Post-Hospital Syndrome: A New Challenge in Cardiovascular Practice

AbstractThe image of the hospital representing the modern medicine and its diagnostic and therapeutic advances becomes more evident in the face of an aging population and patients with multiple comorbidities requiring highly complex care. However, recent studies have shown a growing number of hospital readmissions within 30 days after discharge. The post-hospital syndrome is a new clinical entity associated with multiple vulnerabilities that contribute to hospital readmissions. During hospitalization, the patient is exposed to different stressors of physical, environmental, and psychosocial natures that trigger pathophysiological and multisystemic responses and increase the risk of complications after hospital discharge. Patients with a cardiac disease have high rates of readmission within 30 days. Therefore, it is important for cardiologists to recognize the post-hospital syndrome since it may impact their daily practice. This review aims at discussing the current scientific evidence regarding predictors and stressors involved in the post-hospital syndrome and the measures that are currently being taken to minimize their effects.

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry

Abstract Background: The use of aortic counterpulsation therapy in advanced heart failure is controversial. Objectives: To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure. Methods: Historical prospective, unicentric study to evaluate all patients treated with IABP betwen August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO2), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and diferences in subgroups were evaluated by the Log-rank test. Results: A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO2 (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008). Conclusion: After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.

Analysis Treatment Guideline versus Clinical Practice Protocol in Patients Hospitalized due to Heart Failure

Background: Despite the availability of guidelines for treatment of heart failure (HF), only a few studies have assessed how hospitals adhere to the recommended therapies. Objectives: Compare the rates of adherence to the prescription of angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers (ACEI/ARB) at hospital discharge, which is considered a quality indicator by the Joint Commission International, and to the prescription of beta-blockers at hospital discharge, which is recommended by national and international guidelines, in a hospital with a case management program to supervise the implementation of a clinical practice protocol (HCP) and another hospital that follows treatment guidelines (HCG). Methods: Prospective observational study that evaluated patients consecutively admitted to both hospitals due to decompensated HF between August 1st, 2006, and December 31st, 2008. We used as comparing parameters the prescription rates of beta-blockers and ACEI/ARB at hospital discharge and in-hospital mortality. Results: We analyzed 1,052 patients (30% female, mean age 70.6 ± 14.1 years), 381 (36%) of whom were seen at HCG and 781 (64%) at HCP. The prescription rates of beta-blockers at discharge at HCG and HCP were both 69% (p = 0.458), whereas those of ACEI/ARB were 83% and 86%, respectively (p = 0.162). In-hospital mortality rates were 16.5% at HCP and 27.8% at HCG (p < 0.001). Conclusion: There was no difference in prescription rates of beta-blocker and ACEI/ARB at hospital discharge between the institutions, but HCP had lower in-hospital mortality. This difference in mortality may be attributed to different clinical characteristics of the patients in both hospitals.

Best-Practice - Mobile Testing Viewing mobile usability studies with the example of an eyetracking study in the retail sector

Today, usability testing in the development of software and systems is essential. A stationary usability lab offers many different possibilities in the evaluation of usability, but it reaches its limits in terms of flexibility and the experimental conditions. Mobile usability studies consider consciously outside influences, and these studies require a specially adapted approach to preparation, implementation and evaluation. Using the example of a mobile eye tracking study the difficulties and the opportunities of mobile testing are considered.

Advanced production systems : developing context-oriented method and adaptation capabilities for enhanced supply network

Magdeburg, Univ., Fak. für Maschinenbau, Diss., 2014

Phyletic analysis of fifty characters of advanced snakes [by] Hymen Marx and George B. Rabb.

v.63(1972)

Real equilibrium exchange rates. A panel data approach for advanced and emerging economies.

Based on an behavioral equilibrium exchange rate model, this paper examines the determinants of the real effective exchange rate and evaluates the degree of misalignment of a group of currencies since 1980. Within a panel cointegration setting, we estimate the relationship between exchange rate and a set of economic fundamentals, such as traded-nontraded productivity differentials and the stock of foreign assets. Having ascertained the variables are integrated and cointegrated, the long-run equilibrium value of the fundamentals are estimated and used to derive equilibrium exchange rates and misalignments. Although there is statistical homogeneity, some structural differences were found to exist between advanced and emerging economies.

Codes of best practice in competitive markets for managers

We study firms' corporate governance in environments where possibly heterogeneous shareholders compete for possibly heterogeneous managers. A firm, formed by a shareholder and a manager, can sign either an incentive contract or a contract including a Code of Best Practice. A Code allows for a better manager's control but makes manager's decisions hard to react when market conditions change. It tends to be adopted in markets with low volatility and in low-competitive environments. The firms with the best projects tend to adopt the Code when managers are not too heterogeneous while the best managers tend to be hired through incentive contracts when the projects are similar. Although the matching between shareholders and managers is often positively assortative, the shareholders with the best projects might be willing to renounce to hire the best managers, signing contracts including Codes with lower-ability managers.

Violence: les femmes font confiance au milieu médical [Partner violence: women trust health professionals]

In 2008, the department of gynaecology and obstetrics of a university hospital centre implemented a program addressing interpersonal partner violence (screening, prevention and care of the patient victims). A qualitative survey was conducted to identify the needs and feelings of patients. The results show that patients are in favour of being actively and directly questioned about violence during the consultation and that they trust medical doctors and nurses to help and support them.

Evaluation de la douleur chez les personnes cérébrolésées non-communicantes aux soins intensifs

La douleur est fréquente en milieu de soins intensifs et sa gestion est l'une des missions des infirmières. Son évaluation est une prémisse indispensable à son soulagement. Cependant lorsque le patient est incapable de signaler sa douleur, les infirmières doivent se baser sur des signes externes pour l'évaluer. Les guides de bonne pratique recommandent chez les personnes non communicantes l'usage d'un instrument validé pour la population donnée et basé sur l'observation des comportements. A l'heure actuelle, les instruments d'évaluation de la douleur disponibles ne sont que partiellement adaptés aux personnes cérébrolésées dans la mesure où ces personnes présentent des comportements qui leur sont spécifiques. C'est pourquoi, cette étude vise à identifier, décrire et valider des indicateurs, et des descripteurs, de la douleur chez les personnes cérébrolésées. Un devis d'étude mixte multiphase avec une dominante quantitative a été choisi pour cette étude. Une première phase consistait à identifier des indicateurs et des descripteurs de la douleur chez les personnes cérébrolésées non communicantes aux soins intensifs en combinant trois sources de données : une revue intégrative des écrits, une démarche consultative utilisant la technique du groupe nominal auprès de 18 cliniciens expérimentés (6 médecins et 12 infirmières) et les résultats d'une étude pilote observationnelle réalisée auprès de 10 traumatisés crâniens. Les résultats ont permis d'identifier 6 indicateurs et 47 descripteurs comportementaux, vocaux et physiologiques susceptibles d'être inclus dans un instrument d'évaluation de la douleur destiné aux personnes cérébrolésées non- communicantes aux soins intensifs. Une deuxième phase séquentielle vérifiait les propriétés psychométriques des indicateurs et des descripteurs préalablement identifiés. La validation de contenu a été testée auprès de 10 experts cliniques et 4 experts scientifiques à l'aide d'un questionnaire structuré qui cherchait à évaluer la pertinence et la clarté/compréhensibilité de chaque descripteur. Cette démarche a permis de sélectionner 33 des 47 descripteurs et valider 6 indicateurs. Dans un deuxième temps, les propriétés psychométriques de ces indicateurs et descripteurs ont été étudiés au repos, lors de stimulation non nociceptive et lors d'une stimulation nociceptive (la latéralisation du patient) auprès de 116 personnes cérébrolésées aux soins intensifs hospitalisées dans deux centres hospitaliers universitaires. Les résultats montrent d'importantes variations dans les descripteurs observés lors de stimulation nociceptive probablement dues à l'hétérogénéité des patients au niveau de leur état de conscience. Dix descripteurs ont été éliminés, car leur fréquence lors de la stimulation nociceptive était inférieure à 5% ou leur fiabilité insuffisante. Les descripteurs physiologiques ont tous été supprimés en raison de leur faible variabilité et d'une fiabilité inter juge problématique. Les résultats montrent que la validité concomitante, c'est-à-dire la corrélation entre l'auto- évaluation du patient et les mesures réalisées avec les descripteurs, est satisfaisante lors de stimulation nociceptive {rs=0,527, p=0,003, n=30). Par contre la validité convergente, qui vérifiait l'association entre l'évaluation de la douleur par l'infirmière en charge du patient et les mesures réalisés avec les descripteurs, ainsi que la validité divergente, qui vérifiait si les indicateurs discriminent entre la stimulation nociceptive et le repos, mettent en évidence des résultats variables en fonction de l'état de conscience des patients. Ces résultats soulignent la nécessité d'étudier les descripteurs de la douleur chez des patients cérébrolésés en fonction du niveau de conscience et de considérer l'hétérogénéité de cette population dans la conception d'un instrument d'évaluation de la douleur pour les personnes cérébrolésées non communicantes aux soins intensifs. - Pain is frequent in the intensive care unit (ICU) and its management is a major issue for nurses. The assessment of pain is a prerequisite for appropriate pain management. However, pain assessment is difficult when patients are unable to communicate about their experience and nurses have to base their evaluation on external signs. Clinical practice guidelines highlight the need to use behavioral scales that have been validated for nonverbal patients. Current behavioral pain tools for ICU patients unable to communicate may not be appropriate for nonverbal brain-injured ICU patients, as they demonstrate specific responses to pain. This study aimed to identify, describe and validate pain indicators and descriptors in brain-injured ICU patients. A mixed multiphase method design with a quantitative dominant was chosen for this study. The first phase aimed to identify indicators and descriptors of pain for nonverbal brain- injured ICU patients using data from three sources: an integrative literature review, a consultation using the nominal group technique with 18 experienced clinicians (12 nurses and 6 physicians) and the results of an observational pilot study with 10 traumatic brain injured patients. The results of this first phase identified 6 indicators and 47 behavioral, vocal and physiological descriptors of pain that could be included in a pain assessment tool for this population. The sequential phase two tested the psychometric properties of the list of previously identified indicators and descriptors. Content validity was tested with 10 clinical and 4 scientific experts for pertinence and comprehensibility using a structured questionnaire. This process resulted in 33 descriptors to be selected out of 47 previously identified, and six validated indicators. Then, the psychometric properties of the descriptors and indicators were tested at rest, during non nociceptive stimulation and nociceptive stimulation (turning) in a sample of 116 brain-injured ICLI patients who were hospitalized in two university centers. Results showed important variations in the descriptors observed during the nociceptive stimulation, probably due to the heterogeneity of patients' level of consciousness. Ten descriptors were excluded, as they were observed less than 5% of the time or their reliability was insufficient. All physiologic descriptors were deleted as they showed little variability and inter observer reliability was lacking. Concomitant validity, testing the association between patients' self report of pain and measures performed using the descriptors, was acceptable during nociceptive stimulation (rs=0,527, p=0,003, n=30). However, convergent validity ( testing for an association between the nurses' pain assessment and measures done with descriptors) and divergent validity (testing for the ability of the indicators to discriminate between rest and a nociceptive stimulation) varied according to the level of consciousness These results highlight the need to study pain descriptors in brain-injured patients with different level of consciousness and to take into account the heterogeneity of this population forthe conception of a pain assessment tool for nonverbal brain-injured ICU patients.

Swiss clinical practice guidelines for skin cancer in organ transplant recipients.

Patients with a solid organ transplant have increased in numbers and in individual survival in Switzerland over the last decades. As a consequence of long-term immunosuppression, skin cancer in solid organ recipients (SOTRs) has been recognized as an important problem. Screening and education of potential SOTRs about prevention of sun damage and early recognition of skin cancer are important before transplantation. Once transplanted, SOTRs should be seen by a dermatologist yearly for repeat education as well as early diagnosis, prevention and treatment of skin cancer. Squamous cell carcinoma of the skin (SCC) is the most frequent cancer in the setting of long-term immunosuppression. Sun protection by behaviour, clothing and daily sun screen application is the most effective prevention. Cumulative sun damage results in field cancerisation with numerous in-situ SCC such as actinic keratosis and Bowen's disease which should be treated proactively. Invasive SCC is cured by complete surgical excision. Early removal is the best precaution against potential metastases of SCC. Reduction of immunosuppression and switch to mTOR inhibitors and potentially, mycophenolate, may reduce the incidence of further SCC. Chemoprevention with the retinoid acitretin reduces the recurrence rate of SCC. The dermatological follow-up of SOTRs should be integrated into the comprehensive post-transplant care.

Physiotherapy practice in the private sector: organizational characteristics and models.

BACKGROUND: Even if a large proportion of physiotherapists work in the private sector worldwide, very little is known of the organizations within which they practice. Such knowledge is important to help understand contexts of practice and how they influence the quality of services and patient outcomes. The purpose of this study was to: 1) describe characteristics of organizations where physiotherapists practice in the private sector, and 2) explore the existence of a taxonomy of organizational models. METHODS: This was a cross-sectional quantitative survey of 236 randomly-selected physiotherapists. Participants completed a purpose-designed questionnaire online or by telephone, covering organizational vision, resources, structures and practices. Organizational characteristics were analyzed descriptively, while organizational models were identified by multiple correspondence analyses. RESULTS: Most organizations were for-profit (93.2%), located in urban areas (91.5%), and within buildings containing multiple businesses/organizations (76.7%). The majority included multiple providers (89.8%) from diverse professions, mainly physiotherapy assistants (68.7%), massage therapists (67.3%) and osteopaths (50.2%). Four organizational models were identified: 1) solo practice, 2) middle-scale multiprovider, 3) large-scale multiprovider and 4) mixed. CONCLUSIONS: The results of this study provide a detailed description of the organizations where physiotherapists practice, and highlight the importance of human resources in differentiating organizational models. Further research examining the influences of these organizational characteristics and models on outcomes such as physiotherapists' professional practices and patient outcomes are needed.