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Objective: There are limited data evaluating the impact of postoperative hyperglycemia in patients undergoing vascular procedures. This study evaluated the relationship between suboptimal glucose control and adverse outcomes after carotid artery stenting and carotid endarterectomy. Methods: Patients admitted for elective carotid procedures were selected from the Cerner Health Facts® (2008–2015) database using ICD-9-CM diagnosis and procedure codes. We examined the relationship between patient characteristics, postoperative hyperglycemia (any value > 180 mg/dL), and complications with chi-square analysis. A multivariable model examined the association between patient characteristics, procedure type, and glucose control with infection, renal failure, stroke, respiratory and cardiac complications, and length of stay over 10 days. Results: Of the 4287 patients admitted for an asymptomatic carotid procedure, 788 (18%) underwent carotid artery stenting and 3499 (82%) underwent carotid endarterectomy. Most patients (87%) had optimal postoperative glucose control (80–180 mg/dL); 13% had suboptimal glucose control. On average, patients with suboptimal glucose control experienced: higher stroke rates (6.2% vs. 2.7%; p < 0.001); more cardiac complications (5.1% vs. 2.0%; p < 0.001); longer hospital stays (3.1 vs. 1.8 days; p <.001); higher rates of post-procedure infection (4.0% vs. 1.8%; p =.001); and more complications than patients with optimal glucose control. Multivariable logistic regression demonstrated that patients with suboptimal glucose control had higher odds of having an infectious (pneumonia, cellulitis, surgical site, etc.) complication (OR 1.91, 95% CI 1.10–3.34), renal failure (OR 3.36, 95% CI 1.95–5.78), respiratory complications (OR 1.81, 95% CI 1.21–2.71), stroke (OR 1.82, 95% CI 1.15–2.88), or length of stay > 10 days (OR 4.07, 95% CI 2.02–8.20). Conclusions: Suboptimal glucose control was associated with adverse events after carotid artery stenting and carotid endarterectomy, independent of a diabetes diagnosis. Several adverse outcomes were associated with hyperglycemia, including stroke. Given the singular role of carotid procedures in preventing stroke, we suggest that incorporating rigorous post-operative glucose control into best medical treatment of carotid disease should be considered as a standard practice. [ABSTRACT FROM AUTHOR]

Objective Assess the association between caregiver supervision and acute unintentional injury in young children; evaluate whether lower levels of supervision result in more severe injury. Methods A case cross-over study was conducted. Parents of children aged ≤4 years whose injuries required emergency department (ED sample) treatment or admission to the hospital (inpatient sample) were interviewed. Information on supervision (3 dimensions: proximity, attention, continuity) at the time of injury and 1 h before the injury (control time) was collected. An overall supervision score was created; a higher score indicates closer supervision. Hospital admission served as a proxy for injury severity. ORs and 95% CIs were calculated. Results Interviews were completed by 222 participants; 50 (23%) were in the inpatient sample. For each supervision dimension the inpatient sample had higher odds of injury, indicating effect modification requiring separate analyses for inpatient and ED samples. For both samples, proximity ‘beyond reach' was associated with the highest odds of injury; compared with 1 h before injury, children were more likely to be beyond reach of their caregiver at the time of injury (inpatient sample: OR 11.5, 95% CI 2.7 to 48.8; ED sample: OR 2.9, 95% CI 1.8 to 4.9). Children with lower supervision scores had the greatest odds of injury (inpatient sample: OR 8.0, 95% CI 2.4 to 26.6; ED sample: OR 3.3, 95% CI 1.9 to 5.6). Conclusions Lower levels of adult supervision are associated with higher odds of more severe injury in young children. Proximity is the most important supervision dimension for reducing injury risk. [ABSTRACT FROM AUTHOR]

Background: Collective caregiving, performed by caregivers working in pairs (informal primary and secondary caregivers working together), is common in the hospice setting. Research suggests that caregiving pairs may experience different caregiver outcomes. However, little is known about how caregiving pairs differ from solo caregivers (informal primary caregivers) on outcome measures. Objective: The goal of this study was to determine whether being in a caregiver pair affected caregiver anxiety and depression and how outcomes changed over time. Design: A mixed model analysis was used. Setting/subjects: Hospice caregivers (260 solo caregivers and 44 caregivers in 22 pairs) who participated in a larger, randomized controlled trial completed caregiver measures upon hospice admission and periodically until the death of the patient or hospice decertification. Measurements: Measured were caregiver quality of life, social support, anxiety, and depression. Results: Caregiver pairs had higher anxiety and depression scores than solo caregivers. Emotional, financial, and physical quality of life were associated with decreased depression, whereas only emotional and financial quality of life were correlated with lower levels of anxiety. Social support was associated with lower levels of depression and anxiety. Conclusions: Despite assumptions that social support is positively facilitated vis-a-vis collective caregiving, caregiving pairs may be at higher risk for anxiety and depression. Future research is needed to address why individuals become anxious and/or depressed when working as part of a caregiving pair. [ABSTRACT FROM AUTHOR]

Objectives To explore patterns of change in nursing home ( NH) residents' activities of daily living ( ADLs), particularly surrounding acute hospital stays. Design Longitudinal study using Medicare and Minimum Data Set ( MDS) assessments. Setting National sample of long-stay NH residents. Participants NH residents who were hospitalized for the seven most-common inpatient diagnoses (N = 40,128). Each hospital admission was at least 90 days after any prior hospitalization and had at least two preceding MDS assessments. Measurements The MDS ADL long-form score, a simple sum of seven self-care variables coded from 0 (independent) to 4 (totally dependent) was used to indicate resident ADL function. Scores ranged from 0 to 28, with higher scores indicating greater impairment. A linear mixed model describing ADL trajectories was jointly estimated with time-to-event models for mortality and hospital readmission. Results Before hospitalization, the most common trajectory was stable (53.7%), with 27.5% of residents worsening and 18.8% improving. ADL function after hospital discharge was most often characterized as stable (43.1%) or worsening (39.2%). Mortality (20.3%) was higher for those with worsening prehospital ADL function (28.9%) than for those with stable (19.1%) or improving (11.3%) trajectories. Hospital diagnosis was associated with amount of ADL worsening and rate of subsequent ADL change. Most residents with the best initial function continued to worsen after hospital discharge. Cognitive impairment was associated with poorer ADL function and accelerated worsening of ADLs. Conclusion For many long-stay NH residents, substantial and sustained ADL worsening accompanies acute hospitalization, so acute hospitalization presents an opportunity to revisit care goals; the results of the current study can help inform decision-making. [ABSTRACT FROM AUTHOR]

Background: Although there is poor communication about pain management between informal caregivers and hospice providers, little research has examined these interactions. Objective: This study explored communication between informal caregivers and hospice team members by investigating the use of medical words in care planning discussions. Design: Transcripts of clinical communication between caregivers and hospice team members were reviewed for use of medical words, word placement (statement or question), whether or not the word was explained, and the caregiver's response to the word. Setting/subjects: As part of an ongoing randomized clinical trial in the midwestern United States, informal hospice caregivers participated in recorded hospice care planning discussions. Measures: A selection of videorecorded interactions from an ongoing study was analyzed. Results: Hospice team members used six times as many medical words compared to caregivers. The majority of medical words used by caregivers and team members were drug names. Medical words were predominantly used as statements rather than questions that sought clarification. Three-fourths of medical words used by team members were not explained to caregivers. Caregivers provided little response to medical word use, indicating a lack of understanding. Conclusions: The propensity to use medical words during clinical communication with family caregivers is cautioned. In order to recognize the caregiver as a contributing team member, clinicians should limit the use of medical words, provide lay explanation alongside medical terminology, and use questions to check for understanding. More research is needed to determine assessment tools to capture the caregiver's level of understanding of medication and pain management protocol. [ABSTRACT FROM AUTHOR]

Background. Weight-bearing exercise has been discouraged for people with diabetes mellitus and peripheral neuropathy (DM + PN). However, people with diabetes mellitus and insensate feet have an increased risk of falling. Lower-extremity exercise and balance training reduce fall risk in some older adults. It is unknown whether those with neuropathy experience similar benefits. Objective. As part of a study of the effects of weight-bearing exercise on foot ulceration in people with DM+PN, the effects of a lower-extremity exercise and walking intervention on balance, lower-extremity strength (force-generating capacity), and fall incidence were determined. Design. The study was an observer-masked, 12-month randomized controlled trial. Setting. Part I of the intervention took place in physical therapy offices, and part 2 took place in the community. Patients. The participants were 79 people who were mostly sedentary, who had DM + PN, and who were randomly assigned to either a control group (n = 38) or an intervention group (n = 41). Intervention. Part I included leg strengthening and balance exercises and a graduated, self-monitored walking program; part 2 included motivational telephone calls. Both groups received regular foot care, foot care education, and 8 sessions with a physical therapist. Measurements. The measurements collected were strength, balance, and participant-reported falls for the year after enrollment. Results. There were no statistically significant differences between the groups for falls during follow-up. At 12 months, there was a small increase in the amount of time that participants in the intervention group could stand on 1 leg with their eyes closed. No other strength or balance measurements differed between the groups. Limitations. The study was designed to detect differences in physical activity, not falls. The intensity of the intervention was insufficient to improve strength and balance in this population. Conclusions. The training program had a minimal effect on participants balance and lower-extremity strength. Increasing weight-bearing activity did not alter the rate of falling for participants in the intervention group relative to that for participants in the control group. People who are sedentary and who have DM + PN appear to be able to increase activity without increasing their rate of falling. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Purpose: Although lower respiratory tract infections are a leading cause of death in frail elderly patients, few studies have compared treatments and outcomes. We assessed the effects of different antibiotic treatment strategies on survival of elderly nursing home residents with lower respiratory tract infections in the United States and the Netherlands, where treatment approaches are quite different.Methods: We combined data from 2 prospective cohort studies of lower respiratory tract infections conducted in 36 nursing homes in the United States and 61 in the Netherlands. We included residents whose infections were treated with antibiotics: 806 in the United States and 415 in the Netherlands. Outcome measures were 1-month and 3-month mortality. We used logistic regression to adjust for differing illness severity.Results: Dutch residents had higher mortality than US residents (28.1% vs 15.1% at 1 month, respectively; P <.001). After adjusting for illness severity with logistic regression, the differences between the Dutch and US populations were not significant (odds ratio 1.34; 95% confidence interval, 0.94-1.90). Predicted mortality was overestimated for more severely ill US residents at 1 month but not at 3 months. No antibiotic regimen was consistently associated with increased or decreased mortality.Conclusion: Despite differences in illness severity and treatment, adjusted mortality did not differ between the 2 countries. Although we cannot exclude a short-term survival benefit from more aggressive treatment in the United States, differences in baseline health appear prognostically more important than the type of antibiotic treatment. [ABSTRACT FROM AUTHOR]

Objective Even though more than 25% of Americans die in nursing homes, end-of-life care has consistently been found to be less than adequate in this setting. Even for those residents on hospice, end-of-life care has been found to be problematic. This study had 2 research questions; (1) How do family members of hospice nursing home residents differ in their anxiety, depression, quality of life, social networks, perceptions of pain medication, and health compared with family members of community dwelling hospice patients? (2) What are family members’ perceptions of and experiences with end-of-life care in the nursing home setting? Methods This study is a secondary mixed methods analysis of interviews with family members of hospice nursing home residents and a comparative statistical analysis of standard outcome measures between family members of hospice patients in the nursing home and family members of hospice patients residing in the community. Results Outcome measures for family members of nursing home residents were compared (n = 176) with family members of community-dwelling hospice patients (n = 267). The family members of nursing home residents reported higher quality of life; however, levels of anxiety, depression, perceptions of pain medicine, and health were similar for hospice family members in the nursing home and in the community. Lending an understanding to the stress for hospice family members of nursing home residents, concerns were found with collaboration between the nursing home and the hospice, nursing home care that did not meet family expectations, communication problems, and resident care concerns including pain management. Some family members reported positive end-of-life care experiences in the nursing home setting. Conclusion These interviews identify a multitude of barriers to quality end-of-life care in the nursing home setting, and demonstrate that support for family members is an essential part of quality end-of-life care for residents. This study suggests that nursing homes should embrace the opportunity to demonstrate the value of family participation in the care-planning process. [ABSTRACT FROM AUTHOR]

Context: Family caregivers play a central role in the care of those in hospice care. Little is known about the social support networks for those providing this day-to-day care without training.Objectives: The purpose of this study was to explore changes in family and friend social networks among hospice caregivers over the course of the hospice stay.Methods: Data on social support networks were collected as part of a multisite randomized controlled trial and analyzed using structural equation modeling.Results: A statistically significant decline in the caregivers' family network subscale score was found over the four week period during which they received hospice services, reflecting a possible weakening of their family networks.Conclusion: This result illustrates the potential importance of ongoing comprehensive assessment of caregiver networks and attention to interventions that may assist in capitalizing on both the quantity of support (numbers of individuals asked to help) and the quality of social support (attending to issues of support burden). [ABSTRACT FROM AUTHOR]