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Antibiotic-associated diarrhoea (AAD) is a common cause of morbidity and mortality. Older individuals in long-term care facilities are particularly vulnerable due to multisystem illnesses and the prevailing conditions for nosocomial infections. Lactoferrin, an antimicrobial protein in human breastmilk, was tested to determine whether it would prevent or reduce AAD, including Clostridium difficile in tube-fed long-term care patients. Thirty patients were enrolled in a randomized double-blind study, testing eight weeks of human recombinant lactoferrin compared to placebo for the prevention of antibiotic-associated diarrhoea in long-term care patients. Fewer patients in the lactoferrin group experienced diarrhoea compared to controls (p = 0.023). Based on the findings, it is concluded that human lactoferrin may reduce post-antibiotic diarrhoea. [ABSTRACT FROM AUTHOR]

Objectives: This study evaluated the impact of standardized care protocols, as a part of a quality improvement initiative (J10ohns Hopkins Community Health Partnership, J-CHiP), on hospital readmission rates for patients with a diagnosis of congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) after being discharged to skilled nursing facilities (SNFs)., Design: A retrospective study comparing 30-day hospital readmission rates the year before and 2 years following the implementation of the care protocol interventions., Settings and Participants: Patients discharged from Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center to the participating SNFs diagnosed with CHF and/or COPD., Methods: The standardized protocols included medical provider or nurse assessments on SNF admission, multidisciplinary care planning, and medication management to avoid unplanned readmissions to the hospital. Descriptive analyses were conducted to illustrate the 30-day readmission rates before and after protocol implementation., Results: There were 1128 patients in the pre-J-CHiP cohort and 2297 patients in the J-CHiP cohort. About half of the patients with a recorded diagnosis of CHF without COPD had the standardized protocol initiated, whereas 47% of the patients with a recorded diagnosis of COPD without CHF had the standardized protocol initiated. Of patients with recorded diagnoses of COPD and CHF, 49% had both protocols initiated. A reduction in the readmission rate was observed for patients with COPD protocols, from 23.5% in 2011 to 12.1% in 2015. However, fluctuations in the readmission rates were observed for patients who initiated the CHF protocols., Conclusions and Implications: There were improvements in the readmission rates in this study, especially for patients who had initiated standardized care protocols in the SNFs. Our findings demonstrate great value in standardizing care management and strengthening collaboration with chronic care settings to facilitate a smooth transition of medically complex patients discharged from large health care systems. Future interventions could consider assessing nonclinical factors that may impact preventable hospital readmissions., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Oral cavity squamous cell carcinoma (OCSCC) represents a serious health and socio-economic problem in different geographical areas of the world. It is characterized by a high rate of mortality, recurrence and metastasis. Despite the therapeutic strategies implemented for its management and resolution, currently the survival estimate for locally advanced disease is about 50%. The available therapeutic options comprise surgery and pharmacological treatment. Recently, an increased emphasis has been placed on the drugs that might be of benefit in this life-threatening disease. Therefore, the aim of this present review was to offer a general survey of the current available pharmacological treatment for OCSCC. The PubMed database was used to retrieve the papers using "OCSCC" as the search terms. We limited our search to the last 5 years to give a more updated and recent picture of the state of the art, including preclinical and clinical investigations. We found that 77 out of 201 papers were on the surgical treatment of OCSCC, 43 out of 201 focused on the radiotherapy and 81 out of 201 underwent evaluation for the aim of our review. We excluded the case reports, editorial letters, observational studies and papers written in languages other than English. A total of 12 articles were included in the final review. Our results showed that nanotechnologies use to enhance the efficacy of anticancer drugs such as: cisplatin, paclitaxel, cetuximab, EGFR antagonists, MEK1/2 and immune check inhibitors combination could have promising anti-cancer activity. However, the paucity of available data on drugs suggests the urgent need to improve the pharmacological armamentarium for OCSCC treatment.

Background: Due to technology and pharmaceutical science and increasing life expectancy, the patient population is continuously aging. Patients requiring dental extractions often have systemic and/or chronic diseases and are undergoing polypharmacologic therapy. Oral surgeons often interface with patients who perform anticoagulant therapy. The main aim of this study was to clarify what the contraindications and short-/long-term complications may be., Methods: A sample of 298 patients (mean age 58 years) who required multiple surgical dental extractions has been taken in consideration. Patients were divided into groups and subgroups according to the anticoagulant drug therapy., Results: Long-term complications represented variable bleeding between groups from 8 hours to 7 days after surgery. The One-Way ANOVA Test was used to compare the results between groups. Patients treated with direct oral anticoagulants showed fewer intraoperative problems, but further studies and further collaboration between doctors, cardiologists and oral dentists/surgeons are certainly needed to manage these patients in a predictable manner., Conclusions: This study showed that using direct oral anticoagulants drugs results in few intraoperative bleeding, less postoperative hemorrhagic complications, and an easier administration of the drugs respect vitamin K antagonists, with mild and manageable complications.

Objectives: To assess the association of geriatric syndrome risk factors with postacute utilization among hospitalized Medicare patients (both Medicare Advantage [MA] and fee-for-service [FFS] cohorts) and to examine patterns of postacute care for MA and FFS cohorts with high geriatric syndrome risk., Study Design: Secondary data analysis using encounter-level data from the State Inpatient Databases (SID) of the Healthcare Cost and Utilization Project., Methods: The sample included 3.1 million Medicare hospitalizations from the Florida SID (2010 to 2014). We used multivariate linear regression to examine the impact of a geriatric syndrome risk measure, assessed as high risk, moderate risk, or nonrisk, on outcomes in MA and FFS cohorts. Outcome measures included postacute destination and inpatient utilization. We then examined if this risk measure was associated with differences in outcomes between MA and FFS cohorts., Results: Patients with high geriatric syndrome risk (in both MA and FFS cohorts) are less likely to be discharged to home or to home health care. They also have longer inpatient lengths of stay and higher inpatient costs. This risk measure also explains differences in postacute skilled nursing destination between MA and FFS cohorts., Conclusions: Geriatric syndrome risk factors not only play a role in postacute care and inpatient utilization in MA and FFS cohorts but also explain different utilizations between MA and FFS cohorts. This study's results can be applied to guide discharge planning among a group of high-risk patients and evaluate alternative delivery models for this high-cost, high-need cohort.

Patient portals (PPs), secure websites that allow patients to access their electronic health records and other health tools, can benefit older adults managing chronic conditions. However, studies have shown a lack of PP use in older adults. Little is known about the way they use PPs in community settings and specific challenges they encounter. The aim of this study was to examine the current state of PP use in older adults, employing baseline data (quantitative and qualitative) from an ongoing nationwide online trial. The dataset includes 272 older adults (mean age, 70.0 years [50-92]) with chronic conditions. Findings showed that the majority of participants (71.3%) were using one or more PPs, but in limited ways. Their comments revealed practical difficulties with managing PPs, perceived benefits, and suggestions for improvement. Further studies with different older adult groups (e.g., clinic patients) will help develop and disseminate more usable PPs for these individuals.

Introduction: The high prevalence of chronic illnesses is a serious public health problem in the United States, and more than 70 million older adults have at least one chronic illness. Patient portals (PPs) have an excellent potential to assist older adults in managing chronic illnesses; however, older adults' PP adoption rates have been low. Lack of support for older adults using PPs remains a critical gap in most implementation processes. The main aim of this study was to assess the impact of an older adult friendly Theory-based Patient portal e-Learning Program (T-PeP) on PP knowledge, selected health outcomes (health decision-making self-efficacy [SE] and health communication), PP SE and use, and e-health literacy in older adults. Materials and Methods: A two-arm randomized controlled trial was conducted with older adults ( N  = 272) who had chronic conditions. Participants were recruited online, and data were collected at baseline, 3 weeks, and 4 months. The main intervention effects were tested using linear mixed models. Results: The average age of participants was 70.0 ± 8.5 years, and 78.3% ( n  = 213) were white. At 3 weeks, the intervention group showed significantly greater improvement than the control group in all outcomes except PP use. At 4 months, the intervention effects decreased, but PP SE remained significant ( p  = 0.015), and the intervention group showed higher frequency of PP use than the control group ( p  = 0.029). Conclusion: The study findings showed that the T-PeP was effective in improving selected health and PP usage outcomes. Further studies are needed to test the long-term effects of T-PeP using more diverse samples.

Importance: The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland., Objective: To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower spending., Design, Setting, and Participants: Nonrandomized acute care intervention (ACI) and community intervention (CI) Medicare and Medicaid participants were analyzed in a quality improvement study using difference-in-differences designs with propensity score-weighted and matched comparison groups. The study spanned 2012 to 2016 and took place in acute care hospitals, primary care clinics, skilled nursing facilities, and community-based organizations. The ACI analysis compared outcomes of participants in Medicare and Medicaid during their 90-day postacute episode with those of a propensity score-weighted preintervention group at Johns Hopkins Community Health Partnership hospitals and a concurrent comparison group drawn from similar Maryland hospitals. The CI analysis compared changes in outcomes of Medicare and Medicaid participants with those of a propensity score-matched comparison group of local residents., Interventions: The ACI bundle aimed to improve transition planning following discharge. The CI included enhanced care coordination and integrated behavioral support from local primary care sites in collaboration with community-based organizations., Main Outcomes and Measures: Utilization measures of hospital admissions, 30-day readmissions, and emergency department visits; quality of care measures of potentially avoidable hospitalizations, practitioner follow-up visits; and total cost of care (TCOC) for Medicare and Medicaid participants., Results: The CI group had 2154 Medicare beneficiaries (1320 [61.3%] female; mean age, 69.3 years) and 2532 Medicaid beneficiaries (1483 [67.3%] female; mean age, 55.1 years). For the CI group's Medicaid participants, aggregate TCOC reduction was $24.4 million, and reductions of hospitalizations, emergency department visits, 30-day readmissions, and avoidable hospitalizations were 33, 51, 36, and 7 per 1000 beneficiaries, respectively. The ACI group had 26 144 beneficiary-episodes for Medicare (13 726 [52.5%] female patients; mean patient age, 68.4 years) and 13 921 beneficiary-episodes for Medicaid (7392 [53.1%] female patients; mean patient age, 52.2 years). For the ACI group's Medicare participants, there was a significant reduction in aggregate TCOC of $29.2 million with increases in 90-day hospitalizations and 30-day readmissions of 11 and 14 per 1000 beneficiary-episodes, respectively, and reduction in practitioner follow-up visits of 41 and 29 per 1000 beneficiary-episodes for 7-day and 30-day visits, respectively. For the ACI group's Medicaid participants, there was a significant reduction in aggregate TCOC of $59.8 million and the 90-day emergency department visit rate decreased by 133 per 1000 episodes, but hospitalizations increased by 49 per 1000 episodes and practitioner follow-up visits decreased by 70 and 182 per 1000 episodes for 7-day and 30-day visits, respectively. In total, the CI and ACI were associated with $113.3 million in cost savings., Conclusions and Relevance: A care coordination model consisting of complementary bundled interventions in an urban academic environment was associated with lower spending and improved health outcomes.

Purpose Academic healthcare systems face great challenges in coordinating services across a continuum of care that spans hospital, community providers, home and chronic care facilities. The Johns Hopkins Community Health Partnership (J-CHiP) was created to improve coordination of acute, sub-acute and ambulatory care for patients, and improve the health of high-risk patients in surrounding neighborhoods. The paper aims to discuss this issue. Design/methodology/approach J-CHiP targeted adults admitted to the Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, patients discharged to participating skilled nursing facilities (SNFs), and high-risk Medicare and Medicaid patients receiving primary care in eight nearby outpatient sites. The primary drivers of the program were redesigned acute care delivery, seamless transitions of care and deployment of community care teams. Findings Acute care interventions included risk screening, multidisciplinary care planning, pharmacist-driven medication management, patient/family education, communication with next provider and care coordination protocols for common conditions. Transition interventions included post-discharge health plans, hand-offs and follow-up with primary care providers, Transition Guides, a patient access line and collaboration with SNFs. Community interventions involved forming multidisciplinary care coordination teams, integrated behavioral care and new partnerships with community-based organizations. Originality/value This paper offers a detailed description of the design and implementation of a complex program to improve care coordination for high-risk patients in an urban setting. The case studies feature findings from each intervention that promoted patient engagement, strengthened collaboration with community-based organizations and improved coordination of care.

Background: Older adults with complex medical conditions are vulnerable during care transitions. Poor care transitions can lead to poor patient outcomes and frequent readmissions to the hospital., Factors Contributing to Suboptimal Care Transitions: Key factors related to ineffective care transitions, which can lead to suboptimal patient outcomes, include poor cross-site communication and collaboration; lack of awareness of patient wishes, abilities, and goals of care; and incomplete medication reconciliation. Fundamental elements for effective care transitions put forth by The Joint Commission for effective care transitions include interdisciplinary coordination and collaboration of patient care in care transitions, shared accountability by all clinicians involved in care transitions, and provision of appropriate support and follow-up after discharge., Review of Four Existing Models of Care Transitions: Consideration of four existing care transitions models representing different health care settings-Care Transitions Intervention® Guided Care, Interventions to Reduce Acute Care Transfers (INTERACT®), Home Health Model of Care Transitions-revealed that they are important but limited in their impact on transitions across health care settings., Proposal of the Integrated Care Transitions Approach: An innovative approach, Integrated Care Transitions Approach (ICTA), is proposed that incorporates the best practices of the four models discussed in this article and factors identified as essential for an effective care transition while addressing limitations of existing transitional care models. ICTA's four key characteristics and seven key elements are unique and stem from factors that help achieve effective care transitions., (Copyright © 2018 The Joint Commission. All rights reserved.)

Introduction: Among survivors of intensive care, many remain dependent on mechanical ventilation and are discharged to long-term chronic ventilator units or to skilled nursing facilities. Few long-term outcome data are available on patients transferred from long-term chronic ventilator units., Methods: We retrospectively followed subjects discharged from a long-term chronic ventilator unit from 2010-2012. We determined where these subjects went, evaluating whether location of discharge had an effect on mortality., Results: We followed 79 subjects who were 64.9 ± 15.9 y old. Average stay in the long-term chronic ventilator unit was 38.5 ± 20.1 d. Within the first year after discharge, 24 (30.3%) subjects died: 17 in a skilled nursing facility, 7 at home. Of those who survived the first year, 28 had been discharged to a skilled nursing facility and 27 to home. Survivors were younger (62.6 ± 12.4 vs 70.4 ± 13.1 y, P = .03), had shorter intensive care unit lengths of stay (10.4 ± 5.0 vs 16.4 ± 11.5 d, P = .03), and were more likely discharged home from long-term chronic ventilator unit (49.0% vs 29.1%, P = .040)., Conclusions: Subjects discharged from an long-term chronic ventilator unit and were alive at 1 y had shorter stays in the ICU and were more likely to be discharged home. Further attention is warranted to assure the survival of critical care patients once they are discharged from intensive care units., (Copyright © 2017 by Daedalus Enterprises.)

An estimated 10 million Americans age 50 and older have osteoporosis, and many experience associated fractures. Although several interventions have been shown to be effective in preventing osteoporosis, their impact on bone health among older adults was limited. The aim of this study was, therefore, to examine the effects of a theory-based online bone health program (Bone Power program) for a large number of older adults. The 8-week program included learning modules, discussion boards, and other resources. Participants ( N = 866; M age = 62.5 years) were recruited online and randomized into a Bone Power or control group. At the end of the intervention, the Bone Power group showed significantly greater improvement over the control group in osteoporosis knowledge, self-efficacy/outcome expectations for calcium intake and exercise, and calcium intake and exercise behaviors. This study's findings suggest that online health programs can be effective in improving older adults' knowledge, beliefs, and health behaviors.

Background: Pruritus has a negative impact on quality of life (QoL) in dialysis patients. The reversibility of this symptom after renal transplantation and its impact upon QoL has scarcely been studied in these patients., Methods: Pruritus was evaluated by the Visual Analogue Scale (VAS), the Visual Rating Scale (VRS), and the Numerical Rating Scale (NRS) in 133 unselected renal transplant patients, 62 healthy subjects, and 29 hemodialysis patients. QoL was assessed by KDQOL-SF ™ 1.3. The reversibility of pruritus was studied by applying retrospectively the VRS., Results: The prevalence of pruritus by the VRS was 62% in hemodialysis patients, 32% in renal transplant patients, and 11% in healthy subjects (P<.001). The prevalence of pruritus among transplant patients was 32% by VRS and 38% by VAS and NRS. The prevalence of pretransplantation pruritus (68%) by the VRS recall questionnaire was higher than the prevalence of pruritus in the same patients after renal transplantation (32%, P<.01). Pruritus in transplant patients was associated with important dimensions of QoL, including social, emotional, and working limitations (P<.05 for the three comparisons)., Conclusions: The prevalence of pruritus markedly reduces after renal transplantation but remains substantially higher than in the general population and impacts upon quality of life in these patients., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patient's primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Multidrug-resistant organisms are an emerging and serious threat to the care of patients. Long-term care facilities are considered a reservoir of these organisms partly because of the over-prescribing of antibiotics. Antibiotic use is common in long-term care facilities. Antibiotic stewardship programs have been shown to reduce antibiotic consumption in acute-care facilities. The purpose of our study is to investigate existing infection-control practices and antibiotic stewardship programs in long-term care facilities in Maryland., Methods: We telephoned the infection-control personnel in 231 long-term care facilities in Maryland between February 2014 and July 2015 and reached 124 facilities (59%)., Results: Among the 124 facilities surveyed, there were 14,371 beds and 337 infection-control personnel with basic infection-control training. Close to 20% of facilities use silver- or antimicrobial-impregnated urinary catheters. Most facilities (97%) track urinary tract infections. Although all report to the health department in the case of an outbreak, only 63 (50.8 %) report directly to the Centers for Disease Control and Prevention. About 80% of facilities isolate patients with Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococci with acute infections only. Eighty percent of facilities have basic guidance on choice of antibiotic, and 27% have a restricted formulary. Only 25% of facilities have an antibiotic approval process. Thirty-five percent of facilities have training for antibiotics prescribing. However, 17% of facilities did not know whether such training existed., Conclusions: Antibiotic stewardship programs in long-term care facilities are still in early development stages, but our results demonstrate that the majority of facilities are collecting data on prescribing antibiotics, and a surprising number have antibiotic approval and antibiotics prescribing training., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

In patients with nephrotic syndrome (NS), the lung is considered an organ protected from the risk of edema. However, data on objectively measured lung water in NS patients is lacking. Here we measured lung water by an ultrasound (US) technique as well as by transthoracic impedance in 42 asymptomatic patients with active NS, in 14 stage G5D CKD patients on chronic hemodialysis, and in 21 healthy individuals. In patients with active NS, the median number of US-B lines (a metric of lung water) after 5 min in a supine position was significantly higher (12; interquartile range: 7-25) compared with that in healthy individuals (4; 2-9) but similar to that in hemodialysis patients (23; 10-39). The difference between NS patients and healthy individuals was significantly amplified (16; 10-35 vs. 4; 2-9) after 60 min of supine resting and significantly attenuated after 5 min of standing (10; 7-25 vs. 3; 1-6). Posture-dependent changes in lung water in patients with active NS were significantly accentuated compared with both hemodialysis patients and healthy individuals. After NS remission, the number of US-B lines was significantly reduced to 5 (4-18) at 5 min and to 6 (5-22) at 60 min approaching the normal range. Lung congestion in patients with active NS was confirmed by transthoracic impedance. Thus, asymptomatic pulmonary congestion is pervasive in patients with NS. A clinical trial is needed to assess the utility of lung US for the management of patients with NS.

Purpose: Skilled nursing facility ventilator units (SNF) are a recent attempt to reduce the costs of an increasing number of patients who are in acute intensive care units and are not able to be liberated from ventilators. Transfers of such patients from long-term care chronic vent units (LTCVs) to SNFs in Maryland began in 2006. The safety of these transfers needs to be assessed., Methods: We retrospectively followed up all patients designated as eligible by their insurance for transfer from our LTCV units to SNF from July 1, 2008 through June 30, 2010 looking only at survival. Those patients who refused transfer and appealed and remained in our LTCV were compared to those who were transferred to SNF ventilator units. The analysis was by Kaplan-Meier statistics., Results: There was an increased mortality (P=.025) of those transferred to SNF ventilator facilities as compared to those remaining in the LTCV., Conclusion: We recognize that bias may occur in patients choosing to remain in our LTCV compared to those accepting transfers, the magnitude of the difference in mortality indicates the need for more comprehensive well designed analysis investigating the outcome of all transfers occurring to and from LTCVs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

With the increasing nationwide emphasis on eHealth, there has been a rapid growth in the use of the Internet to deliver health promotion interventions. Although there has been a great deal of research in this field, little information is available regarding the methodologies to develop and implement effective online interventions. This article describes two social cognitive theory-based online health behavior interventions used in a large-scale dissemination study (N = 866), their implementation processes, and the lessons learned during the implementation processes. The two interventions were a short-term (8-week) intensive online Bone Power program and a longer term (12-month) Bone Power Plus program, including the Bone Power program followed by a 10-month online booster intervention (biweekly eHealth newsletters). This study used a small-group approach (32 intervention groups), and to effectively manage those groups, an eLearning management program was used as an upper layer of the Web intervention. Both interventions were implemented successfully with high retention rates (80.7% at 18 months). The theory-based approaches and the online infrastructure used in this study showed a promising potential as an effective platform for online behavior studies. Further replication studies with different samples and settings are needed to validate the utility of this intervention structure., (© The Author(s) 2013.)

Aim: A substantial number of elderly patients take benzodiazepines (BZD) regularly despite concerns about toxicity and possible dependence, and there are relatively few data to guide clinicians' decisions regarding discontinuing benzodiazepines in the elderly., Methods: We carried out a retrospective chart review of 75 elderly patients admitted to a chronic medical/psychiatric unit who were taking a standing dose of benzodiazepines on admission, comparing 40 patients who discontinued benzodiazepines versus 35 who did not discontinue., Purpose: We examined the association of BZD discontinuation versus continuation with clinical outcomes on discharge, and further examined clinical characteristics associated with BZD discontinuation., Results: Discontinuers had shorter length of stay without evidence of worse cognitive and functional outcome except a trend toward increased incidence of agitation. Logistic regression models suggested anxiety, higher age and higher dose of antidepressants at the beginning were significantly related to successful discontinuation during admission after regression., Conclusion: These data imply that BZD withdrawal during admission can be safe and feasible in many elderly frail patients, and that withdrawal might be associated with shorter duration of chronic hospitalization., (© 2013 Japan Geriatrics Society.)

Background and Objectives: Poor physical performance is common in patients with kidney failure on dialysis (CKD-5D). Whether lung congestion, a predictable consequence of cardiomyopathy and fluid overload, may contribute to the low physical performance of CKD-5D patients has not been investigated in hemodialysis patients., Design, Setting, Participants, & Measurements: This study investigated the relationship between the physical functioning scale of the Kidney Disease Quality of Life Short Form and a validated ultrasonographic measure of lung water in a multicenter survey of 270 hemodialysis patients studied between 2009 and 2010., Results: Moderate to severe lung congestion by lung ultrasonography was observed in 156 (58%) patients; among these, 60 (38%) were asymptomatic (New York Heart Association [NYHA] class I). On univariate analysis, physical functioning was inversely associated with lung water in the whole group (r=-0.22; P<0.001) and in the subgroup of asymptomatic patients (r=-0.40; P=0.002). Age (r=-0.45; P<0.001) and past cardiovascular events (r=-0.22; P=0.002) were also inversely associated with physical functioning, whereas albumin (r=0.23; P<0.001) was directly associated with the same parameter. NYHA class correlated strongly with physical functioning (r=-0.52; P<0.001). In a multiple regression analysis, both NYHA class and lung water maintained an independent association with physical functioning, whereas albumin and background cardiovascular events failed to independently relate with the same outcome., Conclusions: Symptomatic and asymptomatic lung congestion is associated with poor physical functioning in hemodialysis patients. This association is independent of NYHA, suggesting that this measurement and NYHA may have complementary value to explain the variability in physical performance in hemodialysis patients.

Background: Lung congestion is emerging as a pervasive, insidious problem in end-stage renal disease (ESRD) patients on dialysis., Summary: Chest ultrasound (US), a novel, easy-to-perform, cheap technique, which is currently applied for objective monitoring of pulmonary congestion in patients with heart failure in Europe, allows reliable quantification of lung water in clinical practice. Before hemodialysis (HD), about 60% of ESRD patients displayed moderate-severe lung congestion and this alteration is frequently asymptomatic. Lung congestion is reduced but not abolished by ultrafiltration dialysis, and about one third to one fourth of patients still have excessive lung water after dialysis. Lung congestion is also prevalent in patients on peritoneal dialysis (PD), and in apparently asymptomatic HD and PD patients this alteration is strongly associated with poor physical performance. Lung water in HD patients correlates in an inverse fashion with echocardiographic parameters of systolic and diastolic function, but it is only weakly related with hydration status measured by bioimpedance analysis. Moderate-severe lung congestion is a strong predictor of death and cardiovascular events and provides prognostic information independent of NYHA class, and traditional and nontraditional risk factors in ESRD patients on HD., Key Messages: Systematic application of chest US in ESRD patients shows that hidden or clinically manifest lung congestion is exceedingly frequent in this population. This alteration largely reflects left ventricular disorders superimposed on volume overload. The clinical usefulness of systematic application of chest US in ESRD remains to be tested in a formal clinical trial., (© 2013 S. Karger AG, Basel.)

Background: Hip fracture is a serious injury for older adults, usually requiring surgical repair and extensive therapy. Informal caregivers can help older adults make a successful recovery by encouraging them to adhere to the therapy plans and improve their health behaviors. Few resources, however, are available for these caregivers to learn about how to assist their care receivers and cope with their unique caregiving situations., Objective: The study aims were to develop a comprehensive theory-based online hip fracture resource center (OHRC) for caregivers, Caring for Caregivers, and conducted a feasibility trial., Methods: The OHRC included self-learning modules, discussion boards, Ask the Experts, and a virtual library. The feasibility of the intervention was assessed by usage and usability. The feasibility of the future trial was tested using a one-group pre-post design on 36 caregiver-care receiver dyads recruited from six hospitals. The caregivers used the OHRC for 8 weeks. The impact of the intervention was assessed on both caregivers (primary) and care receivers (secondary). The data were analyzed by descriptive statistics, paired t tests, and content analyses., Results: On average, caregivers reviewed five modules and used the discussion board 3.1 times. The mean perceived usability score for the OHRC was 74.04 ± 7.26 (range, 12-84). Exposure to the OHRC significantly improved caregivers' knowledge about the care of hip fracture patients (t = 3.17, p = .004) and eHealth literacy (t = 2.43, p = .002). Changes in other caregiver outcomes (e.g., strain, coping, and social support) and care receiver outcomes (e.g., self-efficacy for exercise and osteoporosis medication adherence) were favorable but not significant., Discussion: The findings suggest that the OHRC was user-friendly and could be beneficial for caregivers. Additional larger-scale trials are needed to assess the effectiveness of the intervention on outcomes.

We constantly integrate the information that is available to our various senses. The extent to which the mechanisms of multisensory integration are subject to the influences of attention, emotion, and/or motivation is currently unknown. The "ventriloquist effect" is widely assumed to be an automatic crossmodal phenomenon, shifting the perceived location of an auditory stimulus toward a concurrently presented visual stimulus. In the present study, we examined whether audiovisual binding, as indicated by the magnitude of the ventriloquist effect, is influenced by threatening auditory stimuli presented prior to the ventriloquist experiment. Syllables spoken in a fearful voice were presented from one of eight loudspeakers, while syllables spoken in a neutral voice were presented from the other seven locations. Subsequently, participants had to localize pure tones while trying to ignore concurrent visual stimuli (both the auditory and the visual stimuli here were emotionally neutral). A reliable ventriloquist effect was observed. The emotional stimulus manipulation resulted in a reduction of the magnitude of the subsequently measured ventriloquist effect in both hemifields, as compared to a control group exposed to a similar attention-capturing, but nonemotional, manipulation. These results suggest that the emotional system is capable of influencing multisensory binding processes that have heretofore been considered automatic.

Hip fracture is a significant health problem for older adults and generally requires surgery followed by intensive rehabilitation. Informal caregivers (CGs) can provide vital assistance to older adults recovering from hip fracture. Caregiving is a dyadic process that affects both CGs and care recipients (CRs). In a feasibility study, we assessed the effects of using a theory-based online hip fracture resource program for CGs on both CGs and CRs. In this article, we discuss our recruitment process and the lessons learned. Participants were recruited from six acute hospitals, and CGs used the online resource program for 8 weeks. A total of 256 hip fracture patients were screened, and 164 CRs were ineligible. CG screening was initiated when CRs were determined to be eligible. Among 41 eligible dyads, 36 dyads were recruited. Several challenges to the recruitment of these dyads for online studies were identified, including a low number of eligible dyads in certain hospitals and difficulty recruiting both the CR and the CG during the short hospital stay. Field nurses often had to make multiple trips to the hospital to meet with both the CR and the CG. Thus, when a subject unit is a dyad recruited from acute settings, the resources required for the recruitment may be more than doubled. These challenges could be successfully alleviated with careful planning, competent field staff members, collaboration with hospital staff members, and efficient field operations.

An updated review of cases of reactivated visceral leishmaniasis (VL) in transplant patients is presented, with a new report of a kidney transplant patient who had VL caused by reactivation of a dormant infection contracted 21 years previously. Close to the time of disease reactivation, the patient had a primary varicella-zoster infection.

We report the case of a renal transplant patient on tacrolimus who developed a fully reversible renal failure and a doubling in serum tacrolimus closely associated with initiation of ranolazine (Ranexa) treatment, a new anti-angina drug recently introduced in Europe.

Introduction and Rationale: A performance improvement project was undertaken to increase health care worker (HCW) influenza vaccination acceptance rates in the long-term care setting by using a novel 15-minute education intervention called the "Flu in 15." As a core principle, we taught that more Americans die from complications of influenza than hepatitis B, yet there remains individual reluctance and barriers to achieve high acceptance rates of influenza vaccination among HCWs., Methods: During chance encounters we offered the Flu in 15 in-service to all HCWs at the Johns Hopkins Bayview Care Center including certified nursing assistants (also called geriatric nursing assistants), registered nurses, registered dieticians, environment staff, physical therapists, occupational therapists, speech therapists, respiratory therapists, social workers, and administrators. Of the 106 of 347 HCWs who participated in the Flu in 15 in-service, 58 were by chance encounters selected to be surveyed based on convenience. We surveyed 68 of 241 HCWs who did not attend the Flu in 15 in-service as a comparison., Results: Of the 58 participants who were asked if the in-service helped them understand why a flu vaccine is needed yearly, we found that 15% responded "tremendously," 48% "a lot," 26% "some," 7% "a little," and 2% "no." We had 24% report that the program was effective in changing their behavior to accept the flu vaccination for the first time. We found that 49% responded that the in-service was effective in either changing their behavior to accept the flu vaccination for the first time or reaccept it if recently declined in previous years. With respect to motivation, 42% of the certified nursing assistants stated that the in-service made them think more about returning to school to get a license in some area of health care. Although not cause and effect, we observed an increase in the HCW acceptance rate of the influenza vaccine from 65% in 2006-2007 to 73% in 2007-2008. We noticed a decreased trend in patient deaths attributed to complications of influenza with 4 deaths in 2006-2007 and no deaths in 2007-2008., Conclusions: The Flu in 15 in-service promoted a better understanding of the importance of the influenza vaccine and demonstrated an associated increase in HCW acceptance of the flu vaccine. Although we cannot claim cause and effect, we noted a decrease in resident mortality in the intervention year compared with the prior year. Now that some medical centers require yearly influenza vaccines among HCWs, the education component remains relevant to provide reason behind the mandate., (Copyright 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.)

China has the world's largest and most rapidly growing older adult population. Recent dramatic socioeconomic changes, including a large number of migrating workers leaving their elderly parents and grandparents behind and the 4:2:1 family structure caused by the one-child policy, have greatly compromised the traditional Chinese family support for older adults. These demographic and socioeconomic factors, the improved living standards, and the quest for higher quality of life are creating human economic pressures. The plight of senior citizens is leading to an unprecedented need for geriatrics expertise in China. To begin to address this need, the Johns Hopkins University School of Medicine (JHU) and Peking Union Medical College (PUMC) have developed a joint international project aimed at establishing a leadership program at the PUMC Hospital that will promote quality geriatrics care, education, and aging research for China. Important components of this initiative include geriatrics competency training for PUMC physicians and nurses in the Division of Geriatric Medicine and Gerontology at JHU, establishing a geriatrics demonstration ward at the PUMC Hospital, faculty exchange between JHU and PUMC, and on-site consultation by JHU geriatrics faculty. This article describes the context and history of this ongoing collaboration and important components, progress, challenges, and future prospects, focusing on the JHU experience. Specific and practical recommendations are made for those who plan such international joint ventures. With such unique experiences, it is hoped that this will serve as a useful model for international geriatrics program development for colleagues in the United States and abroad.