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Myocardial infarction and reperfusion constitute a complex injury consisting of many distinct molecular stress patterns that influence cardiomyocyte survival and adaptation. Cell signalling, which is essential to cardiac development, also presents potential disease-modifying opportunities to recover and limit myocardial injury or maladaptive remodelling. Here, we hypothesized that Yap signalling could be sensitive to one or more molecular stress patterns associated with early acute ischemia. We found that Yap, and not Taz, expression patterns differed in a post-myocardial infarct compared to a peri-infarct region of rat hearts post-myocardial infarction, suggesting cell specificity that would be challenging to resolve for causation in vivo. Using H9c2 ventricular myotubes in vitro as a model, Yap levels were determined to be more sensitive to nutrient deprivation than other stress patterns typified by ischemia within the first hour of stress. Moreover, this is mediated by amino acid availability, predominantly L-isoleucine, and influences the expression of connective tissue growth factor (Ctgf)—a major determinant of myocardial adaptation after injury. These findings present novel opportunities for future therapeutic development and risk assessment for myocardial injury and adaptation.

Abstract Purpose There has been a long standing debate regarding superiority of cruciate retaining total knee arthroplasty over posterior stabilized total knee arthroplasty regarding the short‐term outcomes as well as long‐term survivorship. The proponents of both the techniques have published vast evidence in favor of their respective surgical method and early outcome in meta‐analyses does not seem to be significantly different. The decision to select either design should depend on their long‐term survivorship but the literature comparing their long‐term survival is sparse. This meta‐analysis was conducted in order to answer the following questions: (1) Does cruciate retaining total knee arthroplasty has a better long‐term survival beyond 10 years.compared to posterior stabilized total knee arthroplasty? (2) Does cruciate retaining knee arthroplasty has higher complication rates compared to posterior stabilized total knee arthroplasty? Methods The present systematic review and meta‐analysis study was carried out following PRISMA guidelines. The following databases: Embase, Web of Science, PubMed, Scopus, the Cochrane Library, Google Scholar, and CINAHL were used to search potentially interesting articles published from database inception until January 2022. Inclusion criteria for articles were: (1) retrospective comparative studies; (2) patients who had undergone a total knee arthroplasty; (3) publications evaluating the long‐term survival of cruciate‐retaining (CR) versus posterior stabilizing (PS) at a minimum 10 years’ follow‐up; (4) publications evaluating complications of cruciate‐retaining (CR) versus posterior stabilizing (PS) at a minimum 10 years’ follow‐up; and (5) publications reporting sufficient data regarding the outcomes. We used a fixed‐effects design in the case of I2 0.05; if not, we adopted a random‐effects design [4]. We also performed subgroups and sensitivity analysis in order to assess the possible source of heterogeneity. Results Database searching identified 597 studies to be screened, of which 291 abstracts were revealed as potentially eligible and finally 7 articles were included. The forest plot showed that CR had significantly better survival than PS (OR = 2.17; 95% CI: 1.69–2.80) after 10 years. However, complication rate was not significantly different between CR and PS groups (OR = 0.86; 95% CI: 0.52–1.44; P = 0.57). Subgroup analysis showed that only the period of publication constituted a source of heterogeneity in survivorship outcome. Sensitivity analysis revealed that outcomes did not differ markedly, which indicates that the meta‐analysis had strong reliability. Conclusion The results of this meta‐analysis showed that cruciate retaining prosthesis may be preferred over the posterior stabilized design in view of longer survivorship it offers However, further randomized controlled trials are recommended to confirm this finding.

OBJECTIVES: Internal medicine residents often provide hospital care for patients who are admitted from and discharged to nursing homes. This pilot study surveyed internal medicine residents for their assumptions and perceptions about demographics and regulations in the nursing home setting. DESIGN/SETTING/PARTICIPANTS: Internal medicine residents at Winthrop University Hospital in Long Island, New York, were asked to participate in this anonymous, voluntary, and self-administered written survey during October 2006. MEASUREMENTS: Survey answers were collected and analyzed using SAS 9.1 (SAS Institute, Inc., Cary, NC). RESULTS: The mean responses were very close to the actual data; however, the range and standard deviations (SD) of responses revealed a wide variation in perceptions about nursing home demographics and regulations. For example, the internal medicine residents estimated that 60% of nursing home beds are for long-term care but the responses ranged from 20% to 90%, with an SD of 21. Awareness about regulations such as payment sources and the role of the medical director was poor. Fifty-two percent of respondents stated that Medicare is the primary source of payment for long-term care. Eighty-five percent of the respondents believed that the medical director of a nursing home could be a physician, nurse, social worker, or nursing home administrator. CONCLUSION: Although internal medicine residents have high exposure to nursing home patients, many of those surveyed have incorrect perceptions about nursing home demographics and requirements. Further research is required to demonstrate the impact of formal geriatric medicine education on internal medicine residents' knowledge regarding nursing home demographics and regulations. [ABSTRACT FROM AUTHOR]

Fundamento: el Acinetobacter baumannii se ha convertido en uno de los patógenos nosocomiales más relevantes.Objetivo: caracterizar pacientes con diagnóstico de neumonía por Acinetobacter baumannii asociada a la ventilación mecánica en las Unidades de Cuidados Progresivos. Métodos: estudio de serie de casos realizado desde diciembre del 2013 a diciembre del 2014 en Unidades de Cuidados Progresivos del Hospital General Dr. Gustavo Aldereguía Lima, de Cienfuegos, que incluyó pacientes con diagnóstico de neumonía asociada a la ventilación mecánica con aislamiento de Acinetobacter baumannii. Variables analizadas: edad, sexo, comorbilidad, enfermedad que motivó el ingreso, duración de la ventilación, estadía, tipo de antibiótico usado y estado al egreso. Resultados: se estudiaron 39 pacientes, el 69, 2 % de las Unidades de Cuidados Progresivos. La edad media fue de 55,7 años. Predominó el sexo masculino. El 64, 2 % de los pacientes refirió uno o varios antecedentes patológicos personales. Predominó el ingreso en los servicios de urgencia por situaciones clínicas (51, 3 %). El 69,2 % de pacientes fue ventilado entre 3 y 21 días. La estadía media fue de 14,7 días. El 71, 8 % tuvo tratamiento combinado y la mayor parte de ellos egresaron vivos (64,1 %). La mortalidad general fue de 35,9 %.Conclusiones: en la serie analizada predominó el sexo masculino, edad superior a los 60 años y los casos clínicos; necesitaron ventilación mecánica de mediana duración y tratamiento antimicrobiano combinado. La mayor parte de los pacientes egresaron vivos y la mortalidad observada está en el rango de lo reportado en la literatura científica.

El protocolo de resolución de direcciones (ARP) es responsable de convertir las direcciones IP a direcciones de red físicas. Una vulnerabilidad de este protocolo radica en la ausencia de autenticación. La suplantación mediante el protocolo ARP es una técnica “antigua” y aún efectiva hoy día si no se interponen los controles adecuados. Existen varias herramientas de código abierto que permiten ejecutar este tipo de ataque sin necesidad de conocimientos de informática avanzados. Su ejecución afecta gravemente la confidencialidad de la información en la red corporativa, el atacante puede capturar todo el tráfico saliente y entrante (contraseñas, correos electrónicos, mensajería instantánea, etc.) Este trabajo tiene como objetivo la evaluación de la ubicación de controles en la red que permitan detectar la ocurrencia de estos ataques así como implantar medidas que mitiguen la severidad de su ocurrencia.

As the population ages, more older adults will undergo surgical procedures, and common physiologic changes can raise the risk for surgical complications while increasing morbidity and mortality. In conjunction with the National Surgical Quality Improvement Program, we piloted a comprehensive and interdisciplinary assessment and intervention protocol for perioperative care for patients aged ≥75 years undergoing elective general, gynecology-oncologic, and orthopedic surgery. The intervention included screening tools for cognitive, functional, and nutritional deficits, a Geriatric Nurse Champion on each inpatient surgical unit, and an interdisciplinary Geriatric Surgery Quality Committee. Our intervention group was compared to surgical patients during the same time period 1 year prior to the intervention, and the groups were well matched in demographics and comorbidities. The intervention group had significantly higher rates of advance care plan documentation in analysis of all patients (P < .001) and in subgroup analysis of those 85 and older (P = .006). The preintervention group had less postoperative delirium compared to the postintervention group but it was not significant and there was no difference in length of stay between groups. Various explanations for the minimal impact of the protocol exist: small sample size, presence of other hospital initiatives to reduce pressure ulcer and delirium, and clinician's awareness of project planning that led to incorporating ideas prior to official implementation. Future research implementing this protocol in naïve and/or underperforming institutions may demonstrate a greater effect. Larger sample size as well as implementation in other surgical fields may reveal a significant impact. However, if additional study does not reveal a meaningful impact of a comprehensive geriatric assessment for surgical patients, then consideration must be made regarding unrecognized factors in surgical care for older adults or perhaps that factors cannot be mitigated in older adults because they are intrinsically a higher surgical risk., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Given the high rates at which patients present with behavioural health (BH) concerns in primary care (PC), this setting has become the de facto mental health system. As a result, screening for depression and other BH conditions in PC has become a critical target for improving patient outcomes. However, integration of screening into busy PC workflows can be challenging due to barriers such as limited time and resources., Methodology: A digital, cloud-based BH assessment tool, which included electronic health record enhancements, was developed and implemented in two urban PC practices as a prelude to a planned larger-scale implementation. The implementation strategies included a reorganisation of workflows within the PC setting, comprehensive training for staff and PC physicians, and institution of an incentive programme for PC clinic managers. To examine whether the introduction of the cloud-based BH assessment tool and associated implementation strategies was associated with increased screening rates, we compared rates of screening from January through June 2017 to rates of screening from January through June 2018 (subsequent to implementation). We also examined BH symptomatology reported by patients in PC., Results: Following the implementation process, rate of BH screening with Patient Health Questionnaire-2 (PHQ-2) increased from 50.5% to 57% (p<0.00000000000000022) and rates of subsequent screening with PHQ-9, for those scoring at risk, defined as a score of ≥1, on PHQ-2, increased from 34.5% to 91.4% (p<0.00000000000000022). Additionally, high rates of 'moderate' and 'severe' symptoms of depression (40.3%), anxiety (42.6%) and substance use (26.7% alcohol; 31.2% other substance use) were observed among PC patients., Conclusions: Results suggest that a comprehensive implementation plan, including digitisation of BH assessment, reduced the burden of systematic screening. High rates of BH symptomatology underscore the need for comprehensive BH assessment and systems planning to address the high need for BH services among PC patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Geriatricians are skilled in the recognition of asymptomatic and atypical presentations that occur in the elderly and provide comprehensive medication management including recognizing adverse drug events, reducing polypharmacy, and de-prescribing. However, despite the increasing average age of the U.S. population, with the number of individuals above 65 years old predicted to increase 55% by 2030, the geriatric workforce capacity in the United States has actually decreased from 10,270 in 2000 to 8,502 in 2010. Method: We describe physiologic changes in older adults, historical trends in geriatric training, and propose solutions for this looming crisis. Results: Many factors are responsible for the shortage of skilled geriatric providers. Discussion: We discuss the historical context of the lack of geriatricians including changes to the training system, describe the impact of expert geriatric care on patient care and health system outcomes, and propose methods to improve recruitment and retention for geriatric medicine.

To provide policy recommendations for managing Coronavirus 19 (COVID-19) in skilled nursing facilities, a group of certified medical directors from several facilities in New York state with experience managing the disease used e-mail, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, protection of staff, screening of residents, management of Coronavirus 19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Patients often transition between health care settings, such as office to hospital, hospital to nursing facility, or hospital to home. When a patient is admitted, it is imperative that clinicians review prior medication lists along with new orders to reconcile any discrepancies. This process should occur in a standardized manner to reduce medication errors leading to adverse events and patient harm., Methods: We developed this program as an instructional method via PowerPoint to teach the importance of accurate medication reconciliation. We implemented the program in multiple grand rounds settings with students, trainees, and attending physicians in internal medicine and surgery. Approximately 150 learners attended the sessions. We assessed learners with pre/post self-efficacy assessment (74 completed precourse surveys, 39 completed posttest surveys, and 49 participated in the audience response during the course) and multiple-choice knowledge questions., Results: The results of the postcourse knowledge assessment demonstrated improvement in every question we tested, with two of the improvements reaching statistical significance. We found that 30% of attendees were not at all confident or only somewhat confident in conducting an appropriate medication reconciliation on admission to the hospital. Additionally, 82% of respondents reported that the presentation was likely or extremely likely to improve their medication reconciliation efforts., Discussion: Our educational program was successful in improving learners' knowledge in every question we tested; however, only two of the improvements were statistically significant. Our program is an organized and effective tool for teaching effective and reliable medication reconciliation., Competing Interests: None to report., (Copyright © 2019 Lester et al.)

Objective: To describe the current landscape of palliative care (PC) in nursing homes (NHs) in New York State (NYS)., Measurements: A statewide survey was completed by 149 respondents who named 61 different NHs as their workplace. Questions were related to presence, type, and composition of PC programs; perceptions of PC; barriers to implementing PC; and qualifying medical conditions., Results: Hospice is less available than palliative or comfort care programs, with three-fourths of NYS NH responded providing a PC program. In general, medical directors and physicians were more similar in perspective about the role/impact of PC compared to nursing and others. There was general agreement about the positive impact and role of PC in the NH. Funding and staffing were recognized as barriers to implementing PC., Conclusion: There is growing penetration of PC programs in NH facilities in NYS, with good perception of the appropriate utilization of PC programs. Financial reimbursement and staffing are barriers to providing PC in the NH and need to be addressed by the health-care system.

This project aimed to improve pain management through clinician education, updated assessment tools, computer resources, and improved ordering and delivery systems. Clinicians were surveyed and results analyzed using Wilcoxon-Mann-Whitney testing and χ 2 testing. Prescribing patterns were evaluated by comparing proportions of prescription orders and dose intervals. Cochran-Armitage Trend Test was used for linear trends in proportion of prescription orders over time. Knowledge scores improved significantly for nurses ( P = .004) and nurse practitioners/physician assistants ( P < .0001). Patient surveys showed a reduction in the percentage of patients dissatisfied with pain control. There was a decrease of 3.6% in intramuscular orders of opioids ( P < .0001). A significant reduction was found in the percentage of orders of potentially high initial doses of opioids of hydromorphone and morphine after implementing an electronic alert. This project demonstrates that a comprehensive educational strategy with improved assessment tools, clinical resources, and educational programming can have a significant impact on pain management.

Objective: To describe rates and policies in U.S. Nursing Homes (NH) related to palliative care, comfort care, and hospice care based on a nationwide survey of directors of nursing., Measurements: A national survey was distributed online and was completed by 316 directors of nursing of NHs (11% response rate). The directors of nursing were asked about availability and policies in their facilities. Specifically, questions were related to policies, referral patterns, discussion about such care, and types of medical conditions qualifying for such services., Results: Hospice is significantly more available than palliative or comfort care programs; also, for-profit facilities, compared to non-profits, are significantly more likely to have palliative care programs and medical directors for palliative care. Social workers and nurses were most likely to suggest palliative type programs. Only 42% of facilities with palliative program provide consultation by a palliative certified physician. Residents with non-healing pressure ulcers, frequent hospitalizations, or severe/uncontrolled pain or non-pain symptoms were less likely to be referred., Conclusions: There is limited availability of palliative type programs in NH facilities and underutilization in those NH with programs., (© The Author(s) 2014.)

Objective: To identify nursing home (NH) standards related to sexual activity and sexual relationships for residents through a nationwide survey of directors of nursing (DONs)., Methods: A national survey was distributed online and was completed by 366 DONs of skilled nursing facilities. The DONs answered questions concerning policies and experiences related to sexual activities of their residents including types of resident sexual activity they have encountered, perceptions about residents with dementia engaging in sexual activity, and policies pertaining to sexual activity including masturbation., Results: The results of the survey demonstrated that the vast majority (71.2%) indicated that there had been issues regarding residents' sexual activities in their facilities with over one-half (58%) of the DONs reporting situations of resident with resident sexual activity and 60% with situations of resident masturbation. More than one-half (56.6%) require a family or designated representative to approve sexual activity for a cognitively impaired resident. For a cognitively intact resident, 12.4% of facilities still require family or designated representative to approve sexual activity. However, despite the prevalence of sexual activity, the majority of NHs (63.4%) actually do not have policies dealing with resident sexual activity. Of the NHs with policies, 58.6% have written policies in place, with 11.2% requiring a physician order to allow sexual activity and 9.5% requiring a physician order to restrict sexual activity., Conclusions: Issues related to sexual activity in NH residents are quite prevalent, however, the rates of policies related to sexual activity are low and the policies and restrictions are not uniform. Our study suggests nursing homes should have a clear policy addressing resident sexual activity. It would be beneficial for such a policy to be communicated to residents and their families as part of an admission package instead of waiting for sexual interest to be noticed. This would enable residents to engage in sexual activity with understanding and support rather than hiding., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: A computerized physician order entry (CPOE) system provides opportunity for real-time alerts to prescribers. Winthrop University Hospital began using CPOE in 2009., Objective: We sought to improve prescribing among older hospitalized patients by adding alerts to the CPOE system for potentially inappropriate medications., Methods: In January 2011, informational alerts were integrated into the CPOE system for selected high-risk medications: diphenhydramine, metoclopramide, and all antipsychotics. We evaluated the effect of these alerts on prescribing frequency by comparing the number of prescriptions during the second quarters of 2010 ("pre-alert") with the second quarters of 2011 through 2013 ("post-alert"). Prescribing patterns were evaluated through a pharmacy database of medication orders. Frequency of prescribing was adjusted for total discharges. A comparison was made to ages 18-64 years, and comparing "as needed" vs standing orders., Results: In the 65 years of age and older group, there were significant reductions in prescription rates pre-alert vs post-alert for diphenhydramine (p < 0.001) and metoclopramide (p < 0.001). There was no decrease in prescription rates for antipsychotics in older patients (p = 0.80). In the younger comparison group, no decreases in prescription rates for those drugs were observed. Our analysis is based on numbers of written prescriptions and not actual doses administered; therefore, no conclusions concerning the effect of these alerts on communication or documentation of risk/benefits of these medications can be ascertained., Conclusion: The data suggest that prescribing rates for drugs with the least efficacy and potential for harm and with alternative agents (i.e., diphenhydramine and metoclopramide) can be modified by CPOE alerts for older patients.

Purpose: To assess the impact of the current curriculum for physician assistant (PA) students in palliative medicine and end-of-life care., Methods: PA students were invited to participate in an anonymous online survey evaluating seven domains of knowledge in palliative medicine coupled with a self-assessment in competence. Participants were also asked to identify current and desired educational formats in palliative medicine education. There were 1,313 emailed surveys with 139 total responses., Results: Our results demonstrate that a year of clinical training only resulted in minimal improvement in factual knowledge. This suggests that there is insufficient exposure to palliative medicine education during their clinical training., Conclusion: PA students recognize their knowledge gaps and lack of exposure in palliative medicine. A more focused curriculum is needed in training experiences for PA students.

The purpose of this study is to determine the prevalence of tobacco use in patients diagnosed with dementia or cognitive impairment in an outpatient setting as they may be unsafe smokers and present safety risks to themselves and others. We conducted a retrospective chart review of new patients between 1/06 and 8/07 who were diagnosed with dementia or cognitive impairment in a geriatric outpatient practice. The data collected included age, gender, tobacco use patterns and mini-mental state examination (MMSE) score. Data was analyzed using SAS 9.1 for Windows (SAS Institute, Cary, NC). Former tobacco use rates in our study were similar to nationwide published rates for elderly over 65 (39.9% vs. 39.5%, respectively, p=0.99). However, only two patients in our study (1.32%, 95%CI=0.16-4.70) were current tobacco users compared with published census data that 10.2% of those over 65 are current smokers nationwide (p<0.001). Our study revealed a much lower rate of current tobacco use in our series of cognitively impaired patients. Further research is needed to explore the reasons for decreased smoking in those with cognitive impairment and its clinical implications., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The Accreditation Council for Graduate Medical Education requires that internal medicine (IM) core curricula include end-of-life care and pain management concepts and that fellows in hematology/oncology, pulmonary/critical care, and geriatrics should receive formal instruction and clinical experience in palliative and end-of-life care. We aimed to assess the effectiveness of current teaching methods for housestaff in these fields., Method: All of the IM residents, geriatric medicine fellows, hematology/oncology fellows, and pulmonary/critical care fellows from four regional graduate medical education sites were asked to participate in an online survey at the beginning and end of the 2008-2009 academic year. We evaluated seven domains of knowledge of palliative care and pain management with a self-assessment of competence in these areas. We also asked participants to describe their current curriculum and training in palliative medicine., Results: There were 326 e-mailed survey invitations. There were 180 responses for the start-year survey and 102 responses for the end-year survey. All sites were represented in the responses. The only learners to significantly improve their palliative knowledge during a year of training were PGY-1s and PGY-4s. The majority of housestaff surveyed report that their current palliative medicine training is inadequate. The vast majority (84.6%) said a dedicated palliative medicine rotation would be "useful" or "very useful.", Conclusions: Housestaff recognize their lack of experience and training in palliative medicine and are interested in many teaching venues to improve their skills. A more focused curriculum in palliative and end-of-life care is required at both resident and subspecialty fellowship levels.

The palliative medicine literature consistently documents that physicians are poorly prepared to help patients experience a "good death" and are often unaware of their ill patients' preferences for end-of-life care. The present study, enrolling 150 physicians, sought to improve their communication skills for end-of-life care. We found significant attitudinal changes and a greater degree of self-rated competence in delivering end-of-life care for those in the intervention group. This study used a novel approach to train physicians to be better equipped to conduct difficult goals of care conversations with patients and their families at end-of-life.

Delusions, hallucinations and other psychotic symptoms can accompany a number of conditions in late life. As such, elderly patients are commonly prescribed antipsychotic medications for the treatment of psychosis in both acute and chronic conditions. Those conditions include schizophrenia, bipolar disorder, depression and dementia. Elderly patients are at an increased risk of adverse events from antipsychotic medications because of age-related pharmacodynamic and pharmacokinetic changes as well as polypharmacy. Drug selection should be individualized to the patient's previous history of antipsychotic use, current medical conditions, potential drug interactions, and potential side effects of the antipsychotic. Specifically, metabolic side effects should be closely monitored in this population. This paper provides a review of aripiprazole, a newer second generation antipsychotic agent, for its use in a variety of psychiatric disorders in the elderly including schizophrenia, bipolar disorder, dementia, Parkinson's disease and depression. We will review the pharmacokinetics and pharmacodynamics of aripiprazole as well as dosing, diagnostic indications, efficacy studies, and tolerability including its metabolic profile. We will also detail patient focused perspectives including quality of life, patient satisfaction and adherence.

Objective: To identify nursing home standards related to items brought in from the community for residents through a nationwide survey of directors of nursing. Specifically we examined the policies with regard to food, cigarettes, alcoholic beverages, and over-the-counter medications., Methods: A national survey was distributed online and was completed by 299 directors of nursing of skilled nursing facilities. The directors of nursing were asked about policies regarding whether family and friends of residents are permitted to bring in items such as food, cigarettes, alcohol, and over-the-counter medications. Specifically, questions were related to monitoring, staff involvement, safety precautions, and policy implementation., Results: The results of the survey demonstrated a consistent policy practiced among facilities. Items commonly restricted for all residents included over-the-counter medications, alcohol, and cigarettes. On the other hand, food was significantly less likely to be restricted., Conclusion: Despite overall strict policies regarding the monitoring of access to over-the-counter medications, alcohol, and cigarettes by nursing home residents, ingestion of outside food remains fairly unrestricted. This is especially concerning given the growing number of residents with end-stage congestive heart failure, diabetes, dysphagia, or food allergies where access to outside food could result in an adverse event. Perhaps, facilities need to identify at-risk residents and better communicate to residents and their families regarding dietary restrictions on outside food.

The impact of parental substance use on the emotional and behavioral adjustment of their adolescent children was examined over 5 years. A representative sample of 220 parents with HIV (PWH) and 330 adolescent children in New York City were repeatedly assessed. Some parents never used marijuana or hard drugs over the 5 years (nonusers). Among those who were users, substance use varied over time. PWH who used substances during a specific 3-month period were classified as active users and those who abstained from substance use were classified as inactive users. Longitudinal regression analyses were used to analyze the impact of variations in patterns of substance use over time on their adolescent children's emotional adjustment and behavioral problems. PWH relapse exacerbated adolescent substance use, trouble with peers, and adolescent emotional distress. Even time-limited reductions in parents' substance abuse can have a significant positive impact on their adolescent children's emotional and behavioral adjustment. Interventions that address parental substance use among PWH should be developed to ameliorate the impact of substance use relapse on their adolescents.

Previous research has been conducted regarding preferences of physicians for life-sustaining treatments for themselves, but there is a dearth of data on personal use of advance directives (ADs) by geriatricians specifically. Using a phone survey, we contacted all graduates of the geriatric fellowship program to assess their personal use of advance directives and their personal preferences for life-sustaining treatment. Of the 124 living graduates of the Parker Jewish Institute for Health Care and Rehabilitation, 70 agreed to participate. One third of respondents had established ADs for themselves, with higher rates in women than men (p = .054). Older geriatricians were significantly more likely to have advance directives (exact trend test yields, p < .0001). In general, respondents did not inform their health care providers about their desires for end-of-life care. This study revealed that the majority of fellowship-trained geriatricians did not formally establish advance directives for themselves. Further research is needed to determine whether physicians who establish advance directives for themselves are more likely to encourage their patients to do so.

Objective: To identify nursing home standards related to resident smoking through a nation wide survey of directors of nursing., Methods: A national survey was distributed online and was completed by 248 directors of nursing. The directors of nurses answered questions concerning resident smoking including the criteria utilized to determine an unsafe resident smoker. For those residents identified as unsafe, the questions asked were specifically related to monitoring, staff involvement, safety precautions and policy., Results: The results of the survey demonstrated a consistent policy practiced among facilities across the United States. The monitoring of nursing home residents is based on a resident's mental acuity, physical restrictions and equipment requirements. Once a resident was identified as a smoker at risk of harm to self or others, staff involvement ranged from distributing cigarettes to direct supervision. In addition, the majority of facilities required residents to wear fire resistant aprons and provided a fire extinguisher in smoking areas., Conclusion: Monitoring policies of nursing home residents who smoke starts with identifying those residents at risk based on an assessment of mental acuity, physical restrictions and equipment requirements. Those that are identified as being at risk smokers have their cigarettes controlled and distributed by nursing staff and are supervised by facility staff when smoking. This policy is implemented through written policy as well as staff education. Despite some discrepancies in the actual implementation of policies to supervise residents who smoke, the policies for assessment for at-risk smokers requiring monitoring is consistent on a national basis.

We report a case of second- and third-degree burns in an elderly nursing home resident with dementia who was smoking in her room. This case highlights the risks of smoking by residents in long-term care settings. It also raises awareness to the issues involving smoking cessation and restriction of smoking privileges in the long-term care setting.