. A key first step in integrating palliative care services within HHC is to measure preparedness of clinicians and readiness of patients and caregivers to receive it. Objective: The objective of this systematic review was to review existing literature related to the measurement of palliative care-related knowledge, attitudes, and confidence among HHC clinicians, patients, and caregivers. Methods: We searched PubMed, CINAHL, Web of Science, and Cochrane for relevant articles between 2000 and 2021. Articles were included in the final analysis if they (1) reported specifically on palliative care knowledge, attitudes, or confidence, (2) presented measurement tools, instruments, scales, or questionnaires, (3) were conducted in the HHC setting, (4) and included HHC clinicians, patients, or caregivers. Results: Seventeen articles were included. While knowledge, attitudes, and confidence have been studied in HHC clinicians, patients, and caregivers, results varied significantly across countries and health care systems. No study captured knowledge, attitudes, and confidence of the full HHC workforce; notably, home health aides were not included in the studies. Conclusion: Existing instruments did not comprehensively contain elements of the eight domains of palliative care outlined by the National Consensus Project (NCP) for Quality Palliative Care. A comprehensive psychometrically tested instrument to measure palliative care-related knowledge, attitudes, and confidence in the HHC setting is needed.

The Effect of Electrical Stimulation Therapy With Pelvic Floor Muscle Exercise on Stress Urinary Incontinence in Middle-Aged Women: A Nonequivalent Comparison Cohort Study.

PURPOSE: The purpose of this study was to evaluate the effects of combined pelvic floor muscle exercises (PFMEs) and a novel electrical stimulation (ES) device versus PFMEs alone on lower urinary tract symptoms, urinary incontinence-related quality of life, and pelvic floor muscle contractions (PFMCs). DESIGN: Nonrandomized comparison cohort study. SUBJECTS AND SETTING: The sample comprised 54 community-dwelling middle-aged women with stress urinary incontinence recruited from churches and cultural centers in Gyeonggi Province, South Korea. Comparisons of demographic and pertinent clinical characteristics revealed no significant differences between the experimental and comparison groups. METHODS: Participants allocated to the combined intervention group (n = 27) performed self-exercises of the pelvic floor muscles 3 times a day under weekly telephone coaching, and they used the ES device twice daily for 8 weeks. Participants in the comparison group (n = 27) received the PFMEs alone without telephone coaching. The 3 main outcomes including lower urinary tract symptoms, urinary incontinence-related quality of life, and PFMCs were measured using the Bristol Female Lower Urinary Tract Symptom instrument (BFLUTS), King's Health Questionnaire (KHQ), and a perineometer, respectively. Study outcomes were measured at baseline and at the end of the 8-week period. RESULTS: Participants in the experimental group achieved significantly greater reductions in lower urinary tract symptoms (t = -4.07, P < .001) and improvement in urinary incontinence-related quality of life (P = .006), peak PFMC pressure (P = .004), mean pelvic muscle contraction (PMC) pressure (P < .001), and duration of PFMCs (P < .001) when compared to participants undergoing PFMEs alone. CONCLUSIONS: Combined ES and pelvic floor exercise was more effective in reducing severity of lower urinary tract symptoms, enhancing health-related quality of life, and increasing PMC pressure in middle-aged women with stress urinary incontinence than PFMEs alone.

Effects of lateral electrical surface stimulation on scoliosis in children with severe cerebral palsy: a pilot study.

PURPOSE: To evaluate the effects of lateral electrical surface stimulation (LESS) on scoliosis and trunk balance in children with severe cerebral palsy (CP). METHODS: Children with severe CP (GMFCS level IV or V) and stationary or progressive scoliosis were enrolled. Children were recommended of two sessions of LESS/day, 1 h/session, for 3 months at home: at 40-80 mA intensity, 200 µs pulse width, 25 Hz frequency, on for 6 s and then off for 6 s on the convex side of the trunk curve. Radiologic (Cobb's, kyphotic, and sacral angles) and functional [gross motor function measurement (GMFM)-88 sitting score, and trunk control measurement scale (TCMS)] measurements were evaluated at 4 periods: (a) 3 months before, (b) just before, (c) 1 month after, and (d) 3 months after LESS. RESULTS: The median Cobb's angle of 11 children (median age, 9 years) was 25°, and it showed significant improvements after both 1 and 3 months of LESS. The LESS intensity correlated with the improvement of GMFM-88 siting score. The parents or main caregivers of the children believed LESS had several positive effects without major adverse effects. CONCLUSIONS: LESS is effective in scoliosis in children with severe CP and it may improve trunk balance. Implications for rehabilitation Scoliosis is a very complicated problem for the children with severe CP. They do not have many options for treatments and scoliosis is usually refractory. Lateral electrical surface stimulation (LESS) is effective in scoliosis in children with severe CP and it may improve trunk balance. LESS may be another option of managing stationary or progressive scoliosis in the children with severe CP who are unable to undergo surgery.

Correction: Effects of Mirror Therapy Using a Tablet PC on Central Facial Paresis in Stroke Patients.

[This corrects the article on p. 347 in vol. 41, PMID: 28758071.].

Effects of Mirror Therapy Using a Tablet PC on Central Facial Paresis in Stroke Patients.

OBJECTIVE: To investigate the effects of mirror therapy using a tablet PC for post-stroke central facial paresis. METHODS: A prospective, randomized controlled study was performed. Twenty-one post-stroke patients were enrolled. All patients performed 15 minutes of orofacial exercise twice daily for 14 days. The mirror group (n=10) underwent mirror therapy using a tablet PC while exercising, whereas the control group (n=11) did not. All patients were evaluated using the Regional House-Brackmann Grading Scale (R-HBGS), and the length between the corner of the mouth and the ipsilateral earlobe during rest and smiling before and after therapy were measured bilaterally. We calculated facial movement by subtracting the smile length from resting length. Differences and ratios between bilateral sides of facial movement were evaluated as the final outcome measure. RESULTS: Baseline characteristics were similar for the two groups. There were no differences in the scores for the basal Modified Barthel Index, the Korean version of Mini-Mental State Examination, National Institutes of Health Stroke Scale, R-HBGS, and bilateral differences and ratios of facial movements. The R-HBGS as well as the bilateral differences and ratios of facial movement showed significant improvement after therapy in both groups. The degree of improvement of facial movement was significantly larger in the mirror group than in the control group. CONCLUSION: Mirror therapy using a tablet PC might be an effective tool for treating central facial paresis after stroke.

Neurocognitive Dysfunction According to Hypoperfusion Territory in Patients With Moyamoya Disease.

OBJECTIVE: To demonstrate the prevalence of cerebral hypoperfusion without focal cerebral lesions in patients with Moyamoya disease (MMD), and the relationship between areas of hypoperfusion and cognitive impairment. METHODS: Twenty-six MMD patients were included. Patients were categorized according to the presence/absence of hypoperfusion in the frontal, parietal, temporal, and occipital lobes on brain single-photon-emission computed tomography (SPECT) after acetazolamide challenge. Computerized neuropsychological test (CNT) results were compared between groups. RESULTS: Only 3 patients showed normal cerebral perfusion. Baseline characteristics were similar between groups. Patients with frontal lobe hypoperfusion showed lower scores in visual continuous performance test (CPT), auditory CPT, forward digit span test, backward digit span test, verbal learning test, and trail-making test. Patients with parietal lobe hypoperfusion showed lower backward digit span test, visual learning test, and trail-making test scores. Related to temporal and occipital lobes, there were no significant differences in CNT results between the hypoperfusion and normal groups. CONCLUSION: MMD patients without focal cerebral lesion frequently exhibit cerebral hypoperfusion. MMD patients with frontal and parietal hypoperfusion had abnormal CNT profiles, similar to those with frontal and parietal lesions. It is suggested that the hypoperfusion territory on brain SPECT without focal lesion may affect the characteristics of neurocognitive dysfunction in MMD patients.

Accuracies of seven different apex locators under various conditions.

OBJECTIVES: The purpose of this study was to evaluate the accuracies of 7 different frequency-dependent electronic apex locators (EALs) on using different irrigants in the root canal. STUDY DESIGN: Root canal lengths were measured with 7 different EALs in 40 extracted human teeth embedded in an alginate model after canal preparation and compared with the actual canal length measurements taken before embedding the teeth in alginate. The EALs used were Apex Finder 7005, Apit, Bingo-1020, e-Magic Finder, ProPex, Root ZX, and SmarPex. Measurements were taken with the canal dry, and saturated sequentially with 5.25% NaOCl, saline, 0.1% chlorhexidine, and 15% EDTA. Data were analyzed with 1-way ANOVA and Tukey's studentized range test. RESULTS: There were some differences in accuracies among EALs; however, some of the differences were not statistically significant. All EALs were less accurate when the apical foramen size was larger. CONCLUSION: Within the limitations of the present study, most of the EALs tested can be considered reliable in the presence of various root canal irrigants and varying sizes of the apical foramen.

Anti-angiogenic and anti-tumor invasive activities of tissue inhibitor of metalloproteinase-3 from shark, Scyliorhinus torazame.

In order to investigate the anti-angiogenic activity of shark TIMP-3 (sTIMP-3) in endothelial cells, angiogenic assays including in vitro invasion assay, migration assay, zymogram assay and tube formation assay were performed. We observed that the overexpression of sTIMP-3 decreased the invasive capacity by about 70%, the migratory activity by about 50% and the production of gelatinase A in bovine aortic endothelial cells (BAECs). In addition, the overexpression of sTIMP-3 interfered with the formation of capillary-like network in endothelial cells. We also examined whether sTIMP-3 shows the anti-invasive activity in cancer cells. We found that the overexpression of sTIMP-3 diminished the invasive ability of the human fibrosarcoma HT1080 cells by about 40%. Also, the production of specific gelatinases was suppressed in the cancer cells. Therefore, we propose that sTIMP-3 acts as the inhibitor of angiogenesis in endothelial cells and the suppressor of tumor invasion in human fibrosarcoma HT1080 cells.

Phytosphingosine induces apoptotic cell death via caspase 8 activation and Bax translocation in human cancer cells.

PURPOSE: Sphingolipid metabolites, such as sphingosine and ceramide, are highly bioactive compounds and are involved in diverse cell processes, including cell-cell interaction, cell proliferation, differentiation, and apoptosis. However, the physiological roles of phytosphingosine are poorly understood. In this study, we report that phytosphingosine can potently induce apoptotic cell death in human cancer cells via caspase activation and caspase-independent cytochrome c release. EXPERIMENTAL DESIGN: Phytosphingosine-induced apoptosis was determined by Hoechst 33258 staining, flow cytometric analysis, and DNA fragmentation assay. Involvement of caspases was determined by immunoblot analysis and cell death detection assays after treatment with synthetic inhibitor z-Val-Ala-Asp-fluoromethyl ketone, z-DEVD-fmk, or z-IETD-fmk. Death receptor (DR) dependency was analyzed by examining expression of DRs (Fas, DR4, DR5, TNFR1, and R2), and interaction of Fas-associated death domain and caspase 8. Involvement of the mitochondria pathway was examined by monitoring of the mitochondria membrane potential, cytochrome c release, and Bax translocation. RESULTS: Phytosphingosine-treated cells displayed several features of apoptosis, including increase of sub-G(1) population, DNA fragmentation, and poly(ADP-ribose) polymerase cleavage. We observed that phytosphingosine cause activation of caspase 8 in a DR-independent fashion. Phytosphingosine also induced activation of caspase 9 and 3, loss of mitochondrial membrane potential, and the cytochrome c release from mitochondria. However, we failed to detect Bid cleavage. Moreover, caspase 8 inhibitor z-IETD-fmk did not affect phytosphingosine-induced cytochrome c release and caspase 9 activation, suggesting that phytosphingosine-induced cytochrome c release is caused by caspase 8-independent manner. Phytosphingosine induced mitochondrial translocation of Bax from the cytosol without changes in the protein levels of Bcl-2, Bcl-xL, and Bax. In addition, Bcl-2/Bax interaction was diminished after addition of phytosphingosine. CONCLUSION: These findings indicate that phytosphingosine induces apoptotic cell death in human cancer cells by direct activation of caspase 8, and by mitochondrial translocation of Bax and subsequent release of cytochrome c into cytoplasm, providing a potential mechanism for the anticancer activity of phytosphingosine.