Functional outcomes and quality of life in patients with brain tumors: a preliminary report.

OBJECTIVES: To determine the relationship between functional outcome and quality of life (QOL) in patients with brain tumors receiving inpatient rehabilitation, and to assess the sensitivity of 4 assessment tools in measuring changes in that population. DESIGN: Prospective study using longitudinal data collected from consecutively admitted patients. SETTING: Acute inpatient rehabilitation unit. PARTICIPANTS: Ten patients with primary brain tumors admitted to an acute inpatient rehabilitation unit. INTERVENTIONS: Patients participated in an inpatient interdisciplinary rehabilitation program that used the following disciplines: occupational therapy, rehabilitation therapy, recreational therapy, speech therapy, physical therapy, rehabilitation nursing and case management. MAIN OUTCOME MEASURES: The FIM instrument, Disability Rating Scale (DRS), Karnofsky Performance Status Scale (KPS), Functional Assessment of Cancer Therapy-Brain (FACT-BR). RESULTS: Improvement in total functional outcome was indicated by all 3 functional measures (FIM: F = 46.84, p < .05; DRS: F = 19.25, p < .05; KPS: F = 10.11, p < .05). Significant improvements were found between admission and discharge scores for the FIM and DRS. The KPS revealed significant improvement between admission and 3-month follow-up scores. All admission and discharge functional scales (FIM, DRS, KPS) correlated significantly with each other. No significant change was noted in the FACT-BR between admission and discharge scores, but FACT-BR scores did improve at 1- and 3-months postdischarge relative to admission. The FIM, KPS, and DRS did not show significant correlation with the FACT-BR. Ninety percent of patients were initially discharged to a home environment. CONCLUSION: Although patients make functional gains during and after inpatient rehabilitation, gains in QOL are not significant until 1 month postdischarge. QOL does not appear to correlate well with functional outcomes. Further, the KPS is less sensitive than the FIM and DRS in detecting change in functional status.     

The kitchen as therapy: qualitative assessment of an integrative cuisine workshop for patients undergoing chemotherapy

Objective

Patients undergoing chemotherapy frequently suffer from gastrointestinal (GI) symptoms and functional difficulties in preparing and eating meals. We conducted a qualitative assessment of an integrative cuisine workshop program designed for patients receiving chemotherapy, examining the effects of the program on patient-reported GI symptoms and nutritional challenges.

Patients and methods

Patients were referred to a complementary/integrative medicine (CIM)-trained physician for consultation, followed by a patient-tailored treatment program. Patients with GI-related symptoms and nutritional concerns were offered a two-session integrative cuisine workshop program. The effects of the workshops were examined using inductive and deductive qualitative research methodologies. Patient narratives, as recorded in the Measure Yourself Concerns and Wellbeing (MYCAW) study tool, and electronic medical files were analyzed.

Results

Of 125 patients referred to the integrative cuisine program, 86 participated in at least one workshop. Participants and non-participants had similar demographic and disease-related characteristics, as well as quality-of-life (QOL)-related concerns. Inductive analysis suggested that participation in the workshops was helpful in developing social relationships, providing emotional support, and enhancing spirituality and nutritional awareness. Implementing the recommended changes at home led to improved QOL-related outcomes. The predominant themes derived from deductive analysis were the implementation of dietary changes and improved gastrointestinal and emotional issues.

Conclusions

Chemotherapy-treated patients participating in an integrative cuisine workshop program showed improved QOL outcomes, specifically GI and emotional-related symptoms, and a reduction in nutritional and functional concerns. Increased knowledge and awareness of nutrition and supplement use ultimately resulted in implementation of the CIM recommendations by patients at home.

     

Benefits of an inpatient pulmonary rehabilitation program: a prospective analysis

OBJECTIVE: To examine the effect of an inpatient pulmonary rehabilitation program on functional outcome, supplemental oxygen use, quality of life (QOL), and rehospitalization. DESIGN: A prospective study. SETTING: Inpatient pulmonary rehabilitation unit. PATIENTS: One hundred fifty-seven patients with moderate to severe chronic obstructive pulmonary disease (COPD) admitted to an inpatient pulmonary rehabilitation program over a 3-year period. INTERVENTION: Comprehensive interdisciplinary inpatient pulmonary rehabilitation program with an average length of stay of 21 days. MAIN OUTCOME MEASURES: Improvements in QOL questionnaire scores, COPD knowledge questionnaire scores, 6-minute walking test (with 3 ambulation categories: bed-bound, household ambulators, community ambulators), and supplemental oxygen use. Rehospitalization 1 year after completion of the program was also assessed and compared with hospital days for the year before the program. RESULTS: On discharge from the program, 88% of individuals walked farther (p <.0001), and community ambulators doubled their walking distance, whereas bed-bound patients decreased 10-fold; supplemental oxygen use dropped 33% during the day (p <.0001) and 57% during the night (p <.0001); 82% showed improved QOL (p <.0001); 67% showed improved knowledge of COPD (p <.0001); and 67% of the sample spent less time in the hospital during the 12 months after program completion compared with the 12 months before admission (p <.001). CONCLUSIONS: An inpatient pulmonary rehabilitation program leads to improved endurance and functional ambulation, decreased supplemental oxygen use, and fewer hospitalizations 1 year after discharge for patients with COPD.     

Evaluation of the Centers for Disease Control and Prevention's Recommendations Regarding Routine Testing for Human Immunodeficiency Virus by an Inpatient Service: Who Are We Missing?

OBJECTIVE: To assess the proportion of hospitalized patients who tested positive for human immunodeficiency virus (HIV) by a routine inpatient testing service, as recommended by the Centers for Disease Control and Prevention, who might not have been identified had routine testing not been offered. PATIENTS AND METHODS: In this retrospective cohort study, the medical records of patients who tested HIV positive by the inpatient testing service between 1999 and 2003 were compared with the medical records of inpatients who tested HIV negative by the inpatient testing service and the medical records of patients who tested HIV positive in ambulatory settings. We compared HIV risk factors, discharge diagnoses, CD4 cell counts, and HIV RNA concentrations. RESULTS: A total of 243 patients participated in this study: 81 patients who tested HIV positive and 81 who tested HIV negative by the inpatient testing service, and 81 patients who tested HIV positive in ambulatory settings. Both HIV-positive inpatients and HIV-positive outpatients had similar frequencies of HIV risk factors (46% vs 43%; P=.75). Both groups differed significantly from HIV-negative inpatients (4%; P<.001). Comparing HIV-positive inpatients with HIV-positive outpatients, CD4 cell counts were lower (196 vs 371 cells/mm3; P<.001), and HIV RNA levels were higher (4.61 vs 4.09 Iog, HIV RNA; P=.001). At diagnosis, 64 HIV-positive inpatients (79%) met criteria for acquired immunodeficiency syndrome compared with 21 HIV-positive outpatients (26%) (P<.001). CONCLUSION: Patients who tested HIV positive through inpatient testing have more advanced disease than those identified as outpatients. Half of these patients would not have been identified had testing not been routinely offered. Routine inpatient HIV testing offers an important opportunity to identify patients with HIV infection.     

Interrater reliability of the Observer Rating of Medication Taking scale in an inpatient mental health facility

Non‐adherence to medication remains a major barrier to recovery from mental illnesses. Identification of those patients likely to experience adherence difficulties is best undertaken during inpatient treatment, prior to discharge into the community. More objective assessments of adherence behaviours might assist staff to more effectively target support to those patients most in need. This study investigated the interrater reliability of an inpatient behavioural observation scale of patient engagement with medication: the Observer Rating of Medication Taking (ORMT) scale. Eight mental health nurses working in a psychiatric hospital inpatient setting were trained in the use of the ORMT using video‐based vignettes. Working in pairs, staff then independently rated adherence behaviours of 13 inpatients in a rehabilitation unit (total of 160 ratings) over a 1‐week period. Concurrently, two expert raters also undertook independent ratings of patient medication‐taking behaviour using the ORMT. Interrater reliability was assessed across both staff and expert raters. The results indicated that the ORMT has satisfactory interrater reliability, and can be appropriately used in an inpatient setting. The observational location of raters on the ward influenced the range of medication‐taking behaviours observed, and thus the extent of concordance between raters. Further research to determine if the ORMT predicts adherence in the community is warranted.     

Medically supervised water-only fasting in the treatment of borderline hypertension

BACKGROUND: Hypertension-related diseases are the leading causes of morbidity and mortality in industrially developed societies. Surprisingly, 68% of all mortality attributed to high blood pressure (BP) occurs with systolic BP between 120 and 140 mm Hg and diastolic BP below 90 mm Hg. Dietary and lifestyle modifications are effective in the treatment of borderline hypertension. One such lifestyle intervention is the use of medically supervised water-only fasting as a safe and effective means of normalizing BP and initiating health-promoting behavioral changes. METHODS: Sixty-eight (68) consecutive patients with borderline hypertension with systolic BP in excess of 119 mm Hg and diastolic BP less than 91 mm Hg were treated in an inpatient setting under medical supervision. The treatment program consisted of a short prefasting period (approximately 1-2 days on average) during which food consumption was limited to fruits and vegetables followed by medically supervised water-only fasting (approximately 13.6 days on average). Fasting was followed by a refeeding period (approximately 6.0 days on average). The refeeding program consisted of a low-fat, low-sodium, plant-based, vegan diet. RESULTS: Approximately 82% of the subjects achieved BP at or below 120/80 mm Hg by the end of the treatment program. The mean BP reduction was 20/7 mm Hg, with the greatest decrease being observed for subjects with the highest baseline BP. A linear regression of BP decrease against baseline BP showed that the estimated BP below which no further decrease would be expected was 96.0/67.0 mm Hg at the end of the fast and 99.2/67.3 mm Hg at the end of refeeding. These levels are in agreement with other estimates of the BP below which stroke events are eliminated, thus suggesting that these levels could be regarded as the "ideal" BP values. CONCLUSION: Medically supervised water-only fasting appears to be a safe and effective means of normalizing BP and may assist in motivating health-promoting diet and lifestyle changes.     

健康素养对冠心病患者心脏相关生活方式依从性改变的影响

目的 探析冠心病患者健康素养对其住院前和出院后六个月的心脏相关生活方式依从性变化的影响。 方法 采用方便抽样的方法调查了589例冠心病患者的健康素养及其入院前和出院后六个月心脏相关生活方式依从性。 结果 根据冠心病患者心脏相关生活方式依从性改变的情况，将其分为持续不依从组/下降至不依从组（9.76%）、改善至依从组（37.63%）和持续依从组（52.61%）；多项Logistic回归显示，健康素养每提高5分，患者在持续不依从组/下降至不依从组的可能性是持续依从组的0.80倍（95%CI 0.66-0.96）。 结论 健康素养对冠心病患者心脏相关生活方式依从性改变有一定预测作用，提示护理人员应关注患者健康素养，给予有针对性的健康教育。     

The relationship between inpatient discharge timing and emergency department boarding

Background

Patient crowding and boarding in Emergency Departments (EDs) impair the quality of care as well as patient safety and satisfaction. Improved timing of inpatient discharges could positively affect ED boarding, and this hypothesis can be tested with computer modeling.

Study Objective

Modeling enables analysis of the impact of inpatient discharge timing on ED boarding. Three policies were tested: a sensitivity analysis on shifting the timing of current discharge practices earlier; discharging 75% of inpatients by 12:00 noon; and discharging all inpatients between 8:00 a.m. and 4:00 p.m.

Methods

A cross-sectional computer modeling analysis was conducted of inpatient admissions and discharges on weekdays in September 2007. A model of patient flow streams into and out of inpatient beds with an output of ED admitted patient boarding hours was created to analyze the three policies.

Results

A mean of 38.8 ED patients, 22.7 surgical patients, and 19.5 intensive care unit transfers were admitted to inpatient beds, and 81.1 inpatients were discharged daily on September 2007 weekdays: 70.5%, 85.6%, 82.8%, and 88.0%, respectively, occurred between noon and midnight. In the model base case, total daily admitted patient boarding hours were 77.0 per day; the sensitivity analysis showed that shifting the peak inpatient discharge time 4 h earlier eliminated ED boarding, and discharging 75% of inpatients by noon and discharging all inpatients between 8:00 a.m. and 4:00 p.m. both decreased boarding hours to 3.0.

Conclusion

Timing of inpatient discharges had an impact on the need to board admitted patients. This model demonstrates the potential to reduce or eliminate ED boarding by improving inpatient discharge timing in anticipation of the daily surge in ED demand for inpatient beds.     

延续性护理对精神分裂症患者服药依从性和康复状态的影响

目的：探索日间康复中心的延续性护理对康复期精神分裂症患者服药依从性和康复状态的影响。方法：将即将出院的80例康复期精神分裂症患者随机分为干预组(40例)和对照组(40)例,对照组接受常规出院指导,干预组出院后进入日间康复中心,除了接受常规出院指导外,还参加6个月日间康复中心的延续性康复护理干预。对两组患者在出院前、6个月时均采用Morisky问卷、Morningside康复状态量表进行评估。结果：干预组在6个月时Morisky评分显著低于对照组(P < 0.01);6个月时干预组的Morningside康复状态量表总分及依赖、社交及症状和行为维度分值降低幅度大于对照组(P < 0.05),活动能力维度分值降低幅度显著小于对照组(P < 0.05)。结论：日间康复中心延续性护理显著提高了精神分裂症患者的服药依从性,提高了患者的总体康复水平及其社会交往能力,降低了其依赖性,减少了心理行为症状;患者的活动能力还有待进一步提高。     

Process of care in Hispanic,black, and white VA beneficiaries

OBJECTIVE: To examine whether process of hospital care differs among Hispanic, black, and white VA beneficiaries. SUBJECTS: Two thousand eight-hundred fifty-two Hispanic, black, and white male VA beneficiaries from a case-control study discharged alive from one of twelve southern veterans hospitals with one of three diagnoses, diabetes mellitus (DM), congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). METHODS: We applied diagnosis-specific explicit criteria for the process of hospital care to each patient's hospital record and computed the adherence score; the percentage of applicable criteria performed during the hospital stay. We compared mean scores in Hispanic, black, and white patients and then compared adjusted scores using multiple linear regression. MAIN OUTCOME MEASURE: Process of inpatient care (adherence score) in Hispanic, black, and white patients at admission, treatment, and discharge. RESULTS: Mean admission adherence scores differed (P = 0.003) among Hispanic patients, black patients, and white patients for CHF and COPD, but not DM. Mean treatment and discharge scores were not different among Hispanic patients, black patients, and white patients. In bivariate comparisons, mean admission scores were higher in black patients compared with white patients for CHF (P= 0.003) and COPD (P= 0.01). In stratified analyses, admission and treatment scores were higher (P= 0.0001) in patients admitted to teaching compared with nonteaching hospitals. Process of inpatient care did not differ among Hispanic, black, and white patients after adjusting for admission to a teaching hospital and other covariates. CONCLUSION: In contrast to findings in other studies, process of inpatient care was generally similar in Hispanic patients, black patients, and white patients. Our findings may reflect several characteristics of veterans' hospitals that may lead to care that is more equitable.     

Medically supervised water-only fasting in the treatment of hypertension.

BACKGROUND: Hypertension-related diseases are the leading cause of morbidity and mortality in industrially developed societies. Although antihypertensive drugs are extensively used, dietary and lifestyle modifications also are effective in the treatment of patients with hypertension. One such lifestyle intervention is the use of medically supervised, water-only fasting as a safe and effective means of normalizing blood pressure and initiating health-promoting behavioral changes. METHODS: One hundred seventy-four consecutive hypertensive patients with blood pressure in excess of 140 mm Hg systolic, 90 mm Hg diastolic (140/90 mm Hg), or both were treated in an inpatient setting under medical supervision. The treatment program consisted of a short prefasting period (approximately 2 to 3 days on average) during which food consumption was limited to fruits and vegetables, followed by medically supervised water-only fasting (approximately 10 to 11 days on average) and a refeeding period (approximately 6 to 7 days on average) introducing a low-fat, low-sodium, vegan diet. RESULTS: Almost 90% of the subjects achieved blood pressure less than 140/90 mm Hg by the end of the treatment program. The average reduction in blood pressure was 37/13 mm Hg, with the greatest decrease being observed for subjects with the most severe hypertension. Patients with stage 3 hypertension (those with systolic blood pressure greater than 180 mg Hg, diastolic blood pressure greater than 110 mg Hg, or both) had an average reduction of 60/17 mm Hg at the conclusion of treatment. All of the subjects who were taking antihypertensive medication at entry (6.3% of the total sample) successfully discontinued the use of medication. CONCLUSION: Medically supervised water-only fasting appears to be a safe and effective means of normalizing blood pressure and may assist in motivating health-promoting diet and lifestyle changes.     

Rehabilitation Outcomes of Children with Cerebral Palsy

[Purpose] To evaluate the results of Bobath-based rehabilitation performed at a pediatric cerebral palsy (CP) inpatient clinic. [Subjects and Methods] The study subjects were 28 children with CP who were inpatients at a pediatric service. Inclusion criteria were: being an inpatient of our hospital aged 2–12 with a diagnosis of CP; having one permanent primary caregiver; and the caregiver having no medical or psychotic problems. All of the patients received Bobath treatment for 1 hour per day, 5 days a week. The locomotor system, neurologic and orthopedic examination, Gross Motor Function Measure (GMFM) of the patients, and Short Form-36 (SF-36) of permanent caregivers were evaluated at the time of admission to hospital, discharge from hospital, and at 1 and 3 months after discharge. [Results] Post-admission scores of GMFM at discharge, and 1 and 3 months later showed significant increase. Social function and emotional role subscores of SF-36 had increased significantly at discharge. [Conclusion] Bobath treatment is promising and randomized controlled further studies are needed for rehabilitation technics.Key words: Cerebral palsy, Rehabilitation, Bobath     

A descriptive study of psychiatric disorders and psychosocial burden in rehabilitation patients with musculoskeletal diseases

OBJECTIVE: To investigate current, 12-month, and lifetime prevalence rates, and associated psychosocial burden of psychiatric disorders in rehabilitation inpatients with musculoskeletal diseases. DESIGN: Two-stage epidemiologic survey. SETTING: Four orthopedic rehabilitation inpatient clinics in southwest Germany. PARTICIPANTS: A total of 910 inpatients with different musculoskeletal diseases participated in the survey. According to their General Health Questionnaire-12 scores, 205 patients were selected randomly for standardized interviews. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Psychosocial burden (Hospital Anxiety and Depression Scale, Lübeck Alcoholism Screening Test) and quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey), assessment of diagnosis and somatic parameters through standardized medical records. Clinical interview (Munich Composite International Diagnostic Interview) in the second-stage examination to obtain Diagnostic and Statistical Manual of Mental Disorders (4th edition) diagnoses of psychiatric disorders. RESULTS: Prevalence rates of psychiatric disorders are 31.1% for the 4-week period, 47.1% for the 12-month period, and 64.6% for the lifetime period. The most prevalent current disorders are anxiety (15%), affective (10.7%), and substance-related disorders (9.2%). Half of the comorbid ill patients have 2 or more simultaneous psychiatric disorders and report elevated levels of psychosocial burden (eg, intense pain, low quality of life, more days of sick leave). CONCLUSIONS: Patients undergoing musculoskeletal rehabilitation should be assessed carefully for comorbid psychiatric illnesses. Further research should be undertaken to evaluate the effectiveness of psychosocial interventions for comorbid psychiatric disorders on life quality, therapeutic compliance, and outcome of rehabilitation treatment.     

2周住院心脏康复程序对急性心肌梗死患者血脂、生存质量及精神心理状态的影响

目的：探讨2周住院心脏康复程序对急性心肌梗死（AMI）患者血脂、生存质量及精神心理状态（焦虑）的影响。方法：选择轻度AMI患者40例，随机分为对照组20例，康复组20例。对照组进行常规内科治疗．康复组在常规内科治疗的同时进行2周住院心脏康复程序治疗，出院后继续康复治疗3个月。康复前及康复3个月后分别评价血脂水平，生存质量（QOL）、状态-特质焦虑（state-trait anxiety inventory，STAI）及体力活动程度，与对照组及康复前进行比较。结果：康复前，两组间的各项指标比较差异无显著性意义。康复组，与康复前比较．康复3个月后HDL-C（P〈0．01）、TC／HDL-C（P〈0．05）均得到明显改善：康复后QOL总分和社会态度与主观幸福感评分均比康复前明显增加（P均〈0．05）；状态焦虑（S-AI）和特质焦虑（T-AI）均比康复前明显降低（P均〈0．05）；康复后体力活动程度明显改善（P〈0．01）。结论：2周住院心脏康复程序能明显改善轻度AMI患者的血脂．改善体力活动程度，改善精神心理状态（焦虑）．提高生存质量。     

Treatment recommendations in psychosomatic rehabilitation -- empirical analyses based on the pension insurers' standardized discharge report

BACKGROUND: The recommendations for aftercare listed in discharge reports represent a core component of communication between inpatient psychosomatic rehabilitation and ambulatory follow-up care. The standardized discharge report used by the pension insurance institutes makes use of a generic category system for systematization and simplification of recommendations for aftercare. Neither the practice of making recommendations for aftercare as observed by therapists and physicians responsible for treatment in the inpatient setting nor the appropriateness and differentiation of the category system has previously been systematically examined. A randomized sample of discharge reports was analyzed for this purpose. METHODS: A sample of 500 discharge reports from an inpatient-oriented psychosomatic rehabilitation setting were analyzed regarding the categories of recommended aftercare measures and their relationship with socio-demographic variables, clinical diagnosis and sociomedical variables. RESULTS: Outpatient psychotherapy represents the most frequently recommended aftercare treatment, being suggested in nearly 70% of the patients. Further substantial percentages were found in recommendations for areas including occupational rehabilitation, somatic-medical recommendations, and recommendations for health behaviour and self-help groups. In approximately one quarter of the patients, recommendations for aftercare were given that were coded under the category of "other suggestions". In younger and socio-medically burdened patients, recommendations for the fields of occupational rehabilitation and psychotherapy were more frequently given. In patients with a somatic illness or a somatoform disorder as the primary diagnosis, recommendations within the field of outpatient psychotherapy were found less frequently, while recommendations in the somatic-medical area were more commonly found. DISCUSSION: The results give some support for the clinical validity of the form of recommendations given for aftercare measures in an inpatient psychosomatic rehabilitation setting. At the same time, the analyses indicate excessive as well as insufficient differentiation in the generic category system for follow-up treatment recommendations, which could lead to a loss of valuable information at the interface between inpatient and outpatient treatments.     

Comparative cost analysis of inpatient integrative medicine—Results of a pilot study

BackgroundCosts of integrative treatment alone and in comparison with other treatment approaches have scarcely been reported in the past. This study presents results of a comparative cost analysis of an inpatient integrative medicine treatment costs.MethodsData from 2006 for inpatients referred to a Department of Integrative Medicine in Germany were used. Case-related treatment costs were calculated, and transformed into Casemix-Indices and revenues per DRG. Costs were compared between departments at the same hospital and between different hospitals using univariate statistics and Chi-Square tests.ResultsIn total 1253 inpatients (81.4% female, 61.1 ± 14.4 years) were included in the current analysis. Most patients were treated for diseases of the musculoskeletal system (57.2%), followed by diseases of the digestive system (11.4%), and diseases of the nervous system (10.4%). The department received an additional payment for most of the patients (88.0%), which led to an effective appreciation of 10.8% per case compared to the standardized Casemix-Index. In-house comparisons with other departments found the department in close vicinity to the departments of Internal medicine with regards to CMI and mean revenue, however the Patient Clinical Complexity Level was significantly lower in the Integrative medicine department. The interhospital comparison revealed comparable Casemix-Index and DRG-revenue, however the additional payment increased the mean revenue significantly.ConclusionModern integrative in-patient treatment is mostly cost-equivalent to conventional treatment. Cost effectiveness studies should be considered to further investigate the potential of integrative in patient treatment.     

Post-acute intermediate care in nursing-led units: a systematic review of effectiveness

OBJECTIVE: In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence. REVIEW METHODS: The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions. OUTCOMES: Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost. RESULTS: Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality. CONCLUSIONS: The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.     

Satisfaction with quality of life poststroke: effect of sex differences in pain response

OBJECTIVE: To study the relationship between sex differences among men and women in the response to pain and the effect on satisfaction with quality of life (QOL) in poststroke patients approximately 90 days after discharge from inpatient medical rehabilitation. DESIGN: Cross-sectional design. SETTING: Community based. PARTICIPANTS: The sample included 1724 patients (877 men, 847 women) aged 40 years and older with a history of stroke, according to information obtained from the IT HealthTrack database. The average age was 68.7 years; 79.3% were non-Hispanic white. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Satisfaction with QOL. RESULTS: Pain ratings for both the men and the women were significant and inversely associated with satisfaction with QOL after adjustments for possible confounding factors. However, among men with stroke, each 1-point increase in pain rating was associated with an 18% decreased odds of being satisfied with QOL (odds ratio [OR], .81; 95% confidence interval [CI], .77-.86). Conversely, among women with stroke, each 1-point increase in pain rating was associated with an 11% decreased odds of being satisfied with QOL (OR=.89; 95% CI, .84-.95). CONCLUSIONS: Our data indicate that pain after stroke is significantly associated with reduced satisfaction with QOL, particularly among men. Increased awareness and treatment of pain may improve satisfaction with QOL. Our findings suggest that sex differences and pain response are clinically important factors in examining satisfaction with QOL in the poststroke population.     

Therapeutische Empfehlungen in einer pädiatrischen Schmerzambulanz

Background

Supplementary pain-related recommendations for the treatment of chronic pain in children and adolescents are an essential component of multimodal pain treatment. Studies are scarce regarding adherence to these recommendations and their effectiveness.

Objective

The aim of this study was to evaluate patient adherence to pain-related recommendations and their effectiveness 12 months after initial presentation of children and adolescents with chronic pain to a pediatric outpatient pain clinic.

Materials and methods

A total of 413 patients were assessed using a structured telephone interview. The assessment included pain characteristics during the last 4 weeks as well as information regarding the implementation of the pain-related recommendations and the effectiveness. Due to different recommendations given to migraine patients this subgroup was dealt with separately.

Results

Patients reported significant improvements 12 months after the initial presentation and 29.5?% of the patients were pain free. Adherence levels and estimated effectiveness regarding recommendations, such as change of lifestyle, multimodal inpatient treatment and use of medication were high. Other recommendations, such as active relaxation and outpatient psychotherapy had low adherence levels and low estimated effectiveness. Migraine patients had a significantly higher adherence rate and estimated effectiveness regarding the recommendation use of medication than non-migraine patients.

Conclusion

The adherence level as well as the estimated effectiveness regarding the majority of pain-related recommendations was high. Some recommendations had low adherence rates and low estimated effectiveness. These results can help to further improve the performance of outpatient clinics for children and adolescents with chronic pain.

     

Assessment of compliance with lipid guidelines in an academic medical center

BACKGROUND: The importance of achieving a low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL in patients with coronary artery disease (CAD) or cerebrovascular disease (CVD) is well established. Emerging evidence supports the recognition and management of secondary lipid goals, high-density lipoprotein cholesterol (HDL-C) level greater than 40 mg/dL, and triglyceride level less than 150 mg/dL. OBJECTIVE: To evaluate whether inpatient services within an academic setting were achieving/addressing primary and secondary lipid goals in patients with established CAD or CVD. METHODS: Patients with a discharge diagnosis of acute myocardial infarction, myocardial revascularization procedures, and/or ischemic stroke were identified. A retrospective chart review was done to assess adherence to the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for lipid management. RESULTS: On average, 63% of patients with CAD or CVD had a lipid panel assessed during their hospitalization. Of the patients who had a fasting lipid panel checked, only 40% (72/178) had an LDL-C level less than 100 mg/dL. Of those patients, only 31% (22) also had an HDL-C level greater than 40 mg/dL. Even fewer patients (24%; 17) met both primary and secondary goals. Of the 287 patients included in the study, 69% (199) were prescribed a statin, 3% (9) a fibrate, and 3% (8) niacin on discharge. CONCLUSIONS: Few patients with CAD or CVD met the AHA/ACC goals for lipid management, yet a significant number were not prescribed appropriate lipid-lowering therapy at discharge. This finding strongly suggests that more awareness in this area is needed.