Infections and functionnal impairment in nursing home residents : a reciprocal relationship

RESUME: Contexte : l'objectif de cette étude de cohorte prospective était de déterminer la relation entre la survenue d'infections et la dépendance fonctionnelle chez des résidents d'établissements de long séjour durant une période de 6 mois. Population et méthode : les patients inclus (1324 résidents) étaient âgés de 65 ans et plus (âge moyen 85.7 ans, 76.6% de femmes), étaient des résidents de 39 EMS du canton de Vaud. Au baseline, des données démographiques, médicales, concernant les facteurs de risque et protecteurs des infections ont été récoltées. Au cours du suivi de 6 mois, les infirmières des EMS ont documenté la survenue de symptômes et signes d'infection en utilisant les critères développés spécifiquement par l'APIC pour les établissements de long séjour. Les mesures du status fonctionnel ont été évaluées au baseline, à 3 mois et à 6 mois. Deux outcomes différents ont été utilisés : a) le déclin fonctionnel défini comme le décès ou une diminution des capacités fonctionnelles au suivi, b) le status fonctionnel mesuré par une échelle standardisée. Résultats : à la fin du suivi, la mortalité était de 14.6%, similaire pour les résidents avec et sans infection (16.2% versus 13.1%, P .11). Durant les 2 périodes de suivi de 3 mois, les sujets ayant présenté une ou plusieurs infections avaient des odds de déclin fonctionnel plus élevés, y compris après ajustement pour les caractéristiques démographiques, médicales et fonctionnelles du baseline, ainsi que la survenue de nouvelles maladies (odds ratio ajustés (OR) = 1.6, intervalle de confiance à 95% (IC) = 1.2-2.2, P = .002 et OR = 1.5, 95% IC= 1.1-2.0, P= .008, respectivement). Comparés aux résidents non infectés, les odds de déclin fonctionnel augmentaient significativement et graduellement chez ceux ayant eu une, respectivement 2 infections ou plus. L'analyse prédisant le score fonctionnel (restreinte aux sujets ayant survécu) a donné des résultats similaires. Finalement, une analyse de survie prédisant le temps jusqu'à la première infection a confirmé une augmentation progressive de la probabilité d'infection chez les sujets avec dépendance fonctionnelle modérée, respectivement sévère, comparés aux sujets indépendants à la ligne de base. Conclusion : chez les résidents de long séjour, les infections sont à la fois cause et conséquence de la dépendance fonctionnelle. Des études futures devraient être entreprises pour investiguer si des programmes de prévention des infections peuvent également contribuer à prévenir le déclin fonctionnel, un facteur important pour la qualité de vie de ces résidents. ABSTRACT: Objectives: To determine the relationship between infections and functional impairment in nursing home residents. Design: Prospective cohort study (follow-up period, 6 months). Setting: Thirty-nine nursing homes in western Switzerland. Participants: A total of 1,324 residents aged 65 and older (mean age 85.7; 76.6% female) who agreed to participate, or their proxies, by oral informed consent. Measurements: Functional status measured every 3 months. Two different outcomes were used: (a) functional decline defined as death or decreased function at follow-up and (b) functional status score using a standardized measure. Results: At the end of follow-up, mortality was 14.6%, not different for those with and without infection (16.2% vs 13.1%, P= .11) During both 3-month periods, subjects with infection had higher odds of functional decline, even after adjustment for baseline characteristics and occurrence of a new illness (adjusted odds ratio (AOR) = 1.6, 95% confidence interval (CI) = 1.2-2.2, P = .002, and AOR 1.5, 95% CI 1.1-2.0, P .008, respectively). The odds of decline increased in a stepwise fashion in patients with zero, one, and two or more infections. The analyses predicting functional status score (restricted to subjects who survived) gave similar results. A survival analysis predicting time to first infection confirmed a stepwise greater likelihood of infection in subjects -with moderate and severe impairment at baseline than in subjects with no or mild functional impairment at baseline. Conclusion: Infections appear to be both a cause and a consequence of functional impairment in nursing home residents. Further studies should be undertaken to investigate whether effective infection control programs can also contribute to preventing functional decline, an important component of these residents' quality of life.

Can 3T multiparametric magnetic resonance imaging accurately detect prostate cancer extracapsular extension?

BACKGROUND: Accurate staging is essential to determine the correct management of patients diagnosed with prostate cancer. We assess the accuracy of 3T multiparametric magnetic resonance imaging (MRI) with endorectal coil (3TemMRI) in detecting prostate cancer local extension. METHODS: We retrospectively reviewed charts from January 2008 to July 2012 from all patients undergoing radical prostatectomy. Patients were only included if 3TemMRI and radical prostatectomy were performed at our institution. Based on the presence of extracapsular extension (ECE) at 3TemMRI, prostate cancer was dichotomized into locally advanced or organ-confined disease. The accuracy of 3TemMRI local staging was then evaluated using definitive pathology as a reference. RESULTS: Overall, 177 radical prostatectomies were performed within the timeframe. After applying exclusion criteria, 60 patients were included in the final analysis. The mean patient age was 67 ± 7 (standard deviation) years. Mean prostate-specific antigen value was 12.7 ± 12.7 ng/L. Based on preoperative characteristics, we considered 38 of the 60 patients (63%) patients high risk. 3TemMRI identified an organ-confined tumour in 46 patients and locally advanced disease in 14 patients. When correlated to final pathology, 3TemMRI specificity, sensitivity, negative and positive predictive values, and accuracy in detecting locally advanced prostate cancer were 90%, 35%, 57%, 79% and 62%, respectively. INTERPRETATION: This study shows that the use of preoperative 3TemMRI can be used to identify organ-confined prostate cancer when locally advanced disease is suspected.

Iowa Veterans Home, Strategic Plan, FY2015-2019

This report outlines the strategic plan for Iowa Veterans Home, goals and mission.

Iowa Veterans Home Performance Plan, FY2015

Agency Performance Plan

Five years of denosumab exposure in women with postmenopausal osteoporosis: results from the first two years of the FREEDOM extension.

The 3-year FREEDOM trial assessed the efficacy and safety of 60 mg denosumab every 6 months for the treatment of postmenopausal women with osteoporosis. Participants who completed the FREEDOM trial were eligible to enter an extension to continue the evaluation of denosumab efficacy and safety for up to 10 years. For the extension results presented here, women from the FREEDOM denosumab group had 2 more years of denosumab treatment (long-term group) and those from the FREEDOM placebo group had 2 years of denosumab exposure (cross-over group). We report results for bone turnover markers (BTMs), bone mineral density (BMD), fracture rates, and safety. A total of 4550 women enrolled in the extension (2343 long-term; 2207 cross-over). Reductions in BTMs were maintained (long-term group) or occurred rapidly (cross-over group) following denosumab administration. In the long-term group, lumbar spine and total hip BMD increased further, resulting in 5-year gains of 13.7% and 7.0%, respectively. In the cross-over group, BMD increased at the lumbar spine (7.7%) and total hip (4.0%) during the 2-year denosumab treatment. Yearly fracture incidences for both groups were below rates observed in the FREEDOM placebo group and below rates projected for a "virtual untreated twin" cohort. Adverse events did not increase with long-term denosumab administration. Two adverse events in the cross-over group were adjudicated as consistent with osteonecrosis of the jaw. Five-year denosumab treatment of women with postmenopausal osteoporosis maintained BTM reduction and increased BMD, and was associated with low fracture rates and a favorable risk/benefit profile.

Iowa's People: a resource for extension educators, June 1989

Statistics about people and their families interest community planners, social scientists, Extension educators, and others because the family is the fundamental social institution in our society. The purpose of this publication is to bring together in one reference many statistics about people in Iowa counties that have been published separately elsewhere. Most of the data presented are limited to only one year. This cross-sectional view is similar to a photograph that shows only one point in time. At an earlier or later time it might appear differently. Although the statistics reported in the various tables and figures represent different years, the data presented were the most recent available at the time this publication was prepared.

Unplanned nursing home short stay : elderly patients characteristics and 3-month outcomes.

Background: Nursing home short stays (NHSS) in the canton of Vaud have been introduced for respite care purpose. However, a growing number of older patients are urgently admitted from home (within 24h) or directly after hospital discharge (58% of all admissions in 2010). NHSS appears therefore as an increasingly important component of the health care system, but the characteristics of admitted patients have not been previously described. A better knowledge would contribute to identify specific care needs and enhance their care. Objectives: 1) To describe the characteristics of patients admitted in unplanned NHSS ( after hospital stay or urgently from home); 2) To determine living disposition 3-month after NHSS discharge. Method: Over a 18-month period, elderly patients with unplanned NHSS admission to 2 facilities in Lausanne were identified. Demographic, social, health, and functional data, as well as main reason for admission were collected. Death and place of living at 3-months were collected using the administrative database. Results: Overall, 114 patients (mean age 83.1 ± 6.2 years, 77% women, 84% living alone) were assessed, 80% being admitted from hospital. Mean score in Lawton's instrumental ADL before NHSS admission was 4.6 ± 2.5 and 69% of the patients were home care recipients (median number of weekly visits: 5 ± 3). Patients reported going out 4.2 ± 1.3 times/week and 56% reported at least one fall over the past year. Among the 91 patients coming from the hospital, main reason for admission was injury/limb immobilization (58%), recuperation (13%) and functional impairment in basic ADL (10%). Mean score at Katz's Basic ADL at admission was 3.7 ± 1.9. Overall, 90% of patients were identified with gait and balance impairment, 78% with cognitive impairment and 70% with polypharmacy (>6 different drugs). At 3-month after NHSS discharge (N = 92), 72% patients were living at home, 16% had been admitted to long term care, and 6% died. Among patients living at home at follow-up, 11% had been readmitted to hospital during the follow-up period. Conclusion: Older patients with unplanned NHSS admission show a high prevalence of functional, mobility, and cognitive impairments, as well as other geriatric syndromes. Specific measures should be considered during these stays to prevent further functional decline and, possibly, hospital readmission. Patients admitted with basic ADLs impairment might be candidate for higher levels of care (rehabilitation).

Report on the Iowa Veterans Home for the year ended June 30, 2014

Report on the Iowa Veterans Home for the year ended June 30, 2014

Heart failure and community-acquired pneumonia: cases for home hospital?

BACKGROUND: Home hospital is advocated in many western countries in spite of limited evidence of its economic advantage over usual hospital care. Heart failure and community-acquired pneumonia are two medical conditions which are frequently targeted by home hospital programs. While recent trials were devoted to comparisons of safety and costs, the acceptance of home hospital for patients with these conditions remains poorly described. OBJECTIVE: To document the medical eligibility and final transfer decision to home hospital for patients hospitalized with a primary diagnosis of heart failure or community-acquired pneumonia. DESIGN: Longitudinal study of patients admitted to the medical ward of acute care hospitals, up to the final decision concerning their transfer. SETTING: Medical departments of one university hospital and two regional teaching Swiss hospitals. PATIENTS: All patients admitted over a 9 month period to the three settings with a primary diagnosis of heart failure (n= 301) or pneumonia (n=441). MEASUREMENTS: Presence of permanent exclusion criteria on admission; final decision of (in)eligibility based on medical criteria; final decision regarding the transfer, taking into account the opinions of the family physician, the patient and informal caregivers. RESULTS: While 27.9% of heart failure and 37.6% of pneumonia patients were considered to be eligible from a medical point of view, the program acceptance by family physicians, patients and informal caregivers was low and a transfer to home hospital was ultimately chosen for just 3.8% of heart failure and 9.6% of pneumonia patients. There were no major differences between the three settings. CONCLUSIONS: In the case of these two conditions, the potential economic advantage of home hospital over usual inpatient care is compromised by the low proportion of patients ultimately transferred.

Where and how family members spend time at home? A quantitative analysis of the observational tracking on the everyday lives of Italian families

This paper examines a dataset that derives from an observational tracking, in order to analyze where and how middle-class working families spend time at home. We use an ethnographic approach to study the everyday lives of Italian dual-income middle-class families, with the aim to analyze quantitatively the use of home spaces and the types of activities of family members on weekday afternoons and evenings. The different analyses (multiple correspondence analysis, agglomerative hierarchical cluster, discriminant analysis) show how particular spaces and activities in these spaces are dominated by certain family members. We suggest a combination of qualitative and quantitative methodologies as useful tools to explore in detail the everyday lives of families, and to understand how family members use the domestic spaces. In particular, we consider relevant the use of quantitative analyses to examine ethnographic data, especially in connection with the methodological reflexivity among researchers

Specialized home palliative care for adults and children: differences and similarities.

OBJECTIVE: To compare the provision of specialized home palliative care (SHPC) by the adult and pediatric SHPC teams at the Munich University Hospital. METHODS: All patients treated by one of the SHPC teams and their primary caregivers were eligible for the prospective nonrandomized survey. We analyzed the demographics, the underlying diseases, duration and impact of SHPC on symptom control and quality of life (QOL) as well as the caregivers' burden and QOL. RESULTS: Between April 2011 and June 2012, 100 adult and 43 pediatric patients were treated consecutively; 60 adults (median age, 67.5 years; 55% male) and 40 children (median age, 6 years, 57% male) were included in the study. Oncologic diseases were dominant only in the adult cohort (87 versus 25%, p<0.001). The median period of care was higher in the pediatric sample (11.8 versus 4.3 weeks; NS). Ninety-five percent of adult and 45% of pediatric patients died by the end of the study (p<0.001), 75% and 90% of them at home, respectively. The numbers of significant others directly affected by the patient's disease was higher in children (mean 3.4 versus 1.2; p<0.001). The QOL of adult patients and children (p<0.05 for both), as well as of their primary caregivers (p<0.001 for both) improved during SHPC, while the caregivers' burden was lowered (p<0.001 for both). CONCLUSIONS: Our results show important differences in several clinically relevant parameters between adults and children receiving SHPC. This should assist in the development of age-group specific SHPC concepts that effectively address the specific needs of each patient population.

A consistent extension of the local spin density approximation to account for quantum dot mass and dielectric mismatches

A consistent extension of local spin density approximation (LSDA) to account for mass and dielectric mismatches in nanocrystals is presented. The extension accounting for variable effective mass is exact. Illustrative comparisons with available configuration interaction calculations show that the approach is also very reliable when it comes to account for dielectric mismatches. The modified LSDA is as fast and computationally low demanding as LSDA. Therefore, it is a tool suitable to study large particle systems in inhomogeneous media without much effort.