Fatal Complication of Mouthguard Used to Treat Awake Bruxism in Patient with Frontotemporal Dementia.

Awake bruxism is an understudied manifestation of frontotemporal dementia, yet awake bruxism can have fatal consequences in the aging population. This report presents a patient suffering from awake bruxism associated with frontotemporal dementia being treated with a mouthguard, which ultimately becomes lodged in her posterior oropharynx leading to asphyxiation. The case highlights the need for investigation into the occurrence and treatment of awake bruxism among patients with dementia, and the unique risk-benefit analysis that must be performed to develop proper treatment plans for patients with dementia.

External validation of GO-FAR 2 calculator for outcomes after in-hospital cardiac arrest with comparison to GO-FAR and trial of expanded applications.

Aim: Externally validate the GO-FAR 2 tool for predicting survival with good neurologic function after in-hospital cardiac arrest with comparison to the original GO-FAR tool. Additionally, we collected qualitative descriptors and performed exploratory analyses with various levels of neurologic function and discharge destination. Methods: Retrospective chart review of all patients who underwent in-hospital resuscitation after cardiac arrest during the calendar years 2016-2019 in our institution (n = 397). GO-FAR and GO-FAR 2 scores were calculated based on information available in the medical record at the time of hospital admission. Cerebral performance category (CPC) scores at the time of admission and discharge were assessed by chart review. Results: The GO-FAR 2 score accurately predicted outcomes in our study population with a c-statistic of 0.625. The original GO-FAR score also had accurate calibration with a stronger c-statistic of 0.726. The GO-FAR score had decreased predictive value for lesser levels of neurologic function (c-statistic 0.56 for alive at discharge) and discharge destination (0.69). Descriptors of functional status by CPC score were collected. Conclusion: Our findings support the validity of the GO-FAR and GO-FAR 2 tools as published, but the c-statistics suggest modest predictive discrimination. We include functional descriptors of CPC outcomes to aid clinicians in using these tools. We propose that information about expected outcomes could be valuable in shared decision-making conversations.

Caregiving for Older Adults With Dementia During the Time of COVID-19: A Multi-State Exploratory Qualitative Study.

This qualitative semi-structured interview study explores how 64 family caregivers for older adults with Alzheimer's Disease and related dementias across eight states experienced and executed caregiving decisions before and during the COVID-19 pandemic. First, caregivers experienced challenges communicating with loved ones and healthcare workers in all care settings. Second, caregivers displayed resilient coping strategies in adapting to pandemic restrictions, finding novel strategies to balance risks while preserving communication, oversight, and safety. Third, many caregivers modified care arrangements, with some avoiding and others embracing institutional care. Finally, caregivers reflected on the benefits and challenges of pandemic-related innovations. Certain policy changes reduced caregiver burden and could improve care access if made permanent. Telemedicine's increasing use highlights the need for reliable internet access and accommodations for individuals with cognitive deficits. Public policies must pay greater attention to challenges faced by family caregivers, whose labor is both essential and undervalued.

The Quality Measures Domain in Nursing Home Compare: Is High Performance Meaningful or Misleading?

BACKGROUND AND OBJECTIVES: The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective was to assess whether nursing homes with these "discordant" scores are meaningfully better than nursing homes that score poorly across domains. RESEARCH DESIGN AND METHODS: We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together. RESULTS: Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions. DISCUSSION AND IMPLICATIONS: High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.

Inside the Black Box of Improving on Nursing Home Quality Measures.

Nursing Home Compare (NHC) reports quality measures (QMs) for nursing homes (NHs) as part of its 5-star rating system. Most of the QMs are based on facility self-reported data, prompting questions about their validity. To better understand how NHs interact with the QMs, we used qualitative methods, including semistructured interviews with NH personnel (n = 110), NH provider association representatives (n = 23), and observations of organizational processes in 12 NHs in three states. We found that most NHs are working to improve the quality of care they provide, not merely their QM scores. However, our interviews and observations revealed limitations with the QMs, suggesting that the QMs-on their own-may not accurately reflect the quality of care NHs provide. Our findings suggest several changes to improve NHC, including adding information related to resident and family experience, providing greater risk adjustment, and providing incentives for NHs that serve socially and medically complex residents.

Will We Code for Default ECMO?

Cardiopulmonary resuscitation has become the default treatment for all patients who suffer cardiac arrest. The history of how this came to be suggests the clinical and ethical importance of establishing more humane and appropriate indications for extracorporeal membrane oxygenation and other aggressive therapies for patients at the end of life.

Nursing Home Response to Nursing Home Compare: The Provider Perspective.

Nursing Home Compare (NHC) publishes composite quality ratings of nursing homes based on a five-star rating system, a system that has been subject to controversy about its validity. Using in-depth interviews, we assess the views of nursing home administrators and staff on NHC and unearth strategies used to improve ratings. Respondents revealed conflicting goals and strategies. Although nursing home managers monitor the ratings and expend effort to improve scores, competing goals of revenue maximization and avoidance of litigation often overshadow desire to score well on NHC. Some of the improvement strategies simply involve coding changes that have no effect on resident outcomes. Many respondents doubted the validity of the self-reported staffing data and stated that lack of risk adjustment biases ratings. Policy makers should consider nursing home incentives when refining the system, aiming to improve the validity of the self-reported domains to provide incentives for broader quality improvement.

Does Nursing Home Compare Reflect Patient Safety In Nursing Homes?

The past several decades have seen significant policy efforts to improve the quality of care in nursing homes, but the patient safety movement has largely ignored this setting. In this study we compared nursing homes' performance on several composite quality measures from Nursing Home Compare, the most prominent recent example of a national policy aimed at improving the quality of nursing home care, to their performance on measures of patient safety in nursing homes such as pressure sores, infections, falls, and medication errors. Although Nursing Home Compare captures some aspects of patient safety, we found the relationship to be weak and somewhat inconsistent, leaving consumers who care about patient safety with little guidance. We recommend that Nursing Home Compare be refined to provide a clearer picture of patient safety and quality of life, allowing consumers to weight these domains according to their preferences and priorities.

The Role of Severe Dementia in Nursing Home Report Cards.

Health care report cards are intended to improve quality, but there may be considerable heterogeneity in who benefits. In this article, we examine the intended and unintended effects of quality reporting for nursing home residents with severe dementia relative to other residents, using a difference-in-differences design to examine selected reported and unreported quality measures. Our results indicate that prior to public reporting, nursing home residents with severe dementia were at significantly higher risk of poor outcomes on most reported quality measures. After public reporting was initiated, outcomes for nursing home residents with severe dementia did not consistently improve or worsen. We see no evidence that individuals with severe dementia are being avoided by nursing homes, despite their potential negative impact on quality scores, but we do find an increase in coding of end-stage disease. Additional risk-adjustment, stratification, or additional quality measures may be warranted.

The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment.

OBJECTIVES: To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment. DESIGN: Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs. SETTING: Medicare- and Medicaid-certified NHs in the United States. PARTICIPANTS: Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states. INTERVENTION: Public reporting of physical restraint use rates. MEASUREMENTS: Use of physical restraints and antipsychotic medications. RESULTS: Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints. CONCLUSION: This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment.

Organ donation among undocumented hispanic immigrants: an assessment of knowledge and attitudes.

BACKGROUND: Undocumented immigrants can donate their organs, but lack access to organ transplantation.This challenges foundational principles of organ donation: fairness and informed consent. Little is known about undocumented immigrants' knowledge of barriers to their access to organ transplantation or how this might affect their decision to donate their organs. METHODS: The study was performed in an urban, university-affiliated, safety-net hospital.We interviewed hospitalized patients who self-identified as undocumented immigrants and were unaware of having any contraindication to organ donation (for example, cancer). We first recorded their demographic characteristics and knowledge and attitudes regarding organ donation. We then assessed the effects of informing participants about limits to their access to organ transplants on their willingness to donate. RESULTS: This group of 59 uninsured Hispanic immigrants had adequate knowledge about organ donation. Participants were suspicious about inequality within the medical system, but most were willing to donate their organs (74 percent). Most participants (74 percent) were aware that they would have to pay to receive an organ, but they dramatically underestimated the out-of-pocket expenses.Yet willingness to donate their organs was unaffected by participants being explicitly informed of the low likelihood that they would be able to afford to receive an organ transplant. CONCLUSIONS: Despite being well informed about the organ donation system, undocumented Hispanic immigrants underestimate the costs and overestimate their likelihood of receiving an organ. Even when they are given this information, they remain willing to donate their own organs.

Perspective: The doctor as performer: a proposal for change based on a performance studies paradigm.

The authors recognize the pressing need for teaching methods that encourage empathy in both undergraduate and postgraduate medical curricula. While the useful application of theatrical acting techniques in medical education has been reported in major medical journals, these reports present an incomplete picture of these techniques and their potential importance to physician competence. The authors propose a broader understanding of performance theories and practices and a more nuanced appreciation of the experience and knowledge acquired through working with standardized patients and acting exercises. The academic discipline of performance studies offers a paradigm not only for teaching doctors how to "act" in a more truly empathetic and compassionate manner but also for analyzing, and thus evaluating and improving, human interactions in the medical environment. A complex understanding of performance is essential to the development of an empathetic imagination, a cognitive faculty that allows physicians to generate unique responses to given situations rather than employing reactions learned by rote in "communications training." The authors recommend the inclusion of a wide range of performance theories and practices alongside the ubiquitous presence, in medical schools and other physician education forums, of actors performing as standardized patients.

Phospholipase D2 Enhances Epidermal Growth Factor-Induced Akt Activation in EL4 Lymphoma Cells.

Phospholipase D2 (PLD2) generates phosphatidic acid through hydrolysis of phosphatidylcholine. PLD2 has been shown to play a role in enhancing tumorigenesis. The epidermal growth factor receptor (EGFR) can both activate and interact with PLD2. Murine lymphoma EL4 cells lacking endogenous PLD2 present a unique model to elucidate the role of PLD2 in signal transduction. In the current study, we investigated effects of PLD2 on EGF response. Western blotting and RT-PCR were used to establish that both parental cells and PLD2 transfectants express endogenous EGFR. Levels of EGFR protein are increased in cells expressing active PLD2, as compared to parental cells or cells expressing inactive PLD2. EGF stimulates proliferation of EL4 cells transfected with active PLD2, but not parental cells or cells transfected with inactive PLD2. EGF-mediated proliferation in cells expressing active PLD2 is dependent on the activities of both the EGFR and the PI3K/Akt pathway, as demonstrated by studies using protein kinase inhibitors. EGF-induced invasion through a synthetic extracellular matrix is enhanced in cells expressing active PLD2, as compared to parental cells or cells expressing inactive PLD2. Taken together, the data suggest that PLD2 acts in concert with EGFR to enhance mitogenesis and invasion in lymphoma cells.