Do hospitals attaining a public recognition for treating nurses fairly deliver better-quality health care? Evidence from cross-sectional analysis of California hospitals.

AIM: This study explored whether hospitals that allocate greater resources to their nursing staff provide better healthcare services than those that invest less in their nursing personnel. DESIGN: Cross-sectional logistic and tobit analyses. METHODS: We examined a sample of 314 California hospitals in 2017. We obtained a hospital's public recognition for treating nurses fairly between 2015 and 2017 from Nurse.org, the largest online community of nurses. We derived a hospital's healthcare quality in 2018 from the 2019-2020 Best Hospitals rankings released by U.S. News, a well-known media company publishing independent healthcare assessments periodically. RESULTS: Our results showed that a nurse-friendly workplace was a crucial determinant of its overall healthcare quality. CONCLUSION AND IMPLICATIONS: Healthcare administrators keen to enhance the quality of healthcare services should consider creating nurse-friendly workplaces. Furthermore, their evaluation of nurses' contributions to overall healthcare quality should not solely depend on the nurse-assessed quality of care, but rather comprise not only broad aspects of patient outcomes in primary care but also patient experiences, care-related factors and expert opinions. PATIENT OR PUBLIC CONTRIBUTION: Our study helped address the overwhelmed healthcare system, whose long-running shortage of nurses has been exacerbated by the COVID-19 pandemic. Our work suggested that a hospital's investment in a nurse-friendly workplace can enhance its acquisition, retention and devotion of the nursing staff. This, in turn, can have profound impacts on its overall healthcare quality. WHAT ALREADY IS KNOWN: Existing empirical evidence on the relation between nurse-friendly workplace and healthcare quality is limited and inconclusive. WHAT THIS PAPER ADDS: We documented evidence that the quality of healthcare services provided by hospitals varies with their treatment of nursing staff. IMPLICATIONS FOR PRACTICE/POLICY: Our results provided insights into key policies that have the potential to improve healthcare quality.

Synergistic effect of low handgrip strength and malnutrition on 4-year all-cause mortality in older males: A prospective longitudinal cohort study.

BACKGROUND: No studies have yet examined the interrelationship of malnutrition and low handgrip strength in terms of mortality. The aim of the present study was to evaluate the potential synergistic effects of malnutrition and low handgrip strength on mortality among older adults living in a retirement community. METHODS: This prospective longitudinal cohort study recruited subjects aged 65 years and over from a veterans care home in Taiwan in 2013. Nutritional status was assessed using the Mini-Nutritional Assessment-Short Form (MNA-SF, malnutrition was MNA-SF<12); muscle strength was measured by handgrip strength (low handgrip strength was handgrip strength <26 kg). The Kaplan-Meier method with the log-rank test was used to estimate survival differences between groups and Cox proportional regression model was used to estimate the adjusted difference in 4-year all-cause mortality between groups. RESULTS: Recruited for the present study were 333 male participants (mean age 85.4 ± 5.7 years). Of these, 50.2% had malnutrition and 54.7% had low handgrip strength. Compared with subjects with no malnutrition and low handgrip strength, those with malnutrition had significantly greater risk of 4-year all-cause mortality (adjusted hazards ratio: 2.05, 95% confident interval [CI]: 1.04-4.01); hazard ratio increased to 3.41 (95% CI 1.93-6.04) for those with both malnutrition and low handgrip strength. CONCLUSIONS: Malnutrition was an independent risk factor for 4-year all-cause mortality and low handgrip strength with malnutrition synergistically increased the mortality risk. Further study is needed to confirm the effectiveness of integrated programs to assist those at risk.

Gait Speed rather than Dynapenia Is a Simple Indicator for Complex Care Needs: A Cross-sectional Study Using Minimum Data Set.

The impact of dynapenia on the complexity of care for residents of long-term care facilities (LTCF) remains unclear. The present study evaluated associations between dynapenia, care problems and care complexity in 504 residents of Veterans Care Homes (VCHs) in Taiwan. Subjects with dynapenia, defined as low muscle strength (handgrip strength <26 kg), were older adults with lower body mass index (BMI), slow gait speed, and higher numbers of Resident Assessment Protocol (RAP) triggers. After adjusting for age, education, BMI, and Charlson's comorbidity index (CCI), only age, education, BMI and gait speed were independently associated with higher numbers of RAP triggers, but not dynapenia or handgrip strength (kg). Dividing subjects into groups based on quartiles of gait speed, those with gait speed ≤0.803 m/s were significantly associated with higher complexity of care needs (defined as ≥4 RAP triggers) compared to the reference group (gait speed >1 m/s). Significantly slow gait speed was associated with RAP triggers, including cognitive loss, poor communication ability, rehabilitation needs, urinary incontinence, depressed mood, falls, pressure ulcers, and use of psychotropic drugs. In conclusion, slow gait speed rather than dynapenia is a simple indicator for higher complexity of care needs of older male LTCF residents.

Predicting symptomatic intracerebral hemorrhage after intravenous thrombolysis: stroke territory as a potential pitfall.

BACKGROUND: Stroke vascular territories may influence response to thrombolysis, although supporting data are limited. The aim of the study was to test the hypothesis that the current available prediction scores might inaccurately estimate the risk of symptomatic intracerebral hemorrhage (SICH) after intravenous thrombolysis in patients with posterior circulation stroke. METHODS: We applied the Safe Implementation of Thrombolysis in Stroke (SITS) SICH risk score to data from four hospital-based stroke registries. Patients were grouped according to anterior or posterior circulation stroke. The main outcome measure was SICH per various definitions. Performance of the risk score was assessed with the c statistic. RESULTS: Data of 518 thrombolyzed patients (434 anterior, 84 posterior) were studied. The overall rate of SICH varied from 3.5% to 6.9% depending on the SICH definition. Patients with posterior circulation stroke were less likely to have post-thrombolysis SICH per NINDS (P=0.042), per ECASS II (P=0.013), or any ICH (P=0.001), and their rate of SICH was markedly lower than predicted (1.2% versus 7.1% by the NINDS definition; 0% versus 4.8%, ECASS II; 0% versus 1.6%, SITS-MOST). The SITS SICH risk score shows moderate model discrimination across the SICH definitions, with c statistic ranging from 0.64 to 0.70. CONCLUSIONS: The risk of SICH after intravenous thrombolysis in patients with posterior circulation stroke was low enough to render the SITS SICH risk score or other similar prediction models unnecessary. Awareness of stroke territory might help clinicians judiciously use the risk assessment models.

Unsedated transnasal percutaneous endoscopic gastrostomy carried out by a single physician.

AIM: The present prospective observational study investigates the safety of transnasal percutaneous endoscopic gastrostomy (T-PEG) carried out by a single physician using an ultrathin endoscope. METHODS: A single endoscopist attempted the unsedated transnasal insertion of a 20-Fr PEG tube using a pull-method in 31 dysphagic patients: 11 females and 20 males aged 76.5±10.6(46-96)years, using a 5-mm-diameter endoscope. The indications for PEG, cardiopulmonary function before and after T-PEG, operation time, success or failure, and any immediate adverse events that occurred during each procedure were recorded. Complications, including peristomal infection, systemic infection, tube lifespan, and patient mortality were monitored throughout the post-T-PEG follow-up period. RESULTS: Thirty (96.8%) of the transnasal PEG insertions were successful. The mean operation time was 14.7±2.9 (10-20) min, and cardiopulmonary function did not change before and after T-PEG. Complications included three (10%) cases of epistaxis, eight (26.6%) cases of minor Pseudomonas wound infection and two cases of Foley-related urinary tract infection (UTI). No self-extubation was observed, and the mean lifespan of the PEG tubes was 10.7±2.2months. Four patients died from pneumonia 10months after T-PEG insertion. CONCLUSION: Unsedated T-PEG insertion carried out by a single physician is a feasible and safe procedure. No major complications or mortality were observed following the procedures; only minor Pseudomonas aeruginosa wound infections were noted. It is an alternative method for dysphagic patients when transoral insertion of endoscopy is impossible.

[Guideline of neuropathic pain treatment and dilemma from neurological point of view].

Neuropathic pain is a complicated symptomatic disease as migraine in recent years. Not because the pain character differed from the nociceptive inflammatory symptoms but because of its complexity of mechanisms. Though peripheral sensitization, ectopic discharge, central sensitization, central re-organization and loss of inhibition play part of roles in mechanisms, however, based on this mechanistic treatment, the outcome still disappointed physicians and patients, exampled as central post-stroke central pain (CPSP). The pain reduction is far less than the expectation from patients and physician's under-treatment frequently occur due to the fear of adverse effects or off-label use of these anti-neuropathic pain drugs. Therefore, a multidisciplinary procedure including non-pharmacological management, rehabilitation program, careful explanation, stepwise pain reduction, daily diary record, and tailored individual planning for medications are helpful in treating this kind of sufferers. Pharmacological treatment is the mainstream in post-herpetic neuralgia (PHN), diabetic peripheral neuropathic pain (DPNP), central post-stroke pain (CPSP), trigeminal neuralgia (TN), complex regional pain syndrome (CRPS), cancer pain, failed back syndrome etc, while polypharmacy is still the major prescriptions facing such kind of miserable patients. The tricyclic antidepressants (TCA), gamma- aminobutyric acid (GABA), voltage-dependent calcium channel blockers, selective non-epinephrine reuptake inhibitor (SNRI), opioid or morphine etc, are still evidence-based medicines (EBM) but with different outcome for individuals. Acupuncture is to some extend effective in Taiwanese people with perceived evidence or placebo. The Taiwan guidance for total pain management and review of EBM in treating neuropathic pain from neurological point of view will be introduced in this manuscript.

Impact of nutritional status on long-term functional outcomes of post-acute stroke patients in Taiwan.

Nutritional status is important in stroke care, but little is known regarding to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. The main purpose of this study was to evaluate to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. Data of acute stroke registry in Kaohsiung Veterans General Hospital were retrieved for analysis. Overall, 483 patients (mean age = 70.7 ± 10.3 years) with first-ever stroke were found. Among them, 95 patients (19.7%) were malnourished at admission, 310 (mean age = 70.4 ± 10.1 years, 63.5% males) survived for 6 months, and 244 (78.7%) had good functional outcomes. Subjects with poor functional outcomes were older (74.7 ± 8.9 vs. 69.0 ± 10.1 years, p < 0.001), more likely to be malnourished (56.2% vs. 26.6%, p < 0.001), to develop pneumonia upon admission (23.3% vs. 12.7%, p = 0.027), had a longer hospital stay (23.5 ± 13.9 vs. 12.5 ± 8.2 days, p < 0.001), had a higher National Institutes of Health Stroke Scale (NIHSS) score (12.9 ± 9.3 vs. 4.9 ± 4.3, p < 0.001), poorer stroke recovery (NIHSS improvement: 6.9% vs. 27.4%, p = 0.005), and poorer functional improvement (Barthel index = BI improvement in the first month: 31.4% vs. 138%, p < 0.001). Older age (odds ratio = OR) = 1.07, 95% confidence interval (CI = 1.03-1.11, p<0.001), baseline NIHSS score (OR = 1.23, 95%CI = 1.15-1.31, p < 0.001) and malnutrition at acute stroke (OR = 2.57, 95%CI: 1.29-5.13, p<0.001) were all independent risk factors for poorer functional outcomes. In conclusion, as a potentially modifiable factor, more attentions should be paid to malnutrition to promote quality of stroke care since the acute stage.

Familial hyperhomocysteinemia-related cerebral venous sinus thrombosis and pulmonary embolism: a case report.

Elevated plasma homocysteine levels are associated with an increased risk of deep vein thrombosis. Herein we report a case of familial hyperhomocysteinemia-related cerebral venous sinus thrombosis and pulmonary embolism in a 21-year-old man who presented with severe headache over bilateral frontal areas. Neurological examination revealed no evidence of focal neurological deficit. Chest CT showed pulmonary thromboembolism in bilateral basal lung fields and brain MRI disclosed right transverse and sigmoid venous sinus thrombosis. Routine immunological tests, coagulation factors and occult tumor screening were normal, as were vitamin B12 and folate levels. The DIC profile was negative, The only risk factor we were able to identify was an elevated serum homocysteine level, namely 46.23 microM/L. Hyperhomocysteinemia was also noted in the patient's asymptomatic elder brother (68.0 microM/L) and, to a lesser extent, in his parents (father 12.5 microM/L; mother 11.7 microM/L). In conclusion, the cause of cerebral venous thrombosis and pulmonary embolism in this young patient was most likely related to familial hyperhomocysteinemia, with the thromboembolic events precipitated by a preceding systemic infection. After anticoagulation therapy; the patient recovered completely without any residual neurological deficit.

Lithium intoxication-induced acute parkinsonism complicated with hyperparathyroidism and nephrogenic diabetes insipidus: report of a case.

OBJECTIVE: To describe a patient with lithium intoxication presenting as acute parkinsonism, adverse metabolic effects and nephrogenic diabetes insipidus (DI). CASE REPORT: We report a case of a 67-year-old woman with a bipolar affective disorder who was treated with lithium for 10 years. Under concomitant renal insufficiency and urinary tract infarction, she experienced progressive hand tremor, bradykinesia, and unsteady gait. Laboratory results revealed hypercalcemia and hypermagnesiemia. A high serum lithium level (3.6 mEq/L) was found; thus lithium was discontinued. She was found to have a high serum level of intact parathyroid hormone: 135.0 pg/ml and a suspicious parathyroid adenoma. Polyuria with hypernatremia was also noted. A water deprivation test confirmed nephrogenic diabetes insipitces. After correction of electrolyte imbalance and reduction of lithium level, her consciousness recovered. Her parkinsonian features were responsive to levodopa 400 mg/day in 2 divided doses. One month later, apart from the residual extrapyramidal symptoms and mania, her condition was otherwise stationary. CONCLUSIONS: Tremor is the most frequent movement disorder associated with lithium therapy, while severe parkinsonism has been rarely reported. It should be kept in mind in differential diagnosis of acute parkinsonism especially in elder patients who receive a chronic lithium carbonate therapy.