Families and caregivers of older people: expectations, communication and care decisions

While family caregivers may temporarily relinquish responsibility for daily care to health professionals for the period of hospitalization, new expectations and demands are placed upon them. Family caregivers can be asked to commit to new relationships with health professionals, contribute to care decisions and discharge planning. For the caregivers of older patients these new expectations may be challenging, and contribute to feelings of burden and increased stress. The aim of this qualitative descriptive study was to explore the experience of family caregivers when their relative is an inpatient in this outer Melbourne geriatric evaluation and management facility. This study found that the burden associated with the experience of caregiving continued despite the hospitalization of their relative. The challenges faced by families included communicating with health professionals, and being asked to contribute to care decisions, in particular those regarding discharge planning, and managing conflict. In conclusion, the issues and challenges faced by family caregivers needs to be acknowledged and considered as an extension of patient care planning

Gender differences in presentation, coronary intervention, and outcomes of 28,985 acute coronary syndrome patients in Victoria, Australia

BACKGROUND: Differences in demographics, presenting characteristics, and treatment of heart disease in women may contribute to adverse outcomes. The purpose of this paper was to describe gender differences in the epidemiology, treatment, and outcomes of all admissions for acute coronary syndrome (ACS) in Victoria that occurred between June 2007 and July 2009. METHODS: We undertook a retrospective cohort study of all patients admitted to Victorian hospitals with a first time diagnosis of ACS. Use of angiograms, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and adverse outcomes (death and/or unplanned readmission) were compared by gender and hierarchical logistic regression models were used to account for confounding variables. RESULTS: Of a total of 28,985 ACS patients, 10,455 (36%) were women. Compared with men, women were older (aged ≥75 years: 54% vs 31%; p < .001), more likely to present with multiple comorbidities (>1 comorbidity: 53% vs 46%; p < .001), and more likely to be diagnosed with non-ST-segment elevation ACS (86% vs 80%; p < .001). Women were less likely to receive coronary interventions (angiogram: adjusted odds ratio [aOR], 0.71; 95% CI, 0.66-0.75; PCI: aOR, 0.73; 95% CI, 0.66-0.80; CABG: aOR, 0.58; 95% CI, 0.53-0.64). Adverse outcomes were similar in women and men after accounting for confounding variables. CONCLUSIONS: Our results show that women in Victoria were less likely to receive coronary interventions after an admission for ACS. Clinicians should be wary of inherent gender bias in decisions to refer patients for angiography.

A pilot feasibility, safety and biological efficacy multicentre trial of therapeutic hypercapnia after cardiac arrest: study protocol for a randomized controlled trial

BACKGROUND: Cardiac arrest causes ischaemic brain injury. Arterial carbon dioxide tension (PaCO2) is a major determinant of cerebral blood flow. Thus, mild hypercapnia in the 24 h following cardiac arrest may increase cerebral blood flow and attenuate such injury. We describe the Carbon Control and Cardiac Arrest (CCC) trial. METHODS/DESIGN: The CCC trial is a pilot multicentre feasibility, safety and biological efficacy randomized controlled trial recruiting adult cardiac arrest patients admitted to the intensive care unit after return of spontaneous circulation. At admission, using concealed allocation, participants are randomized to 24 h of either normocapnia (PaCO2 35 to 45 mmHg) or mild hypercapnia (PaCO2 50 to 55 mmHg). Key feasibility outcomes are recruitment rate and protocol compliance rate. The primary biological efficacy and biological safety measures are the between-groups difference in serum neuron-specific enolase and S100b protein levels at 24 h, 48 h and 72 h. Secondary outcome measure include adverse events, in-hospital mortality, and neurological assessment at 6 months. DISCUSSION: The trial commenced in December 2012 and, when completed, will provide clinical evidence as to whether targeting mild hypercapnia for 24 h following intensive care unit admission for cardiac arrest patients is feasible and safe and whether it results in decreased concentrations of neurological injury biomarkers compared with normocapnia. Trial results will also be used to determine whether a phase IIb study powered for survival at 90 days is feasible and justified. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000690853 .

Impact of early valve surgery on outcome of Staphylococcus aureus prosthetic valve infective endocarditis: analysis in the International Collaboration of Endocarditis-Prospective Cohort Study

BACKGROUND: The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. METHODS: Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. RESULTS: EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). CONCLUSIONS: In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE.

Associations between outdoor fungal spores and childhood and adolescent asthma hospitalisations.

BACKGROUND: Childhood asthma is a significant public health problem and severe exacerbations can result in diminished quality of life and hospitalisation. OBJECTIVE: To examine the contribution of outdoor fungi to childhood and adolescent asthma hospitalisations. METHODS: The Melbourne Air Pollen Children and Adolescent (MAPCAH) study is a case-crossover study of 644 children and adolescents (aged 2-17 years) hospitalised for asthma. MAPCAH collected individual data on human rhinovirus (HRV) infection and sensitisation to Alternaria and Cladosporium; and daily counts of ambient concentrations of fungal spores, pollen and air pollutants. Conditional logistic regression models were used to assess associations with increases in spore counts while controlling for potential confounding and testing interactions. RESULTS: Exposure to Alternaria (aOR=1.07, 95%CI 1.03-1.11), Leptosphaeria (aOR=1.05, 95%CI 1.02-1.07), Coprinus (aOR=1.04, 95%CI 1.01-1.07), Drechslera (aOR=1.03, 95%CI1.00-1.05) and total spores (aOR=1.05, 95%CI 1.01-1.09) were significantly associated with child asthma hospitalisations independent of HRV infection. There were significant lagged effects up to 3-days with Alternaria, Leptosphaeria, Cladosporium, Sporormiella, Coprinus, and Drechslera. Some of these associations were significantly greater in participants with Cladosporium sensitisation. CONCLUSION: Exposures to several outdoor fungal spore taxa, including some not reported in previous research, are associated with the risk of child and adolescent asthma hospitalisation, particularly in individuals sensitised to Cladosporium. We need further studies to examine cross-reactivity causing asthma exacerbations. Identifying sensitisation to multiple fungal allergens in asthmatic children could support the design and implementation of more effective strategies to prevent asthma exacerbations.

Current features of infective endocarditis in elderly patients: results of the International Collaboration on Endocarditis Prospective Cohort Study.

BACKGROUND: Elderly patients are emerging as a population at high risk for infective endocarditis (IE). However, adequately sized prospective studies on the features of IE in elderly patients are lacking. METHODS: In this multinational, prospective, observational cohort study within the International Collaboration on Endocarditis, 2759 consecutive patients were enrolled from June 15, 2000, to December 1, 2005; 1056 patients with IE 65 years or older were compared with 1703 patients younger than 65 years. Risk factors, predisposing conditions, origin, clinical features, course, and outcome of IE were comprehensively analyzed. RESULTS: Elderly patients reported more frequently a hospitalization or an invasive procedure before IE onset. Diabetes mellitus and genitourinary and gastrointestinal cancer were the major predisposing conditions. Blood culture yield was higher among elderly patients with IE. The leading causative organism was Staphylococcus aureus, with a higher rate of methicillin resistance. Streptococcus bovis and enterococci were also significantly more prevalent. The clinical presentation of elderly patients with IE was remarkable for lower rates of embolism, immune-mediated phenomena, or septic complications. At both echocardiography and surgery, fewer vegetations and more abscesses were found, and the gain in the diagnostic yield of transesophageal echocardiography was significantly larger. Significantly fewer elderly patients underwent cardiac surgery (38.9% vs 53.5%; P < .001). Elderly patients with IE showed a higher rate of in-hospital death (24.9% vs 12.8%; P < .001), and age older than 65 years was an independent predictor of mortality. CONCLUSIONS: In this large prospective study, increasing age emerges as a major determinant of the clinical characteristics of IE. Lower rates of surgical treatment and high mortality are the most prominent features of elderly patients with IE. Efforts should be made to prevent health care-associated acquisition and improve outcomes in this major subgroup of patients with IE.

Protecting skeletal muscle with protein and amino acid during periods of disuse

Habitual sedentary behavior increases risk of chronic disease, hospitalization and poor quality of life. Short-term bed rest or disuse accelerates the loss of muscle mass, function, and glucose tolerance. Optimizing nutritional practices and protein intake may reduce the consequences of disuse by preserving metabolic homeostasis and muscle mass and function. Most modes of physical inactivity have the potential to negatively impact the health of older adults more than their younger counterparts. Mechanistically, mammalian target of rapamycin complex 1 (mTORC1) signaling and muscle protein synthesis are negatively affected by disuse. This contributes to reduced muscle quality and is accompanied by impaired glucose regulation. Simply encouraging increased protein and/or energy consumption is a well-intentioned, but often impractical strategy to protect muscle health. Emerging evidence suggests that leucine supplemented meals may partially and temporarily protect skeletal muscle during disuse by preserving anabolism and mitigating reductions in mass, function and metabolic homeostasis.

An integrated model of care for inflammatory bowel disease sufferers in Australia: development and the effects of its implementation.

BACKGROUND: Psychological comorbidities are associated with poor outcome and increased healthcare utilization in patients with inflammatory bowel disease (IBD). However, a model of care addressing the biopsychosocial dimension of disease is not routinely applied in IBD. This review describes the development of such a model and the effects of its implementation in a hospital-based cohort of patients with IBD. METHODS: Three different approaches were used: 1) collecting baseline epidemiological data on mental health comorbidities; 2) raising awareness of and targeting mental health problems; 3) examining the effects of the model implementation. RESULTS: High rates of anxiety and depressive symptoms (36% and 13%, respectively) that are maintained over time were identified in IBD patients presenting at a metropolitan teaching hospital. Patients with documented psychological comorbidities were more likely to be hospitalized than those without (odds ratio [OR] = 4.13, 95% confidence interval [CI]: 1.25, 13.61). Improvements in disease activity, anxiety, depression, quality of life, and coping have been noted when cognitive-behavioral therapy (CBT) was provided to patients. A drop in the use of opiates (P = 0.037) and hospitalization rates (from 48% to 30%) in IBD patients has been noted as a result of introduction of the changed model of care. In addition, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 [US$15,236.79] vs. US$ 30,467.78 [US$ 53,760.20], P = 0.005). CONCLUSION: Our data to date suggest that an integrated model of care for patients with IBD may yield superior long-term outcomes in terms of medication use and hospitalization rates and reduce healthcare costs.