Outcomes of Patients Discharged to Skilled Nursing Facilities After Acute Care Hospitalizations.

OBJECTIVES: To evaluate previously independent older patients discharged to skilled nursing facilities (SNFs) and identify risk factors for failure to return home and death and development of a predictive tool to determine likelihood of adverse outcome. BACKGROUND: Little is known about the likelihood of return to home, and higher than expected mortality rates in SNFs have recently been described, which may represent an opportunity for quality improvement. METHODS: Retrospective cohort of older hospitalized patients discharged to SNFs during 2007 to 2009 in 5 states using Centers for Medicare & Medicaid Services linked minimum data set data from SNFs. We assessed mortality, hospital readmission, discharge to home, and logistic regression models for predicting risk of each outcome. RESULTS: Of 416,997 patients, 3.8% died during the initial SNF stay, 28.6% required readmission, and 60.5% were ultimately discharged home. Readmission to a hospital was the strongest predictor of death in the years after SNF admission (unadjusted hazard ratio, 28.2; 95% confidence interval, 27.2-29.3; P < 0.001). Among all patients discharged to SNFs, 7.8% eventually died in an SNF and overall 1-year mortality was 26.1%. Risk factors associated with mortality and failure to return home were increasing age, male sex, increasing comorbidities, decreased cognitive function, decreased functional status, parenteral nutrition, and pressure ulcers. CONCLUSIONS: A large proportion of older patients discharging to SNFs never return home. A better understanding of the natural history of patients sent to SNFs after hospitalization and risk factors for failure to return to home, readmission, and death should help identify opportunities for interventions to improved outcome.

Emergency department-reported injuries associated with mechanical home exercise equipment in the USA.

The goal of this study was to generate national estimates of injuries associated with mechanical home exercise equipment, and to describe these injuries across all ages. Emergency department (ED)-treated injuries associated with mechanical home exercise equipment were identified from 2007 to 2011 from the National Electronic Injury Surveillance System. Text narratives provided exercise equipment type (treadmill, elliptical, stationary bicycle, unspecified/other exercise machine). Approximately 70 302 (95% CI 59 086 to 81 519) mechanical exercise equipment-related injuries presented to US EDs nationally during 2007-2011, of which 66% were attributed to treadmills. Most injuries among children (≤4 years) were lacerations (34%) or soft tissue injuries (48%); among adults (≥25 years) injuries were often sprains/strains (30%). Injured older adults (≥65 years) had greater odds of being admitted, held for observation, or transferred to another hospital, compared with younger ages (OR: 2.58; 95% CI 1.45 to 4.60). Mechanical exercise equipment is a common cause of injury across ages. Injury awareness and prevention are important complements to active lifestyles.

Increase in pediatric magnet-related foreign bodies requiring emergency care.

STUDY OBJECTIVE: We describe magnetic foreign body injuries among children and obtain national estimates of magnetic foreign body injury incidence over time. METHODS: We searched the National Electronic Injury Surveillance System for cases of magnetic foreign bodies in children younger than 21 years in the United States, from 2002 to 2011. Cases were analyzed by location: alimentary or respiratory tract, nasal cavity, ear canal, or genital area. RESULTS: We identified 893 cases of magnetic foreign bodies, corresponding to 22,581 magnetic foreign body cases during a 10-year period (95% confidence interval [CI] 17,694 to 27,469). Most magnetic foreign bodies were ingested (74%) or intranasal (21%). Mean age was 5.2 years for ingested magnetic foreign bodies and 10.1 years for nasal magnetic foreign bodies (difference 4.9; 95% CI 4.1 to 5.6), suggesting different circumstances of injury. The incidence of pediatric magnet ingestions increased from 2002 to 2003 from 0.57 cases per 100,000 children per year (95% CI 0.22 to 0.92) to a peak in 2010 to 2011 of 3.06 cases per 100,000 children per year (95% CI 2.16 to 3.96). Most ingested magnetic foreign bodies (73%) and multiple magnet ingestions (91%) occurred in 2007 or later. Patients were admitted in 15.7% of multiple magnet ingestions versus 2.3% of single magnet ingestions (difference 13.4%; 95% CI 2.8% to 24.0%). CONCLUSION: Magnet-related injuries are an increasing public health problem for young children, as well for older children who may use magnets for play or to imitate piercings. Education and improved magnet safety standards may decrease the risk small magnets pose to children.

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children.

BACKGROUND: Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies. METHODS: The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated. RESULTS: Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563. CONCLUSION: Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.

Stress and Salivary Telomere Length in the Second Half of Life: A Comparison of Life-course Models.

Background: Previous research has explored the relationship between childhood and adulthood stressful life events (SLEs) and adult salivary telomere length (TL), but no research to date has tested different life-course models in which stress in adulthood may fully, partly, or not mediate the relationship between childhood stress and adult TL. Methods: To fill this gap, we elaborate over previous work by Puterman et al. (2016) and other standard models that do not account for the temporal order of stressors in childhood and adulthood, by using structural equation modeling (SEM) for a sample of 5,754 Health and Retirement Study (HRS) participants to compare the fit of three nested life-course models-social trajectory, early critical period, and cumulative risk. Results: Results indicated that the social trajectory model, in which the association between childhood SLEs and TL in later adulthood is fully mediated by adulthood SLEs, fit the data better than the early critical period (no mediation) and cumulative risk (partial mediation) models. Conclusion: In the social trajectory model, childhood SLEs are related to TL in later life only through adulthood SLEs. The direct physiological effect of childhood SLEs on TL in later life would be overestimated if adulthood SLEs are overlooked.

A scoping systematic review of social stressors and various measures of telomere length across the life course.

Numerous studies examine the relationship between social stressors and telomere length (TL). Beyond considering methods and major findings, this scoping systematic review takes a novel approach as it groups studies according to the types of social stressor considered and by age groups. Following PRISMA guidelines, we searched PubMed, Web of Science, Embase, and Scopus. We included all English-language human subject research articles that modeled any measure of TL as a dependent variable and exposure to a social stressor as an independent variable. For the sample of 105 articles, we summarized methods and findings by type of social stressor (socioeconomic stressors, stressful life events, work-related stressors, and neighborhood stressors) and by age of the study population (infants/children, middle-aged adults, older adults, and mixed samples of middle-aged and older adults). We found more variation in TL measurement methodology in studies of infants/children and older adults than in studies focusing on middle-aged adults. The most consistent finding was a relationship between early-life stressors and shorter TL. Work and neighborhood stressors, and older populations, are currently understudied. Across all stressors, limited evidence suggests that the stress-TL relationship may be moderated by characteristics such as age, sex, and race/ethnicity. We conclude with specific suggestions for future research.

Availability of Outpatient Rehabilitation Services for Children After Traumatic Brain Injury: Differences by Language and Insurance Status.

OBJECTIVE: The objective of this study was to explore associations between English proficiency, insurance status, outpatient rehabilitation service availability, and travel time for children with traumatic brain injury. DESIGN: The authors used an ecologic cross-sectional design. Data were analyzed from a cohort of 82 children with moderate to severe traumatic brain injury and rehabilitation providers in Washington State. Main measures included availability and travel time to services. RESULTS: Less than 20% of providers accepted children with Medicaid and provided language interpretation. Mental health services were most limited. Adjusted for median household income, multilingual service availability was lowest in counties with greater language diversity; for every 10% increase in persons older than 5 yrs speaking a language other than English at home, there was a 34% decrease in availability of multilingual services (prevalence ratio, 0.66; 95% confidence interval, 0.48-0.90). Adjusted for education and Medicaid status, children from Spanish-speaking families had significantly longer travel times to services (mean, 16 additional minutes to mental health; 9 to other therapies). CONCLUSIONS: Children in households with limited English proficiency and Medicaid faced significant barriers in availability and proximity of outpatient rehabilitation services. Innovative service strategies are needed to equitably improve availability of rehabilitation for children with traumatic brain injury. Similar studies in other regions will inform one's understanding of the scope of these disparities.

Health problems among low-income parents in the aftermath of Hurricane Katrina.

OBJECTIVE: Although the mental health consequences of disasters have been well documented, relatively less is known about their effects on survivors' physical health. Disaster studies have also generally lacked predisaster data, limiting researchers' ability to determine whether postdisaster physical health problems were influenced by disaster exposure, or whether they would have emerged even if the disaster had not occurred. The current study aimed to fill this gap. METHOD: Participants were low-income, primarily non-Hispanic Black mothers (N = 334) who survived Hurricane Katrina and completed 4 survey assessments, 2 predisaster and 2 postdisaster. In each assessment, participants reported on whether they had experienced 3 common health problems (frequent headaches or migraines, back problems, and digestive problems) and completed 2 mental health measure (the K6 scale, the Perceived Stress Scale). RESULTS: The descriptive results suggested that the hurricane led to at least short-term increases in the 3 health outcomes. Fixed effects modeling was conducted to explore how changes in various predictor variables related to changes in each health condition over the study. Bereavement and increases in psychological distress were significant predictors of increases in health problems. CONCLUSIONS: Based on these results, further research that explores the processes through which disasters lead to both physical and mental health problems, postdisaster screenings for common health conditions and psychological distress, and interventions that boost survivors' stress management skills are suggested.

Burst fractures of the lumbar spine in frontal crashes.

BACKGROUND: In the United States, major compression and burst type fractures (>20% height loss) of the lumbar spine occur as a result of motor vehicle crashes, despite the improvements in restraint technologies. Lumbar burst fractures typically require an axial compressive load and have been known to occur during a non-horizontal crash event that involve high vertical components of loading. Recently these fracture patterns have also been observed in pure horizontal frontal crashes. This study sought to examine the contributing factors that would induce an axial compressive force to the lumbar spine in frontal motor vehicle crashes. METHODS: We searched the National Automotive Sampling System (NASS, 1993-2011) and Crash Injury Research and Engineering Network (CIREN, 1996-2012) databases to identify all patients with major compression lumbar spine (MCLS) fractures and then specifically examined those involved in frontal crashes. National trends were assessed based on weighted NASS estimates. Using a case-control study design, NASS and CIREN cases were utilized and a conditional logistic regression was performed to assess driver and vehicle characteristics. CIREN case studies and biomechanical data were used to illustrate the kinematics and define the mechanism of injury. RESULTS: During the study period 132 NASS cases involved major compression lumbar spine fractures for all crash directions. Nationally weighted, this accounted for 800 cases annually with 44% of these in horizontal frontal crashes. The proportion of frontal crashes resulting in MCLS fractures was 2.5 times greater in late model vehicles (since 2000) as compared to 1990s models. Belted occupants in frontal crashes had a 5 times greater odds of a MCLS fracture than those not belted, and an increase in age also greatly increased the odds. In CIREN, 19 cases were isolated as horizontal frontal crashes and 12 of these involved a major compression lumbar burst fracture primarily at L1. All were belted and almost all occurred in late model vehicles with belt pretensioners and buckets seats. CONCLUSION: Major compression burst fractures of the lumbar spine in frontal crashes were induced via a dynamic axial force transmitted to the pelvis/buttocks into the seat cushion/pan involving belted occupants in late model vehicles with increasing age as a significant factor.