The impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients.

BACKGROUND: Toxin-producing Clostridium difficile is the most common cause of nosocomial diarrhea in geriatric units. AIM: The purpose of study was to check the impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients. METHODS: The sampling frame was all patients suffering from diarrhea checked for Clostridium difficile toxin during the years 2017-2018. Clostridium difficile-positive patients were compared to a similar number of Clostridium difficile toxin-negative patients. The data were compared to our previous study, followed by medical staff's educational program for Clostridium difficile control and prevention. RESULTS: Among 217 patients with diarrhea, 60 (27.6%) were positive for Clostridium difficile toxin. The study group tended to be of older age (p = 0.06), and showed higher rate of functional impairment (p < 0.001) and mortality (p < 0.001) than Clostridium difficile toxin negative patients. The rate of Clostridium difficile toxin-positive patients did not significantly differ between the previous and current studies (20.0% and 27.6%, respectively). CONCLUSIONS AND DISCUSSION: In spite of findings, that patients tended to be older, with high rate of mortality, the rate of Clostridium difficile did not change from the previous study.

The relation between gain in cognition during rehabilitation on functional outcome among hip fracture adult patients with and without pre- hip fracture dementia.

The purpose of the present study was focused on the relationship between change in cognition and the functional outcome during rehabilitation in demented and non-demented adult hip fracture patients. We studied seventy consecutive adult patients with hip fracture admitted to our rehabilitation wards. Functional outcome was assessed by the Functional Independence Measure (FIM). The gain in cognition during the rehabilitation process was measured by the difference in Mini Mental State Examination scores at admission and discharge. Data was analyzed by t-test, chi square-test and linear regression. Patients without dementia presented and discharged from the rehabilitation ward with statistically significant higher total, motor, and gain functional independence measure scores compared to patients with dementia. In a multiple regression analyses, gain in Mini Mental State scores examination were not independently associated with higher total and motor functional independence measure scores at discharge (beta = 0.086, p = 0.194; beta = 0.077, p = 0.309, respectively). Our findings suggest that there is no association between functional outcome and cognitive gain at the end of the rehabilitation process among adult hip fracture patients with and without dementia. However hip fracture adult patients with dementia should not be deprived of a post-acute rehabilitation.

Comparative characteristic of antimicrobial resistance in geriatric hospital: a retrospective cohort study.

BACKGROUND AND AIMS: To examine antimicrobial resistance of commonly isolated pathogens in elderly hospitalized patients. METHODS: Data regarding all clinically significant isolates from blood and urine cultures of patients admitted to a multilevel geriatric hospital during March 2015 to April 2016 were collected. Antimicrobial susceptibility testing was performed according to Clinical and Laboratory Standard Institute guidelines. RESULTS: Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae were the most common isolates, with proportions of extended spectrum beta-lactamase positivity of 60, 40, and 61% respectively. Adjusted logistic regression models indicated that resistance of Escherichia coli to ceftriaxone [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.5-5.1], ceftazidime (OR 2.8, 95% CI 1.5-5.1), ciprofloxacin (OR 2.2, 95% CI 1.2-4.0), amoxicillin/clavulanic acid (OR 2.3, 95% CI 1.2-4.3), and trimethoprim/sulfamethoxazole (OR 2.4, 95% CI 1.4-4.3) was significantly higher in skilled nursing wards than in acute geriatric wards. Resistance of Proteus mirabilis to ceftriaxone (OR 3.1, 95% CI 1.5-6.4) and Klebsiella pneumoniae to ciprofloxacin (OR 3.2, 95% CI 1.3-7.9) was significantly higher in skilled nursing wards than in acute wards. CONCLUSIONS AND DISCUSSION: Antimicrobial resistance was found to be high in a multilevel geriatric hospital, especially in skilled nursing wards. These findings call for rethinking of the empirical antimicrobial therapy and of the efforts for prevention of nosocomial infection.

Functional gain following rehabilitation of recurrent ischemic stroke in the elderly: experience of a post-acute care rehabilitation setting.

The aim of the study was to evaluate whether rehabilitation of patients with recurrent ischemic strokes is associated with functional gain. We studied a total of 919 consecutive post-acute ischemic stroke elderly patients admitted for rehabilitation. 22% out of the patients had recurrent stroke on index day. Functional outcomes of first-ever stroke patients and recurrent ischemic stroke patients were assessed by the Functional Independence Measurement scale (FIM™) at admission and discharge. Data was analyzed by t-test, Chi-square test and by multiple linear regression analysis. There were 716 patients with first ever stroke and 203 patients with recurrent stroke. Total and motor FIM scores at admission and total, motor, gain and Montebello Rehabilitation Factor (RFG) FIM scores at discharge were similar in the two groups. A multiple linear regression analysis showed that age (beta=-0.13, p=0.001) length of stay (beta=0.21, p<0.001), Mini-Mental State Examination score (MMSE) (beta=0.1, p=0.01), and admission total FIM (beta=-0.12, p=0.01) emerged as the only independent predictors of higher gain FIM scores at discharge. The finding suggests that elderly patients with recurrent ischemic stroke admitted to rehabilitation ward, showed similar FIM gain scores at discharge, compared with first-ever stroke patients. It is concluded that recurrent stroke should not be considered as adversely affecting the short-term functional outcomes of patients in a post-acute rehabilitation setting.

Short-term functional outcome of ischemic stroke in the elderly: a comparative study of atrial fibrillation and non-atrial fibrillation patients.

The purpose of this study was to evaluate whether atrial fibrillation affects the short-term functional outcome of elderly patients with ischemic stroke, undergoing post-acute in-hospital rehabilitation. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation, out of whom 19.6% were diagnosed with atrial fibrillation. The Functional outcome of atrial fibrillation (AF) and non-atrial fibrillation (Non-AF) patients were assessed by the Functional Independence Measurement scale (FIM) at admission and discharge. Data were analyzed by t-test, Chi-square test and by multiple linear regression analysis. Compared with Non-AF, patients with AF were slightly older (p<0.001), and had lower Mini-Mental State Examination (MMSE) scores (p=0.001). Discharge total FIM scores were significantly higher in Non-AF compared with AF patients (84.34 ± 29.44 vs. 79.02 ± 30.68, p=0.031). However, total and motor FIM gains at discharge were similar in the two groups. A multiple linear regression analysis showed that age (p<0.001), admission total and motor FIM (p<0.001) and MMSE score (p<0.001) emerged as the only independent predictors of total, motor and gain FIM scores at discharge. AF was not predictive, whatsoever, of adverse FIM scores (total, motor, gain) at discharge (ß=-0.024, p=0.303; ß=-0.019, p=-0.455 and ß=-0.04, p=0.303, respectively). The finding suggests that Non-AF ischemic stroke elderly show higher total discharge FIM scores, compared with AF patients. However, both groups achieve similar FIM gains during rehabilitation period. AF should not be considered as adversely affecting the short-term rehabilitation process of such patients.

Gender and the functional outcome of elderly ischemic stroke patients.

The purpose of this study was to investigate the effect of gender on the functional outcome after ischemic stroke. In a retrospective chart review we studied 919 survivors of ischemic stroke admitted for rehabilitation at a geriatric rehabilitation ward of a university affiliated hospital. Functional outcome of female and male patients was assessed by Functional Independence Measurement (FIM) at admission and discharge. Data were analyzed by t test, Chi-square test and Linear Regression. A total number of 919 patients were admitted of whom 56% were males. A higher proportion of male patients reported ischemic heart disease (p<0.001), hypercholesterolemia (p=0.035), Parkinson's disease (p=0.044), and previous stroke (p<0.001). Males had also higher Mini-Mental State Examination (MMSE) scores (p<0.001). Total FIM at admission (62.54 ± 25.98 and 66.00 ± 25.49; p=0.043), and total FIM at discharge (80.39 ± 30.35 and 85.59 ± 29.08; p=0.008), motor FIM at admission (40.04 ± 18.89 and 42.51 ± 18.47; p=0.047) and motor FIM at discharge (56.41 ± 23.04 and 60.44 ± 21.84; p=0.007) were higher among male patients. However, a trend for a borderline statistical difference was observed for FIM gains upon discharge between men and women. A multiple linear regression analysis showed that total FIM at discharge was neither associated with male nor female gender (ß=-0.009; p=0.69). The findings suggest that the functional outcome of male survivors presenting for rehabilitation after acute ischemic stroke is slightly better. After adjusting for possible covariates, gender did not emerge as an independent predictor for higher FIM at discharge, suggesting that gender should not be held as adversely affecting rehabilitation of such patients.

Bladder management and the functional outcome of elderly ischemic stroke patients.

The purpose of this study was to investigate how bladder management, rather than urinary incontinence, may affect the functional outcome of ischemic stroke patients. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation. Level of bladder management was determined by Functional Independence Measurement (FIM TM) sub-scale scores relevant to bladder control. FIM scores less than 5 points was determined as low-bladder management score (Low-BMS) while FIM scores greater than 5 was determined as high-bladder management score (High-BMS). Data were analyzed by t-test, Pearson correlation, and chi-square test as well as by multiple linear regression analysis. There were 594 low-bladder score patients (Low-BMS) and 325 high-bladder score patients (High-BMS), at admission. Compared with High-BMS, Low-BMS patients were slightly older (p = 0.002), had longer rehabilitation stays (p < 0.001) and lower mini-mental state examination (MMSE) scores (p < 0.001). Total FIM at admission and discharge were lower in Low-BMS, yet their total FIM gain upon discharge was higher, compared with High-BMS (19.5 ± 16.46 vs. 17.59 ± 12.55, p = 0.07). Multiple linear regression analyses showed that total FIM at discharge was inversely associated with Low-BMS at admission (beta = -0.407; p<0.001) and age (beta = -0.127; p < 0.001). A high MMSE score (beta = 0.334; p < 0.001) emerged as predicting higher total FIM scores upon discharge. Low-BMS was independently predictive for total FIM gain at discharge (beta = 0.166; p < 0.001). The findings suggest that Low-BMS should be held as adversely affecting the rehabilitation outcomes of elderly stroke patients. However, Low-BMS patients do obtain significant gains and should not be deprived of rehabilitation.

Risk management in clinical practice. Part 7. Dento-legal aspects of orthodontic practice.

Orthodontic treatment, like any aspect of general dentistry, exposes the clinician to the risk of malpractice and litigation. While for orthodontists this issue has not been a major concern over the last century, risk management has, over the last decade, become a significant issue in orthodontic practice. The patient-orthodontist contact may be classified into pre-treatment, active treatment and post-treatment periods. Risk management issues pertinent to each time period are discussed in this article with the intention of increasing the clinician's awareness of potential problems. Armed with this knowledge the overriding message for the clinician is to practise orthodontics with the philosophy of prevention and avoidance. To the best of your ability, avoid giving patients a reason to institute legal proceedings.

Predictors of individual visual memory decline after unilateral anterior temporal lobe resection.

BACKGROUND: Different types of neuropsychological visual memory tasks have been created to quantify deficits associated with right hemisphere dysfunction. There are reports of visual memory impairment after right anterior temporal lobe resection (ATR) compared to left ATR for the processing of faces, abstract designs, and spatial locations, but there are also studies showing no between-group differences. One potential reason for the conflicting results is the use of group mean changes, which mask individual differences. METHODS: Proportions of individual subjects with decline, no change, or improvement in memory for spatial locations, abstract designs, and unfamiliar faces were evaluated in 83 individuals who underwent a standard ATR (47 right, 36 left) and were left hemisphere language dominant. RESULTS: Type of visual memory ability was an important factor as there were differential individual declines found for memory for spatial locations after right ATR compared to left ATR (27.3% vs 5.9%), but not memory for abstract designs or face memory. Logistic regression indicated that the odds of a spatial memory decline were six times higher for patients who underwent right ATR than left ATR. CONCLUSIONS: Memory for spatial locations appears to be particularly vulnerable to decline when a patient undergoes right-anterior temporal lobe resection (ATR) and when the patient has better spatial memory before surgery. Results provide proportions of subjects with significant change to help clinicians and patients make better informed decisions about risks associated with undergoing right ATR.

A five-year review of cases appearing before the General Dental Council's Professional Conduct Committee.

The General Dental Council (GDC) has as its primary responsibility the protection of the general public by regulating all dental professionals in the United Kingdom. Complaints brought to the attention of the GDC regarding the conduct of members of the dental profession are dealt with in a regulated manner. This study briefly reviews the relevant procedures and analyses 209 cases brought before the Professional Conduct Committee of the GDC over a five-year period. The results show an annual increase from 23 cases in 2003 to 65 cases in 2007 (0.18% of registered dentists) and provide information on the geographic distribution of registrants as well as their country of origin and year of qualification. The charges, outcomes and determinations give an indication of the clinical and non-clinical misdemeanours committed by members of the profession. The outcomes and final determinations handed down (56 erasures and 37 suspensions) reflect the serious view the GDC holds regarding the professional conduct of all dental professionals.

Discharge hemoglobin and functional outcome of elderly hip fractured patients undergoing rehabilitation.

AIM: Low hemoglobin level is considered a marker of poor functional outcome. The objective of this study was to explore possible relationship of discharge hemoglobin levels and functional outcome of elderly hip fracture patients, undergoing in-hospital rehabilitation. METHODS: A retrospective chart review study, comprising consecutive elderly patients suffering traumatic hip fractures. Main outcome measurement was the functional outcome of patients, as assessed by motor and total Functional Independence Measurement (FIM) scores upon admission and discharge. RESULTS: Mean discharge hemoglobin levels were significantly associated with prefracture function and Mini Mental State Examination (MMSE) score (P=0.002 and P=0.01, respectively). The authors observed a significant positive correlation between serum hemoglobin and total FIM at discharge (Pearson's coefficient =0.13; P=0.005) as well as with motor FIM at discharge (Pearson's coefficient =0.13; P=0.005). Regression analyses showed that high MMSE scores (beta=0.55; P<0.001), female gender (beta=0.07; P=0.01), younger age (beta=-0.10, P=0.001) and a better pre-fracture function (beta=-0.27 P<0.001) are associated with higher total FIM scores upon discharge. Neither discharge hemoglobin levels nor the number of transfused blood packs were significantly associated with better total FIM, motor FIM, FIM gain or FIM= or >80.scores. CONCLUSION: Higher hemoglobin at discharge was not associated with a better postfracture function, as reflected by FIM scores. The authors suggest that clinically reasonable low hemoglobin levels are not associated with adverse functional outcome of elderly hip fracture patients, thus, actively correcting hemoglobin levels, per se, may not result in better functional outcomes in this population.

Rehabilitation outcome of hip fracture patients: the importance of a positive albumin gain.

Low serum albumin level is associated with poor functional outcome and predicting a greater functional decline in the elderly. The aim of this study is to determine the interrelation between change of serum albumin level during rehabilitation period and functional outcome in hip fracture patients. We studied 433 consecutive elderly hip fracture patients admitted for rehabilitation. Functional outcome was assessed by the Functional Independence Measure (FIM) at admission and discharge of patients with no albumin gain (<0 g/dl) or with positive albumin gain (>or=0 g/dl). Data were analyzed by t-test, Pearson correlation, chi(2)-test and linear regression. Of patients 66.7% showed no albumin gain. These patients had a higher prevalence of previous stroke (p=0.04), lower Mini Mental State Examination (MMSE) scores (p=0.05) and were less likely to have hyperlipidemia (p=0.008) compared with patients with albumin gains. Admission and discharge FIM parameters and total and motor FIM gain/day were statistically significantly lower among patients with no albumin gain. In a linear regression analysis total FIM at discharge was inversely associated with pre-fracture function (beta=-0.148; p<0.001), Albumin gain (beta=0.047; p=0.005), high MMSE score (beta=0.143; p<0.001), and higher admission total FIM score (beta=0.69; p<0.001) emerged as significant predictors of higher total FIM scores upon discharge. The results suggest that patients with albumin gain have better admission and discharge FIM scores. Albumin gain emerged as a significant predictor for higher discharge FIM scores. We conclude that greater attention and efforts should be made regarding the dietary intervention and protein supplementation, in order to improve the rehabilitation outcome.

The Quatro appliance: a removable aligner with a changeable labial bow.

Lower labial segment irregularity is a feature that is presenting more frequently as greater emphasis is placed on aesthetics than ever before. The authors report on a removable appliance that is easy to construct and use and is designed to deal with mild labial tooth irregularity. In cases of crowding the aligner can be used in conjunction with inter-proximal stripping. The device incorporates a removable labial bow attached bilaterally to a sliding lock. This lock permits the addition of sectional archwires to the labial part of the appliance. The versatility of the aligner allows round and rectangular wires of different materials and dimensions to be placed with or without bends.

Functional outcome of elderly hip fracture patients: does diabetes matter?

The purpose of this study was to investigate whether diabetes mellitus may affect the functional outcome of hip fractured patients. We studied 759 consecutive patients admitted for hip fracture rehabilitation, out of whom 18.2% were diabetics. The functional outcomes of diabetics and nondiabetics were assessed by the functional independence measurement scale (FIM) at admission and discharge. Data were analyzed by t-tests, Pearson correlation, and chi-square test as well as by multiple logistic regression analysis. Compared with nondiabetics, diabetic patients were slightly younger (p=0.003) and more hyperlipidemic (p=0.01), had a higher prevalence of previous stroke (p=0.03) and lower cognitive Mini-Mental State Examination (MMSE) scores (p=0.007). Absolute and relative FIM parameters, at admission and discharge, were similar in both groups. A multiple logistic regression analysis showed that diabetes was independently, and inversely, associated with male gender [odds ratio (OR), 2.11 (95% CI, 1.41-3.18)] and higher admission motor-FIM [OR, 1.05 (95% CI, 1.03-1.07)], whereas higher cognitive scores upon admission emerged as being "protective" for being in the motor-FIM gain <20 [OR, 0.94 (95% CI, 0.91-0.97)]. However, diabetes was not associated with any of the parameters indicating unsuccessful rehabilitation. The findings suggest that there is no difference in the functional outcome of diabetic and nondiabetic patients, presenting for rehabilitation after surgery of hip fractures. Diabetes should not be considered as adversely affecting rehabilitation of such patients.

Plasma homocysteine, vitamin B12 and folate in Alzheimer's patients and healthy Arabs in Israel.

High plasma homocysteine (tHcy) is a risk factor for cardiovascular disease and stroke and Alzheimer's disease (AD). An inverse relationship has been reported between tHcy and plasma B12 and folate levels. Seventy-nine AD patients and 156 controls from three Arab villages in northern Israel participated. Plasma tHcy, B12 and folate levels were determined. Data were analyzed using univariate statistical tests and logistical regression with confounders. tHcy was significantly higher in AD patients (20.6+/-8.7 micromol/l) than in controls (16.4+/-6.5 micromol/l) (p=0.03) after correction for year of birth, gender and smoking status. Plasma B12 (322.9+/-136.0/350.5+/-175.3 pmol/l) and plasma folate (4.5+/-3.8/4.9+/-2.6 nmol/l) levels did not differ significantly between AD patients and controls. Subjects in the highest tHcy tertile or in the lowest B12 and folate tertiles did not have greater risk to develop AD. In this population residing in Arab villages in northern Israel, tHcy levels were significantly higher among AD patients than in controls. Plasma B12 and folate levels were lower among cases but were not significant. There was not a significant association between plasma tHcy, B12 and folate levels in controls or AD patients. High levels of tHcy may suggest the need for folate and vitamin B12 supplementation in this population.

Quantifying and visualizing uncertainty in EEG data of neonatal seizures.

This paper presents an approach to quantifying and visualizing uncertainty in EEG data of neonatal seizures. This approach exploits the inherent ability of trained quantum neural networks (QNNs) to learn arbitrary membership profiles from sample data. The ability of QNNs to quantify uncertainty in data is combined with the ability of ordered self-organizing maps (SOMs) to recognize structure in data and allow its visualization in two dimensions. The proposed approach is evaluated using EEG data of neonates monitored for seizures.

Quantifying motion in video recordings of neonatal seizures by feature trackers based on predictive block matching.

This work introduces predictive block matching, a method developed to track motion in video by exploiting the advantages of block motion estimation and adaptive block matching. The proposed method relies on a pure translation motion model to estimate the displacement of a block between two successive video frames before initiating the search for the best match of the block tracked throughout the frame sequence. The search for the best match relies on adaptive block matching, which employs an update strategy based on Kalman filtering to account for the changing appearance of the block. Predictive block matching was used to extract motor activity signals from video recordings of neonatal seizures.

Discrete optical flow estimation methods and their application in the extraction of motion strength signals from video recordings of neonatal seizures.

This work presents a methodology for the development of regularized optical flow computation methods for video. The proposed methodology is based on a discrete formulation of the optical flow problem. The optical flow computation methods produced by the proposed methodology are utilized to extract temporal motion strength signals from video recordings of neonatal seizures.

Plasma total homocysteine levels, dietary vitamin B6 and folate intake in AD and healthy aging.

PURPOSE: To study the association between Alzheimer s disease (AD) and plasma total homocysteine (tHcy), dietary folate and vitamin B6. METHODS: 64 AD patients were matched by gender, age, and smoking status to 64 healthy controls. tHcy was determined using an automated immunoassay. Dietary patterns for three age periods (20-39, 40-59, and 60 + yrs) were assessed using a questionnaire adapted from the Block Health Habits and History Questionnaire. Respondents (cases by proxy) reported food frequencies, which were translated into estimated daily nutrient intakes. APOE genotype, cognitive performance (CDR, MMSE), blood lipids, and albumin were obtained for patients and controls. RESULTS: tHcy did not differ significantly between controls (11.5 +/- 3.7 mmol/L) and AD patients (12.3 +/- 4.3 mmol/L)(p=0.25). tHcy levels were not related in AD patients or controls to education, CDR, MMSE, blood lipids, albumin or ApoE genotype (p>0.15). There was a negative correlation between plasma tHcy and triglyceride levels in AD patients (p=0.023), but not in controls. AD patients consumed significantly less dietary vitamin B6 (p=0.05) and folate (p=0.001) after age 60 than controls. CONCLUSIONS: Although plasma tHcy levels were higher in cases than controls, this difference was not significant. tHcy levels were not related to cognitive status. Plasma tHcy was inversely correlated with triglyceride levels in AD patients but not in controls.

Extraction of motion strength and motor activity signals from video recordings of neonatal seizures.

This paper presents two methods developed to extract quantitative information from video recordings of neonatal seizures in the form of temporal motion strength and motor activity signals. Motion strength signals are extracted by measuring the area of the body parts that move during the seizure and the relative speed of motion using a combination of spatiotemporal subband decomposition of video, nonlinear filtering, and segmentation. Motor activity signals are extracted by tracking selected anatomical sites during the seizure using a modified version of a feature-tracking procedure developed for video, known as the Kanade-Lucas-Tomasi (KLT) algorithm. The experiments indicate that the temporal signals produced by the proposed methods provide the basis for differentiating myoclonic from focal clonic seizures and distinguishing these types of neonatal seizures from normal infant behaviors.