Post-Acute Care Trends and Disparities After Joint Replacements in the United States, 1991-2018: A Systematic Review.

OBJECTIVE: To review evidence on post-acute care (PAC) use and disparities related to race and ethnicity and rurality in the United States over the past 2 decades among individuals who underwent major joint replacement (MJR). DESIGN: Systematic review. SETTING AND PARTICIPANTS: We included studies that examined US PAC trends and racial and ethnic and/or urban vs rural differences among individuals who are aged ≥18 years with hospitalization after MJR. METHODS: We searched large academic databases (PubMed, CINAHL, Embase, Web of Science, and Scopus) for peer-reviewed, English language articles from January 1, 2000, and January 26, 2022. RESULTS: Seventeen studies were reviewed. Studies (n = 16) consistently demonstrated that discharges post-MJR to skilled nursing facilities (SNFs) or nursing homes (NHs) decreased over time, whereas evidence on discharges to inpatient rehab facilities (IRFs), home health care (HHC), and home without HHC services were mixed. Most studies (n = 12) found that racial and ethnic minority individuals, especially Black individuals, were more frequently discharged to PAC institutions than white individuals. Demographic factors (ie, age, sex, comorbidities) and marital status were not only independently associated with discharges to institutional PAC, but also among racial and ethnic minority individuals. Only one study found urban-rural differences in PAC use, indicating that urban-dwelling individuals were more often discharged to both SNF/NH and HHC than their rural counterparts. CONCLUSIONS AND IMPLICATIONS: Despite declines in institutional PAC use post-MJR over time, racial and minority individuals continue to experience higher rates of institutional PAC discharges compared with white individuals. To address these disparities, policymakers should consider measures that target multimorbidity and the lack of social and structural support among socially vulnerable individuals. Policymakers should also consider initiatives that address the economic and structural barriers experienced in rural areas by expanding access to telehealth and through improved care coordination.

Current knowledge and practice of Candida auris screening in France: A nationwide survey from the French Society of Medical Mycology (SFMM).

Due to large outbreaks observed worldwide, Candida auris has emerged as a major threat to healthcare facilities. To prevent these phenomena, a systematic screening should be performed in patients transferred from regions where the pathogen is highly endemic. In this study, we recorded and analyzed French mycologists' current knowledge and practice regarding C. auris screening and diagnosis. Thirty-six centers answered an online questionnaire. Only 11 (30.6 %) participants were aware of any systematic screening for C. auris for patients admitted to their hospital. In the case of post-admission screening, axillae/groins (n = 21), nares (n = 7), rectum (n = 9), and mouth (n = 6) alone or various combinations were the body sites the most frequently sampled. Only six centers (8.3 %) reported using a commercially available plate allowing the differentiation of C. auris colonies from that of other Candida species, while five laboratories (13.8 %) had implemented a C. auris-specific qPCR. Considering the potential impact on infected patients and the risk of disorganization in the care of patients, it is crucial to remember to biologists and clinicians the utmost importance of systematic screening on admission.

Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents.

Importance: Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). Objective: To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. Design, Setting, and Participants: This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Exposure: Race and ethnicity of NH residents. Main Outcomes and Measures: Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Results: Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). Conclusions and Relevance: In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.

Insurance-based Disparities in Outcomes and Extracorporeal Membrane Oxygenation Utilization for Hospitalized COVID-19 Patients.

BACKGROUND: The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. METHODS: Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS: Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSIONS: Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.

Physical activity promotion in French cystic fibrosis centers: capitalizing on experience.

BACKGROUND: Physical activity (PA) provides physical and psychosocial benefits for people with cystic fibrosis (pwCF). However, practice levels remain below recommendations and strategies for promoting PA in specialist centers need to be better identified. The socio-ecological model of health emphasizes the central role of policies and environment in influencing individuals' health behaviors. This model provides a basis for understanding how health professionals perceive the promotion of PA in their centers. OBJECTIVE: The aim of this study was to explore intervention components of PA promotion in specialized CF centers in France that are "experienced" in PA promotion, to identify elements that can be transferable to other centers. METHODS: A descriptive qualitative study was conducted with 16 healthcare professionals and pwCF. Semi-structured interviews were conducted and analyzed using inductive and deductive methods classically used in psychology. RESULTS: Five themes were extracted: the action and its context, the partnerships established around this action to promote physical activity, the evaluation of the action, its reproducibility, and the changes induced by COVID-19. CONCLUSIONS: Some factors emerged as essential for promoting PA among pwCF, notably the dialogue between the health professionals and patients, the presence of adapted PA instructors, and the involvement of partners.

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.

Water quality in a lagoon in the southeast pampa region of Argentina / Calidad del agua en una laguna del sudeste pampeano (Argentina)

This work evaluates the chemical and bacteriological qualities of the recreational waters of the Sauce Grande lagoon (Argentina). Samples were taken between March 2002 and December 2003. Ninety-six samples from three sampling stations were analyzed in order to determine the density of aerobic heterotrophic microorganisms, the presence of sulphite-reducing clostridia, and the most probable number of total coliforms, E. coli, fecal enterococci and P. aeruginosa. The water pH, temperature and chemical composition (N-NO3-, PO4³-, Na+, Ca++ +Mg++, EC and SAR) were also determined. Statistical analysis shows an increase in the microbial parameters of fecal pollution and in the population of heterotrophic microorganisms during the warmest months, influenced by higher temperatures and the more intensive recreational use. Bacterial count indicated that fecal pollution was statistically lower at the recreational area monitoring station; however, P. aeruginosa, an opportunistic pathogen, was present in higher than permitted densities in all determinations. These results show that, from the physico-chemical point of view, anthropogenic activities do not significantly affect the quality of the resource.

En el presente trabajo se evaluó la calidad bacteriológica y química en aguas de la laguna Sauce Grande (Argentina). Los muestreos fueron realizados entre marzo de 2002 y diciembre de 2003. Se analizaron un total de 96 muestras provenientes de tres estaciones de monitoreo, determinando: densidad de microorganismos heterótrofos mesófilos, presencia de clostridios sulfito-reductores y número más probable de coliformes totales, Escherichia coli, enterococos fecales y Pseudomonas aeruginosa. También se efectuaron determinaciones de pH, temperatura del agua y composición química (N-NO3-, PO4(3-), Na+, Ca++ + Mg++, CE y RAS). Se observó que en los meses más cálidos se produjo un aumento en los parámetros microbianos indicadores de contaminación fecal y en la población de microorganismos heterotrófos; dicho comportamiento estaría influenciado por el aumento de la temperatura y el mayor uso recreativo del recurso. El recuento de bacterias indicadoras de contaminación fecal fue menor en la estación de monitoreo donde se encuentra ubicado el balneario; no obstante, P. aeruginosa, patógeno oportunista, estuvo presente en todas las determinaciones con densidades mayores a los valores permitidos. Desde el punto de vista fisicoquímico, no hay un aporte antropogénico significativo de contaminantes que afecten la calidad del recurso.

Hypertension arterielle apres transplantation renale : Influence du profil tensionnel au stade de dialyse

L'objectif de ce travail cooperatif est d'etudier l'influence d'une hypertension pre-existante en dialyse (D); sur la frequence de l'hypertension arterielle (HTA) chez les transplantes renaux (TR); et de definir ses caracteristiques cliniques