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1.
Disabil Rehabil Assist Technol ; : 1-8, 2019 Aug 20.
Artículo en Inglés | MEDLINE | ID: mdl-31429328

RESUMEN

Purpose: A complete description of the process of physical therapy clinical reasoning for walking assistive devices in patients with stroke and brain injury has never been undertaken. Describing the clinical reasoning process used in post-acute inpatient rehabilitation is important to shed light on the clinical activities and factors used in practice, prevent device abandonment, and, inform entry-level clinical training. The two purposes were first, to describe the clinical reasoning process used during inpatient rehabilitation for walking assistive devices in patients with stroke and brain injury, and second, to determine whether clinical reasoning differed by two facility types and by diagnosis. Methods: A mixed methods study of 67 participants in either an online survey or focus groups. Results: A consistent and comprehensive method to determine the need and justification for a walking assistive device regardless of diagnosis or facility type was found. The clinical reasoning process included five primary factors, considered throughout the rehabilitation stay (safety, balance, cognition, strength, and function). The three therapist-related factors (experience/preference, training parameters, and use of objective tools), and seven patient-related factors (experience/preference, fluctuations, fear, age, diagnosis/comorbidities, discharge environment, and payer) individualized care. Definitions of the five primary factors were derived from participants' responses. Conclusions: Results from this study revealed complexity in the clinical reasoning process used in physical therapy practice to determine the best walking assistive device for patients with stroke and brain injury during inpatient rehabilitation. Information from this study can inform post-acute physical therapy practice and education, and may reduce device abandonment. Implications for rehabilitation Clinical reasoning (CR) is a complex process in which a clinician must consider multiple factors, which requires non-linear and iterative thinking, and involves many people, making it shared among the patient, caregivers, and the healthcare team. Describing the actual CR process used by physiotherapists when prescribing a walking assistive device (WAD) will identify the factors considered, thus more accurately explain the process of care. Such a description could lead to better justification of rehabilitation for patients with stroke and brain injury, and furthermore, determine whether treatments are rendered consistently and when, if ever, divergent approaches occur. Better understanding of the CR process of WAD prescription may also reduce the possibility of device abandonment.

2.
Palliat Med ; 33(8): 1114-1124, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31250704

RESUMEN

BACKGROUND: Specialist palliative care services have various configurations of staff, processes and interventions, which determine how care is delivered. Currently, there is no consistent way to define and distinguish these different models of care. AIM: To identify the core components that characterise and differentiate existing models of specialist palliative care in the United Kingdom. DESIGN: Mixed-methods study: (1) semi-structured interviews to identify criteria, (2) two-round Delphi study to rank/refine criteria, and (3) structured interviews to test/refine criteria. SETTING/PARTICIPANTS: Specialist palliative care stakeholders from hospice inpatient, hospital advisory, and community settings. RESULTS: (1) Semi-structured interviews with 14 clinical leads, from eight UK organisations (five hospice inpatient units, two hospital advisory teams, five community teams), provided 34 preliminary criteria. (2) Delphi study: Round 1 (54 participants): thirty-four criteria presented, seven removed and seven added. Round 2 (30 participants): these 34 criteria were ranked with the 15 highest ranked criteria, including setting, type of care, size of service, diagnoses, disciplines, mode of care, types of interventions, 'out-of-hours' components (referrals, times, disciplines, mode of care, type of care), external education, use of measures, bereavement follow-up and complex grief provision. (3) Structured interviews with 21 UK service leads (six hospice inpatients, four hospital advisory and nine community teams) refined the criteria from (1) and (2), and provided four further contextual criteria (team purpose, funding, self-referral acceptance and discharge). CONCLUSION: In this innovative study, we derive 20 criteria to characterise and differentiate models of specialist palliative care - a major paradigm shift to enable accurate reporting and comparison in practice and research.

3.
Stroke ; 50(8): 1959-1967, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-31208302

RESUMEN

Background and Purpose- International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) codes are often used for disease surveillance. We examined changes in concordance between ICD-CM codes and clinical diagnoses before and after the transition to ICD-10-CM in the United States (October 1, 2015), and determined if there were systematic variations in concordance by patient and hospital characteristics. Methods- We included Paul Coverdell National Acute Stroke Program patient discharges from 2014 to 2017. Concordance between ICD-CM codes and the clinical diagnosis documented by the physician (assumed as accurate) was calculated for each diagnosis category: ischemic stroke, transient ischemic attack, subarachnoid hemorrhage, and intracerebral hemorrhage. Results- In total, 314 857 patient records were included in the analysis (n=280 hospitals), 55.9% of which were obtained after the transition to ICD-10-CM. While concordance was generally high, a small, and temporary decline occurred from the last calendar quarter of ICD-9-CM (average unadjusted concordance =92.8%) to the first quarter of ICD-10-CM use (91.0%). Concordance differed by diagnosis category and was generally highest for ischemic stroke. In the analysis of ICD-10-CM records, disagreements often occurred between ischemic stroke and transient ischemic attack records and between subarachnoid and intracerebral hemorrhage records. Compared with the smallest hospitals (≤200 beds), larger hospitals had significantly higher odds of concordance (ischemic stroke adjusted odds ratio for ≥400 beds, 1.7; 95% CI, 1.5-1.9). Conclusions- This study identified a small and transient decline in concordance between ICD-CM codes and stroke clinical diagnoses during the coding transition, indicating no substantial impact on the overall identification of stroke patients. Researchers and policymakers should remain aware of potential changes in ICD-CM code accuracy over time, which may affect disease surveillance. Systematic variations in the accuracy of codes by hospital and patient characteristics have implications for quality-of-care studies and hospital comparative assessments.

4.
J Pers Assess ; 101(6): 653-661, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30388903

RESUMEN

This article introduces the Inventory of Problems (IOP)-a new, computerized, 181-item tool designed to discriminate bona fide from feigned mental illness and cognitive impairment-and presents the development and validation of its focal, feigning scale, the False Disorder Score (IOP-FDS). The initial sample included (a) 211 patients and 64 offenders who took the IOP under standard conditions, and (b) 210 community volunteers and 64 offenders who feigned mental illness. We split this sample into three subsamples. The first (n = 301) was used to select the variables to generate the IOP-FDS; the second (n = 148) scaled the IOP-FDS into a probability score; and the third (n = 100) tested its validity with an independent data set. In this third subsample, the IOP-FDS had sensitivity = .90, specificity = .80, and a greater area under the curve (AUC = .95) than the IOP-29 (.91). For 40 participants, the Personality Assessment Inventory (PAI) was available, too. Within this subgroup, the IOP-FDS outperformed the selected PAI validity scales (AUC = .99 vs. AUC ≤ .85).

5.
J Clin Gastroenterol ; 2019 Dec 24.
Artículo en Inglés | MEDLINE | ID: mdl-31895167

RESUMEN

GOAL: The goal of this study was to determine if there is an association between the insulin-insulin-like growth factor axis, the metabolic syndrome (MetS), type 2 diabetes mellitus and risk of Barrett esophagus (BE), and if these associations are modified by sex. BACKGROUND: BE is more common in males. Gastroesophageal reflux disease, the major risk factor for BE occurs at similar frequencies in both sexes, suggesting that sex-related factors such as the metabolic effects of abdominal obesity may be important in the causation of BE. MATERIALS AND METHODS: A structured interview, anthropometric measures, and fasting blood were collected within a population-based case-control study. We recruited 227 BE cases (70% male) and 241 population controls, frequency matched by age and sex. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for association with BE using multivariable logistic regression models. RESULTS: Hyperinsulinemia (highest vs. lowest tertile, OR=1.9; 95% CI: 1.2-3.1), Homeostatic Model Assessment of Insulin Resistance (OR=1.9; 95% CI: 1.2-3.1) and the MetS (OR=1.8; 95% CI: 1.2-2.6) were independently associated with an increased risk of BE. With each additional MetS criterion, there was a 20% increased risk of BE (OR=1.2; 95% CI: 1.0-1.4). When stratified by sex, these associations were found in males but not females. We found no association with serum measures of insulin-like growth factors or interleukin-6 and risk of BE. CONCLUSION: Hyperinsulinemia, insulin resistance, and the MetS are associated with the risk of BE in males but not females, suggesting these factors may contribute to the higher prevalence of BE in males.

6.
BMJ Open ; 8(3): e020071, 2018 03 17.
Artículo en Inglés | MEDLINE | ID: mdl-29550781

RESUMEN

INTRODUCTION: Provision of palliative care is inequitable with wide variations across conditions and settings in the UK. Lack of a standard way to classify by case complexity is one of the principle obstacles to addressing this. We aim to develop and validate a casemix classification to support the prediction of costs of specialist palliative care provision. METHODS AND ANALYSIS: Phase I: A cohort study to determine the variables and potential classes to be included in a casemix classification. Data are collected from clinicians in palliative care services across inpatient hospice, hospital and community settings on: patient demographics, potential complexity/casemix criteria and patient-level resource use. Cost predictors are derived using multivariate regression and then incorporated into a classification using classification and regression trees. Internal validation will be conducted by bootstrapping to quantify any optimism in the predictive performance (calibration and discrimination) of the developed classification. Phase II: A mixed-methods cohort study across settings for external validation of the classification developed in phase I. Patient and family caregiver data will be collected longitudinally on demographics, potential complexity/casemix criteria and patient-level resource use. This will be triangulated with data collected from clinicians on potential complexity/casemix criteria and patient-level resource use, and with qualitative interviews with patients and caregivers about care provision across difference settings. The classification will be refined on the basis of its performance in the validation data set. ETHICS AND DISSEMINATION: The study has been approved by the National Health Service Health Research Authority Research Ethics Committee. The results are expected to be disseminated in 2018 through papers for publication in major palliative care journals; policy briefs for clinicians, commissioning leads and policy makers; and lay summaries for patients and public. TRIAL REGISTRATION NUMBER: ISRCTN90752212.


Asunto(s)
Servicios de Salud Comunitaria/economía , Prestación de Atención de Salud/economía , Hospitales para Enfermos Terminales/economía , Hospitales Públicos/economía , Cuidados Paliativos/economía , Especialización/economía , Estudios de Cohortes , Costos y Análisis de Costo , Prestación de Atención de Salud/organización & administración , Grupos Diagnósticos Relacionados/clasificación , Grupos Diagnósticos Relacionados/economía , Femenino , Humanos , Masculino , Cuidados Paliativos/clasificación , Cuidados Paliativos/organización & administración , Reino Unido
7.
Arch Phys Med Rehabil ; 99(1): 107-115, 2018 01.
Artículo en Inglés | MEDLINE | ID: mdl-28860096

RESUMEN

OBJECTIVES: To determine the association between therapy intensity and discharge outcomes for aged Medicare skilled nursing facilities (SNFs) fee-for-service beneficiaries and to determine the association between therapy intensity and time to community discharge. DESIGN: Retrospective observational design. SETTING: SNFs. PARTICIPANTS: Aged Medicare fee-for-service beneficiaries (N=311,338) in 3605 SNFs. INTERVENTIONS: The total minutes of physical therapy, occupational therapy, and speech therapy per day were divided into intensity groups: high (≥60min); medium-high (45-<60min); medium-low (30-<45min); and low (<30min). MAIN OUTCOME MEASURES: Four discharge outcomes-community, hospitalization, permanent placement, and death-were examined using a multivariate competing hazards model. For those associated with community discharge, a Poisson multivariate model was used to determine whether length of stay differed by intensity. RESULTS: High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95). CONCLUSIONS: High intensity therapy was associated with desirable discharge outcomes and may shorten SNF length of stay. Despite growing reimbursements to SNFs for rehabilitation services, there may be desirable benefits to beneficiaries who receive high intensity therapy.


Asunto(s)
Tiempo de Internación/estadística & datos numéricos , Terapia Ocupacional/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Modalidades de Fisioterapia/estadística & datos numéricos , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Logoterapia/estadística & datos numéricos , Reclamos Administrativos en el Cuidado de la Salud , Anciano , Anciano de 80 o más Años , Planes de Aranceles por Servicios , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Medicare , Mortalidad , Estudios Retrospectivos , Instituciones de Cuidados Especializados de Enfermería/economía , Factores de Tiempo , Estados Unidos
8.
J Allied Health ; 46(3): 138-142, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28889162

RESUMEN

OBJECTIVE: This study investigated whether patients with chronic neurologic diagnoses who attended a student-run pro bono physical therapy (PT) clinic achieved the minimum detectable change (MDC) on functional measures and the factors associated with such change. METHODS: Retrospective chart review included 71 patients with a primary diagnosis of stroke, traumatic brain injury, or multiple sclerosis from 2010 to 2014. The sample was 45% female, with a mean age of 62 yrs (SD 12.6) and mean 7.9 yrs (10.1) postdiagnosis. Second-year DPT students provided supervised weekly sessions. Meaningful functional change was defined as the achievement of the MDC on one functional outcome measure. Multivariate logistic regression, controlled for semester, was used to analyze factors associated with achievement of MDC. RESULTS: MDC was achieved in approximately 70% of cases. Factors associated with MDC achievement were number of visits (OR 1.04, p<0.02) and the Charlson Comorbidity Index (OR 1.06, p<0.02). Factors not associated were age, sex, diagnosis, years post-diagnosis, number of medications, admission functional status, and distance to the clinic. CONCLUSIONS: Weekly 60-min PT sessions provided in a student-run neurologic clinic were associated with achieving the MDC on functional measures. Such clinics may be a safety net.


Asunto(s)
Enfermedades del Sistema Nervioso/rehabilitación , Modalidades de Fisioterapia , Clínica Administrada por Estudiantes/organización & administración , Anciano , Enfermedad Crónica , Comorbilidad , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
9.
J Pain Symptom Manage ; 54(3): 417-425, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28782701

RESUMEN

CONTEXT: End-of-life care (EoLC) communication skills training for generalist palliative care providers is recommended in policy guidance globally. Although many training programs now exist, there has been no comprehensive evidence synthesis to inform future training delivery and evaluation. OBJECTIVES: To identify and appraise how EoLC communication skills training interventions for generalist palliative care providers are developed, delivered, evaluated, and reported. METHODS: Systematic review. Ten electronic databases (inception to December 2015) and five relevant journals (January 2004 to December 2015) were searched. Studies testing the effectiveness of EoLC communication skills training for generalists were included. Two independent authors assessed study quality. Descriptive statistics and narrative synthesis are used to summarize the findings. RESULTS: From 11,441 unique records, 170 reports were identified (157 published, 13 unpublished), representing 160 evaluation studies of 153 training interventions. Of published papers, eight were of low quality, 108 medium, and 41 high. Few interventions were developed with service user involvement (n = 7), and most were taught using a mixture of didactics (n = 123), reflection and discussion (n = 105), and role play (n = 86). Evaluation designs were weak: <30% were controlled, <15% randomized participants. Over half (n = 85) relied on staff self-reported outcomes to assess effectiveness, and 49% did not cite psychometrically validated measures. Key information (e.g., training duration, participant flow) was poorly reported. CONCLUSIONS: Despite a proliferation of EoLC communication skills training interventions in the literature, evidence is limited by poor reporting and weak methodology. Based on our findings, we present a CONSORT statement supplement to improve future reporting and encourage more rigorous testing.


Asunto(s)
Comunicación , Personal de Salud/educación , Cuidados Paliativos , Cuidado Terminal , Competencia Clínica , Humanos , Cuidados Paliativos/métodos , Cuidado Terminal/métodos
10.
J Pain Symptom Manage ; 54(3): 404-416.e5, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-28778560

RESUMEN

CONTEXT: As most end-of-life care is provided by health care providers who are generalists rather than specialists in palliative care, effective communication skills training for generalists is essential. OBJECTIVES: To determine the effect of communication training interventions for generalist palliative care providers on patient-reported outcomes and trainee behaviors. METHODS: Systematic review from searches of 10 databases to December 2015 (MEDLINE, EMBASE, PsycINFO, ERIC, CINAHL, CENTRAL, Web of Science, ICTRP, CORDIS, and OpenGrey) plus hand searching. Randomized controlled trials of training interventions intended to enhance generalists' communication skills in end-of-life care were included. Two authors independently assessed eligibility after screening, extracted data, and graded quality. Data were pooled for meta-analysis using a random-effects model. PRISMA guidelines were followed. RESULTS: Nineteen of 11,441 articles were eligible, representing 14 trials. Eleven were included in meta-analyses (patients n = 3144, trainees n = 791). Meta-analysis showed no effect on patient outcomes (standardized mean difference [SMD] = 0.10, 95% CI -0.05 to 0.24) and high levels of heterogeneity (chi-square = 21.32, degrees of freedom [df] = 7, P = 0.003; I2 = 67%). The effect on trainee behaviors in simulated interactions (SMD = 0.50, 95% CI 0.19-0.81) was greater than in real patient interactions (SMD = 0.21, 95% CI -0.01 to 0.43) with moderate heterogeneity (chi-square = 8.90, df = 5, P = 0.11; I2 = 44%; chi-square = 5.96, df = 3, P = 0.11; I2 = 50%, respectively). Two interventions with medium effects on showing empathy in real patient interactions included personalized feedback on recorded interactions. CONCLUSIONS: The effect of communication skills training for generalists on patient-reported outcomes remains unclear. Training can improve clinicians' ability to show empathy and discuss emotions, at least in simulated consultations. Personalized feedback on recorded patient interactions may be beneficial. REGISTRATION NUMBER: CRD42014014777.


Asunto(s)
Competencia Clínica , Comunicación , Personal de Salud/educación , Cuidados Paliativos , Humanos , Medición de Resultados Informados por el Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto
11.
Phys Ther ; 96(9): 1381-8, 2016 09.
Artículo en Inglés | MEDLINE | ID: mdl-26916929

RESUMEN

BACKGROUND: In the United States, people 85 years of age or older have a growing number of strokes each year, and this age group is most at risk for disability. Inpatient rehabilitation facilities (IRFs) adhere closest to post-acute stroke rehabilitation guidelines and have the most desirable outcomes compared with skilled nursing facilities. As stroke is one of the leading causes of disability, knowledge of postrehabilitation outcomes is needed for this age group, although at present such information is limited. OBJECTIVE: The purpose of this study was to describe functional and discharge outcomes after IRF rehabilitation in people with stroke aged 85 years or older. DESIGN: A serial, cross-sectional design was used. METHODS: Inpatient Rehabilitation Facility-Patient Assessment Instrument data were analyzed beginning in 2002 for the first 5.5 years after implementation of the prospective payment system and included 71,652 cases. Discharge function, measured using the Functional Independence Measure (FIM), and community discharge were the discharge outcome measures. Sample description used frequencies and means. Generalized estimating equations (GEEs) with post hoc testing were used to analyze the annual trends for discharge FIM and community discharge by age group (85-89, 90-94, 95-99, and ≥100 years). Risk-adjusted linear and logistic GEE models, with control for cluster, were used to analyze the association between both outcome measures and age group. RESULTS: Over 5.5 years, mean discharge FIM scores decreased by 3.6 points, and mean achievement of community discharge decreased 5.5%. Approximately 54% of the sample achieved community discharge. Continuous and logistic GEEs revealed factors associated with discharge outcomes. LIMITATIONS: Results obtained using an observational design should not be viewed as indicating causation. The lack of control for a caregiver may have altered results. CONCLUSIONS: The very elderly people admitted to IRF stroke rehabilitation made functional gains, and most were able to return to the community.


Asunto(s)
Recuperación de la Función , Rehabilitación de Accidente Cerebrovascular/métodos , Actividades Cotidianas , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Pacientes Internos , Masculino , Medicare , Resultado del Tratamiento , Estados Unidos
12.
PLoS One ; 10(6): e0129836, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26090820

RESUMEN

BACKGROUND: Gastroesophageal reflux is overrepresented in people with obstructive sleep apnea (OSA) and it has been suggested that OSA worsens gastroesophageal reflux symptoms. Aggravated reflux might lead to an increased risk of Barrett's esophagus. AIM: To assess the association between sleep apnea symptoms and Barrett's esophagus. METHODS: Included in a case-control study in Brisbane, Australia were 237 patients with histologically confirmed Barrett's esophagus and 247 population controls. The controls were randomly selected from the electoral roll and frequency-matched to the cases by age and sex. Information on OSA symptoms (excessive daytime sleepiness and sleep related apnea symptoms), gastroesophageal reflux symptoms and anthropometric measures were collected through interviews and written questionnaires. Multivariable logistic regression provided odds ratios (OR) and 95% confidence intervals (CI), adjusted for potential confounding by BMI and gastroesophageal reflux. RESULTS: The prevalence of Barrett's esophagus was higher among people with excessive daytime sleepiness than those without (24% vs. 18%; p-value 0.1142) and in participants with sleep-related apnea symptoms (20% vs. 13%; p-value 0.1730). However, there were non-significantly increased ORs of Barrett's esophagus among people with excessive daytime sleepiness (OR 1.42, 95% CI 0.90-2.34) and sleep related apnea symptoms (OR 1.32, 95% CI 0.74-2.36) when adjusting for age, sex and BMI. After further adjustment for gastroesophageal reflux symptoms, the point ORs were no longer increased (OR 1.02, 95% CI 0.61-1.70 for daytime sleepiness and OR 0.72, 95% CI 0.38-1.38 for sleep related apnea symptoms). CONCLUSIONS: Symptoms of OSA are possibly associated with an increased risk of Barrett's esophagus, an association that appears to be mediated entirely by gastroesophageal reflux.


Asunto(s)
Esófago de Barrett/epidemiología , Esófago de Barrett/etiología , Reflujo Gastroesofágico/complicaciones , Vigilancia de la Población , Apnea Obstructiva del Sueño/complicaciones , Adulto , Anciano , Anciano de 80 o más Años , Australia , Estudios de Casos y Controles , Femenino , Reflujo Gastroesofágico/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Riesgo , Apnea Obstructiva del Sueño/diagnóstico , Adulto Joven
13.
BMJ Support Palliat Care ; 5 Suppl 1: A3, 2015 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-25960520

RESUMEN

BACKGROUND: Family caregivers suffer physically, mentally, and spiritually. Community volunteers play an important role in supporting patients at the end of life or former caregivers in bereavement. However, there are no research reports of volunteer services focused on maintaining the wellbeing of end-of-life caregivers. AIM: To have volunteers, a hired volunteer coordinator, health care providers, and researchers implement and formatively evaluate a volunteer service to enable family caregivers to maintain their well being while providing care and subsequent bereavement. This presentation will focus on the volunteers' roles with the project as both agents of change to the service and as support for the caregivers. METHOD: A qualitative formative evaluation informed by Guba and Lincoln's Fourth Generation Evaluation (1989) participatory design was conducted. Data was collected through individual interviews, focus groups, participant observation during volunteer support meetings, and through volunteers' written reflections. RESULTS: Amongst the volunteers, volunteer coordinator, and principal investigator, there was mutual respect for and interest in learning about everyone's roles and experiences in the project. The experience was rewarding because they felt they helped the family caregiver and enjoyed developing and improving the service and working in a supportive team. Volunteers' challenges included being nervous for their first meeting with a caregiver, and frustration with some rules put in place to protect them (e.g. not helping the caregiver with direct care for the patient). CONCLUSION: Volunteers can be an effective part of the research team, while providing valuable support and encouragement for family caregivers to maintain their own wellbeing.

14.
Support Care Cancer ; 23(10): 3081-8, 2015 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-25744289

RESUMEN

PURPOSE: Multiple myeloma (MM) is often associated with osteolytic bone disease and anemia, resulting in skeletal fragility and persistent fatigue, pain, and reduced quality of life. Exercise is considered safe and beneficial for this population. Our objectives were to evaluate the extent to which MM patients undergoing chemotherapy complied with exercise recommendations and to identify factors associated with noncompliance. METHODS: This retrospective study included 41 MM patients referred to a hospital-based rehabilitation program while undergoing chemotherapy. Variables collected at baseline (T1) and follow-up (T2) included: (a) demographics and medical history, (b) exercise levels (MET-hours/week), preferences and barriers, and (c) fatigue severity scores (0-10). Statistical analyses included logistic regression to identify factors associated with exercise noncompliance and t-tests and chi-squared tests to compare outcomes between the groups according to compliance. RESULTS: The mean age of the participants was 61 years; 73 % were male and 81 % had bone lesions. Overall exercise compliance at T2 was 71 %, with an observed increase in exercise levels (mean group difference: 6.5 MET-hours/week; p < 0.001) and decrease in fatigue severity scores (mean group difference -1.2; p = 0.003). Factors associated with exercise noncompliance included history of pathological fracture (odds ratio [OR] 4.7; p = 0.049), spinal cord compression (SCC) (OR 14.1; p = 0.023), and radiation (OR 28.0; p < 0.001). CONCLUSIONS: In this sample of MM patients, high compliance with exercise and associated improvements in fatigue were observed. However, participants with a history of pathological fracture, SCC, or radiation are at increased risk of noncompliance and may require additional supervision to improve exercise compliance.


Asunto(s)
Terapia por Ejercicio/métodos , Mieloma Múltiple/tratamiento farmacológico , Mieloma Múltiple/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Estudios Retrospectivos
15.
Cancer Epidemiol ; 38(3): 266-72, 2014 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-24726825

RESUMEN

BACKGROUND: Body mass index is associated with the risk of Barrett's oesophagus (BO). It is uncertain whether this is related to total body fat or other factors that correlate with body mass index. We aimed to quantify the association between total body fat (measured by bioelectrical impedance) and risk of BO and examine if this association was modified by gastro-oesophageal reflux (GOR) and abdominal obesity. METHODS: In 2007-2009, we surveyed 235 cases (69% Males, Mean age 62.1 years) and 244 age and sex matched population controls from a population based case-control study of BO. We conducted structured interviews, standard anthropometry and bioimpedance analysis of total body fat. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using multivariable logistic regression analysis. RESULTS: There was a significantly increased risk of BO among those in the highest tertile of total body fat weight (OR 2.01; 95%CI 1.26-3.21) and total body fat percentage (OR 1.86; 95%CI 1.10-3.15). These risks were largely attenuated after adjustment for GOR and waist circumference. There was a significantly increased risk of BO among those in the highest tertile of waist circumference (OR 2.21; 95%CI 1.39-3.51) and this was minimally attenuated after adjustment for total body fat and moderately attenuated after adjustment for GOR. CONCLUSIONS: Total body fat is associated with an increased risk of BO but this appears to be mediated via both abdominal obesity and GOR. These findings provide evidence that abdominal obesity is more important than total body fat in the development of BO.


Asunto(s)
Esófago de Barrett/epidemiología , Obesidad/epidemiología , Adulto , Anciano , Australia/epidemiología , Esófago de Barrett/fisiopatología , Índice de Masa Corporal , Estudios de Casos y Controles , Recolección de Datos , Impedancia Eléctrica , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Obesidad/fisiopatología , Factores de Riesgo
16.
Disabil Rehabil ; 36(15): 1273-8, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24151817

RESUMEN

PURPOSE: Few studies have investigated the ability of treatment teams to predict functional improvement and whether an association between predicted goals and discharge function in patients with stroke exists. This study investigated goal prediction during stroke rehabilitation delivered in inpatient rehabilitation facilities (IRF) and the factors associated with goal prediction. METHODS: A serial, cross-sectional design analyzing the Medicare IRF Patient Assessment Instrument dataset. The sample included 179 479 admissions for stroke aged over 65 years in 968 IRFs. Generalized estimating equations (GEE) controlled for facility cluster effects were used for analysis of time trends for length of stay (LOS), predicted Functional Independence Measure (FIM) scores, discharge FIM scores and predicted-discharge difference FIM scores (goal FIM scores minus discharge FIM scores). GEE models were employed to determine the correlation between predicted FIM and discharge FIM scores and factors associated with goal achievement. RESULTS: Mean LOS, predicted FIM scores and discharge FIM scores decreased 1.8 d, 2.2 points and 3.6 points, respectively, while predicted-discharge difference FIM scores increased 1.3 points. Discharge goals were not met 78.9% of the time. After controlling for patient characteristics, each predicted FIM point was associated with 0.6 discharge FIM points (p < 0.0001). Factors associated with not meeting or exceeding goals were: age (odds ratio; OR = 0.997), African Americans (OR = 0.905), number of comorbidities (OR = 0.970), number of complications (OR = 0.932) and right brain stroke (OR = 0.869). Factors associated with meeting or exceeding goals were: LOS (OR = 1.03), admission FIM score (OR = 1.02) and females (OR = 1.05). CONCLUSIONS: Trends for lower goals and lower discharge function occurred over time. A correlation existed between predicted FIM scores and discharge FIM scores. Patient factors were associated with goal achievement. IMPLICATIONS FOR REHABILITATION: Using the Functional Independence Measure, rehabilitation teams set lower goals for stroke rehabilitation in inpatient rehabilitation facilities during first 5.5 years of the IRF-PAI dataset. Discharge FIM scores also trended lower and fell at faster rate than goal FIM scores. Teams' goal FIM scores averaged nearly 12 points higher than discharge FIM scores, and over 75% of patients did not reach goals for the rehabilitation stay. Factors associated with meeting or exceeding goals were: length of stay, admission FIM scores and being a female. Factors associated with not meeting or exceeding goals were: age, number of comorbidities and complications, having a right-brain stroke and being African American.


Asunto(s)
Evaluación de la Discapacidad , Planificación de Atención al Paciente , Alta del Paciente/estadística & datos numéricos , Centros de Rehabilitación , Accidente Cerebrovascular , Actividades Cotidianas , Afroamericanos , Factores de Edad , Anciano , Comorbilidad , Estudios Transversales , Femenino , Humanos , Masculino , Medicare/estadística & datos numéricos , /tendencias , Planificación de Atención al Paciente/estadística & datos numéricos , Planificación de Atención al Paciente/tendencias , Valor Predictivo de las Pruebas , Recuperación de la Función , Centros de Rehabilitación/estadística & datos numéricos , Centros de Rehabilitación/tendencias , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Rehabilitación de Accidente Cerebrovascular , Resultado del Tratamiento , Estados Unidos/epidemiología
17.
Phys Ther ; 93(12): 1592-602, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-23886846

RESUMEN

BACKGROUND: Understanding of the potential impact that length of stay (LOS) may have on Medicare beneficiaries' poststroke discharge function and discharge destination since implementation of a prospective payment system is lacking. OBJECTIVE: This study examined the trends and associations between LOS and discharge outcomes in Medicare beneficiaries with stroke treated in inpatient rehabilitation facilities (IRFs). DESIGN: A serial, cross-sectional analysis of the Inpatient Rehabilitation Facility Patient Assessment Instrument dataset was conducted. The sample consisted of 371,211 patients with stroke who were over 65 years of age in all IRFs in the United States between January 1, 2002, and June 30, 2007. METHODS: Annual trends for means of LOS, admission and discharge Functional Independence Measure (FIM) scores, and percent community discharge were examined using generalized estimating equations (GEEs) with facility level control and post hoc testing. The association between discharge FIM scores and LOS was examined using a continuous, multivariate GEE model. The association between community discharge and LOS was examined using a logistic, multivariate GEE model. RESULTS: Time trends showed mean LOS decreased 1.8 days; admission and discharge FIM scores declined 4.4 points and 3.6 points, respectively; and mean community discharges declined 5.4%. Controlling for study year and covariates, each day was associated with an increase of 0.50 discharge FIM points (95% confidence interval=0.48, 0.52). Each day also was associated with a 0.3% decrease in odds of community discharge (95% confidence interval=0.994, 0.999). LIMITATIONS: Reliability and validity of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) are lacking. Results may have been biased by a lack of control at the patient and facility levels. CONCLUSIONS: Medicare beneficiaries with stroke treated in IRFs experienced shorter LOS, had worsening admission and discharge function, and had fewer community discharges. Worsening admission function and shorter LOS may contribute to worsening discharge outcomes, which may indicate a lack of readiness for IRF treatment and that facility-level factors may be playing a role in shorter LOS.


Asunto(s)
Tiempo de Internación/estadística & datos numéricos , Medicare/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Rehabilitación de Accidente Cerebrovascular , Actividades Cotidianas , Anciano , Anciano de 80 o más Años , Estudios Transversales , Evaluación de la Discapacidad , Femenino , Humanos , Modelos Logísticos , Masculino , Pronóstico , Índice de Severidad de la Enfermedad , Estados Unidos
18.
Int J Cancer ; 132(9): 2192-9, 2013 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-23034724

RESUMEN

Esophageal adenocarcinoma arises from Barrett's esophagus (BE). Both occur predominantly in males. The role of abdominal obesity in this sex distribution is uncertain. Our study aimed to determine whether there is an association between abdominal obesity and risk of BE and if present was it modified by sex. A structured interview and anthropometric measures were conducted within a population-based case-control study. We recruited 237 BE cases (70% male) and 247 population controls, frequency matched by age and sex. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using multivariable logistic regression analysis. In the overall group and males, all measures of abdominal obesity [waist circumference (WC), waist-hip ratio (WHR), sagittal abdominal diameter (SAD) and waist-height ratio (WHtR)] were strongly associated with risk of BE (Overall: WC OR 2.2 95% CI 1.4-3.5, WHR 1.8 95% CI 1.2-2.9, SAD 2.3 95% CI 1.4-3.7, WHtR 1.9 95% CI 1.2-3.0, males WC 2.5 95% CI 1.4-4.3, WHR 2.4 95% CI 1.3-4.2, SAD 2.5 95% CI 1.4-4.3, WHtR 1.9 95% CI 1.1-3.4). These associations were minimally attenuated by adjusting for ever-symptoms of gastroesophageal reflux (GER). These findings suggest in males, non-GER factors related to abdominal obesity may be important in the development of BE. In females, there was modest association between measures of abdominal obesity and risk of BE but these were all abolished after adjusting for ever-symptoms of GER. The power to detect differences between sexes in the risk of BE associated with abdominal obesity was limited by the number of females in the study.


Asunto(s)
Esófago de Barrett/etiología , Obesidad Abdominal/complicaciones , Adolescente , Adulto , Anciano , Estudios de Casos y Controles , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , Factores Sexuales , Adulto Joven
19.
J Clin Epidemiol ; 65(12): 1329-36, 2012 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-22974496

RESUMEN

OBJECTIVE: To examine the test-retest reliability and validity of self-reported items capturing phenotypic characteristics and sun exposure measures in the baseline survey instrument used for a prospective study of skin cancer and melanoma. STUDY DESIGN AND SETTING: Repeatability/validity study conducted among 114 participants randomly selected from the cohort to complete the survey instrument a second time and to undergo a physician skin examination. We calculated intraclass correlation coefficients (ICCs) and kappa (κ) statistics as measures of agreement for continuous and categorical measures, respectively. RESULTS: Measures of phenotypic characteristics showed moderate-to-high agreement (e.g., eye color, κ=0.87; 95% confidence interval [CI]: 0.80, 0.94). Measures of sun exposure had slightly lower estimates of agreement. The repeatability of items relating to medical and family history of skin cancer was high (e.g., the number of skin cancers removed surgically, κ(w)=0.79; 95% CI: 0.71, 0.88). Physician counts of nevi correlated well with categorical measures of self-reported nevus density at the age of 21 years but correlated only modestly with absolute nevus counts conducted by participants (ICC, 0.38; 95% CI: 0.19, 0.54). CONCLUSION: Our survey instrument demonstrated fair-to-good test-retest reliability for most self-reported risk factors for melanoma, indicating the suitability of these items for developing risk prediction tools in the future.


Asunto(s)
Melanoma/etiología , Neoplasias Cutáneas/etiología , Luz Solar/efectos adversos , Adulto , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Factores de Riesgo , Encuestas y Cuestionarios/normas
20.
Int J Epidemiol ; 41(4): 929-929i, 2012 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-22933644

RESUMEN

The QSkin Sun and Health Study comprises a cohort of 43 794 men and women aged 40-69 years randomly sampled from the population of Queensland, Australia in 2011. The cohort was established to study the development of skin cancer and melanoma in the population with the highest reported incidence of these diseases in the world. At baseline, besides demographic items and general medical history, information about standard pigmentary characteristics (including hair and eye colour, freckling tendency, tanning ability and propensity to sunburn), past and recent history of sun exposure and sunburns, sun protection behaviours, use of tanning beds and history of skin cancer was collected by self-completed questionnaire. Participants have given their consent for data linkage to the universal national health insurance scheme and for linkage to cancer registries and pathology databases, thus ensuring complete ascertainment of all future skin cancer and melanoma occurrences and medical treatments and other cancer events. Linkage to these registers will occur at predetermined intervals. Approval to access QSkin data can be obtained on application to the study investigators and submission of a formal research plan that has previous approval from the human research ethics committee of the applicant's institution.


Asunto(s)
Conductas Relacionadas con la Salud , Melanoma/epidemiología , Melanoma/prevención & control , Neoplasias Cutáneas/epidemiología , Neoplasias Cutáneas/prevención & control , Adulto , Anciano , Actitud Frente a la Salud , Estudios de Cohortes , Demografía , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Queensland/epidemiología , Sistema de Registros , Proyectos de Investigación , Medición de Riesgo , Factores de Riesgo , Encuestas y Cuestionarios
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