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Clinical depression affects approximately 15% of community-dwelling older adults, of which half of these cases present in later life. Falls and depressive symptoms are thought to co-exist, while physical activity may protect an older adult from developing depressive symptoms. This study investigates the temporal relationships between depressive symptoms, falls, and participation in physical activities amongst older adults recently discharged following extended hospitalization.
A prospective cohort study in which 311 older adults surveyed prior to hospital discharge were assessed monthly post-discharge for six months. N = 218 completed the six-month follow-up. Participants were recruited from hospitals in Melbourne, Australia. The survey instrument used was designed based on Fiske's behavioral model depicting onset and maintenance of depression. The baseline survey collected data on self-reported falls, physical activity levels, and depressive symptoms. The monthly follow-up surveys repeated measurement of these outcomes.
At any assessment point, falls were positively associated with depressive symptoms; depressive symptoms were negatively associated with physical activity levels; and, physical activity levels were negatively associated with falls. When compared with data in the subsequent assessment point, depressive symptoms were positively associated with falls reported over the next month (unadjusted OR: 1.20 (1.12, 1.28)), and physical activity levels were negatively associated with falls reported over the next month (unadjusted OR: 0.97 (0.96, 0.99) household and recreational), both indicating a temporal relationship.
Falls, physical activity, and depressive symptoms were inter-associated, and depressive symptoms and low physical activity levels preceded falls. Clear strategies for management of these interconnected problems remain elusive.
Introduction: Decreasing readmission rates and return emergency department (ED) visits represent a major challenge for health organizations. Seniors are especially vulnerable to discharge adverse events which can result in unplanned readmissions and loss of physical, functional and/or cognitive capacity. The ACE Collaborative is a national quality improvement initiative that aims to improve care of elderly patients. We aimed to adapt Mount Sinai’s Care Transitions program to our local context in order to decrease avoidable readmissions and ED visits among seniors. Methods: We performed a prospective pre/post implementation cohort study. We recruited frail elderly hospitalized patients (≥50 years old) discharged to home and at risk of readmission (modified LACE index score≥7/12). We excluded patients being discharged to long-term nursing homes or institutions. Our intervention is based on selected strategic ACE Care Transitions best practices: transition coach, telehealth personal response services and a structured discharge checklist. The intervention is offered to selected patients before hospital discharge. Our primary outcome is a 30-day post-discharge composite of hospital readmission and return ED visit rate. Our secondary outcomes are functional autonomy, satisfaction with care transition, quality of life, caregiver strain and healthcare resource use at recruitment and at 30-days follow-up. Hospital-level administrative data is also collected to measure global effect of practice changes. Results: The project is currently ongoing and preliminary results are available for the pre-implementation cohort only. Patients in this cohort (n=33) were mainly men (61%), aged 75±10 years and presented an OARS score (Activities of Daily Living instrument that ranges from 0-28) of 5.6±4.9. At 30 days post-discharge, the patients in our cohort had a 42.4% readmission rate (14 hospitalisations) and a 54.5% return ED visit rate (18 visits). For the same time period, readmission and return ED rates for all patients in the same corresponding age-group at the hospital level were 14.4% and 21.9%, respectively. Further results for our post-intervention cohort will be presented at CAEP 2017. Conclusion: Our cohort of elderly patients have high readmission and return ED visit rates. Our ongoing quality improvement project aims to decrease these readmissions and ED visits.
The synthesis of aluminum nitride (AlN) powders from aluminum (Al) particles via a thermal nitridation process was carried out at high temperature (>900 °C) with a long reaction time (∼several hours). This study proposes a two-stage plasma-chemical synthesis process to efficiently minimize the agglomeration of Al particles, reduce the reaction time and temperature, and promote the formation of AlN powders. In the first stage, partially nitrided Al powders were produced at temperatures lower than 600 °C in atmospheric-pressure microwave N2 plasma. The particle size of the as-prepared powders was similar to that of the original Al powders. In the second stage, the reaction temperature was increased to 700–800 °C and the reaction time was less than 5 min in N2 plasma. Well-dispersed AlN powders with almost no agglomeration were produced. Moreover, the particle size was lower than that of the original Al.
Multi-field coupling simulation method based on the physical principles is used to simulate the discharge characteristics of nanosecond pulsed plasma synthetic jet actuator. Considering the effect of the energy transferring for air, the flow characteristics of nanosecond pulsed plasma synthetic jet actuator are simulated. The elastic heating sources and ion joule heating sources are the two main sources of energy. Through the collisions, the energy of ions is transferred to the neutral gas quickly. The flow characteristics of a series of blast waves and the synthetic jet which erupt from the plasma synthetic jet (PSJ) actuator are simulated. The blast wave not only promotes outward, but also accelerates the gas mixing the inhaled gas from the outside cavity with the residual gas inside the cavity. The performances of PSJ actuator fluctuate in the first three incentive cycles and become stable after that.
In many developing countries, children with CHD are now receiving surgical repair or palliation for their complex medical condition. Consequently, parents require more in-depth discharge education programmes to enable them to recognise complications and manage their children’s care after hospital discharge. This investigation evaluated the effectiveness of a structured nurse-led parent discharge teaching programme on nurse, parent, and child outcomes in India.
Materials and methods
A quasi-experimental investigation compared nurse and parent home care knowledge before and at two time points after the parent education discharge instruction program’s implementation. Child surgical-site infections and hospital costs were compared for 6 months before and after the discharge programme’s implementation.
Both nurses (n=63) and parents (n=68) participated in this study. Records of 195 children who had undergone cardiac surgery were reviewed. Nurses had a high-level baseline home care knowledge that increased immediately after the discharge programme’s implementation (T1=24.4±2.89; T2=27.4±1.55; p<0.005; 30 point scale), but decreased to near baseline (T3=23.8±3.4; ns) 4 months after the programme’s implementation. Nurse teaching documentation increased by 56% after the programme’s implementation. Parent knowledge scores increased from 1.76±1.4 for Cohort 1 to 3.68±0.852 for Cohort 2 (p<0.005; 0–4 scale) after the discharge programme’s implementation. Surgical-site infections decreased from 27% in Cohort 1 to 2% in Cohort 2 (p>0.05) after the programme’s implementation.
Nurse, parent, and child outcomes were improved after implementation of the structured nurse-led parent discharge programme for parents in India. Structured nurse-led parent discharge programmes may help prepare parents to provide better home care for their children after cardiac surgery. Further investigation of causality and influencing factors is warranted.
Parents of children with CHD require home care knowledge in order to ensure their child’s health and safety, but there has been no research on how to achieve this in a resource-constrained environment. The aim of this investigation was to compare parent and nurse perceptions of parent readiness for discharge after a structured nurse-led parent discharge teaching programme in India.
Materials and methods
A pre-post design was used to compare parent and nurse perceptions of parental uncertainty and readiness for hospital discharge before and after introduction of the parent education discharge instruction programme in a paediatric cardiac surgery unit.
Parents (n=68) and nurses (n=63) participated in this study. After the discharge programme implementation, parents had less uncertainty (M=93.3 SD=10.7 versus M=83.6 SD=4.9, p=0.001) and ambiguity (M=40.8 SD=6.8 versus M=33.4 SD=3.7, p=0.001) about their child’s illness; however, they rated themselves as being less able to cope with the transition to home (M=24.3 SD=4.1 versus 23.1 SD=2.2, p=0.001) and as having less support at home than that required (M=31.5 SD=9.9 versus 30.9 SD=3.2, p=0.001). Parents’ and nurses’ perception of parental readiness for hospital discharge were more closely aligned after implementation of a nurse-led discharge programme (r=0.81, p=0.001).
The results of this study suggest that the discharge programme had positive and negative effects on parental perceptions of uncertainty and readiness for discharge. Further examination is warranted to delineate these influences and to design methods for supporting parents during the transition to home care.
There has been a recent move in psychiatry towards the use of electronic discharge (e-discharge) summaries in an effort to improve the efficiency of communication between primary and secondary care, but there are little data on how this affects the quality of information exchanged.
To evaluate the quality of psychiatric discharge summaries before and after the introduction of the e-discharge summary system.
A retrospective analysis of 50 dictated discharge summaries from 1 January to 1 July 2010 and of 50 e-discharge summaries from 1 January to 1 July 2012, evaluating for the inclusion of 15 key items of clinical information.
The average total score of the dictated summaries (mean=9.5, s.d.=2.0) was significantly higher (p<0.001) than the e-discharge summaries (mean=6.7, s.d.=1.8). There were statistically significant differences in five of the standards: findings of physical examination (p<0.001), ICD-10 code (p<0.001), forensic history (p<0.001), alcohol history (p<0.001) and drug history (p<0.001).
Our results revealed a decline in the quality of discharge summaries following the introduction of an electronic system. The reasons for this are unclear and require further analysis. Specific suggestions will depend on the local need, but include improvements in software design and layout as well as better education and training.
Cardiac troponin elevation portends a worse prognosis in diverse patient populations. The significance of troponin elevation in patients discharged from emergency departments (EDs)without inpatient admission is notwell known.
Patients without a diagnosis of acute coronary syndrome discharged fromtwo EDs between April 1, 2006, and December 31, 2007, with an abnormal cardiac troponin (troponin positive [TP]) were compared to a troponin-negative (TN) cohort matched for age, sex, and primary discharge diagnosis. Outcomes were obtained by linking with a regional ED and a provincial vital statistics database and adjusted for the following: estimated glomerular filtration rate, do-not-resuscitate status, history of coronary artery disease, Canadian Triage and Acuity Scale, and left ventricular hypertrophy on electrocardiography. The primary outcome was a composite of death or admission to hospital within 1 year.
Our total cohort (n 5 344) consisted of 172 TP and 172 TN patients. In the univariate analysis, TP patients had a higher rate of the primary outcome (OR 3.2, 95% CI 2.1–5.0, p < 0.001) and both of its components (p < 0.001). After adjusting for covariates, positive troponin remained an independent predictor of the primary outcome (OR 2.1, 95% CI 1.3–3.4, p 5 0.005) and inpatient admission (OR 2.0, 95% CI 1.2–3.4, p 5 0.006). There was no significant difference in death (OR 1.3, 95% CI 0.6–2.9, p 5 0.5) after adjustment.
A positive troponin assay during ED stay in discharged patients is an independent marker for risk of subsequent admission. Our findings suggest that the prognostic power of an abnormal troponin extends to patients discharged from the ED.
The alien and potentially invasive species Elodea nuttallii was observed for the first time in Slovenia's Drava River in 2007, when its huge biomasses were observed at some locations. Changes in biomass of submerged macrophyte communities and abiotic factors such as water temperature, discharge and level were monitored at two impoundments of the Drava River (2009, 2010 and 2011). The correlations between abiotic factors and developed final biomass were assessed to determine if the level of abiotic factors has an impact on the final biomass and invasive behaviour of E. nuttallii. The results obtained showed that biomass of E. nuttallii was not excessive in 2009 and 2010, while in the year 2011 it developed huge biomass at locations, which were not directly exposed to the main water current. The biomass of Myriophyllum spicatum was also higher in 2011 in comparison with 2009 and 2010 but not in such high degree. The key factor for the development of the final biomass of E. nuttallii was the water temperatures in winter and spring and also the point at which water temperatures in spring surpassed 10°C. The invasive behaviour of E. nuttallii is expected in the years with higher temperatures in January and March and at the locations which are not directly exposed to the main water current. We assume that continuation of the deposition of silt in the impoundments of the Drava River could contribute to invasive behaviour of species E. nuttallii in the years with mild winters and warmer springs.
Sedimentological analyses of 289 years (AD 1718–2006) of varved sediment from Shadow Bay, southwest Alaska, were used to investigate hydroclimate variability during and prior to the instrumental period. Varve thicknesses relate most strongly to total annual discharge (r2 = 0.75, n = 43, p < 0.0001). Maximum annual grain size depends most strongly on maximum spring daily discharge (r2 = 0.63, n = 43, p < 0.0001) and maximum annual daily discharge (r2 = 0.61, n = 43, p < 0.0001), while varve thickness is poorly correlated with maximum annual grain size (r2 = 0.004, n = 287, p = 0.33). Relations between varve thickness and annual climate variables (temperature, precipitation, North Pacific (NP) and Pacific Decadal Oscillation (PDO) indices) are insignificant. On multidecadal timescales, however, regime shifts in varve thickness and total annual discharge coincide with shifts in NP and PDO indices. Periods with increased varve thickness and total annual discharge were associated with warm PDO phases and a strengthened Aleutian Low. The varve-inferred record of PDO suggests that any periodicity in the PDO varied over time, and that the early 19th century marked a transition to a more frequent or detectable shifts.
Radiocarbon-dated sediment cores from the Champlain Valley (northeastern USA) contain stratigraphic and micropaleontologic evidence for multiple, high-magnitude, freshwater discharges from North American proglacial lakes to the North Atlantic. Of particular interest are two large, closely spaced outflows that entered the North Atlantic Ocean via the St. Lawrence estuary about 13,200–12,900 cal yr BP, near the beginning of the Younger Dryas cold event. We estimate from varve chronology, sedimentation rates and proglacial lake volumes that the duration of the first outflow was less than 1 yr and its discharge was approximately 0.1 Sv (1 Sverdrup = 106 m3 s−1). The second outflow lasted about a century with a sustained discharge sufficient to keep the Champlain Sea relatively fresh for its duration. According to climate models, both outflows may have had sufficient discharge, duration and timing to affect meridional ocean circulation and climate. In this report we compare the proglacial lake discharge record in the Champlain and St. Lawrence valleys to paleoclimate records from Greenland Ice cores and Cariaco Basin and discuss the two-step nature of the inception of the Younger Dryas.
Primary Objective: To explore levels of depression, anxiety, stress and strain symptomatology experienced by caregivers of adults with traumatic brain injury (TBI) during the phase of transition from hospital to home. Research Design: Prospective study with data collected at three time-points: pre-discharge, 1-month post-discharge, and 3-months post-discharge. Methods and Procedures: Twenty-nine caregivers of adults with TBI (mean age 48 years), recruited on patient discharge from rehabilitation, completed the Caregiver Strain Index and the Depression, Anxiety and Stress Scale at the three time points. Results: Paired t tests showed significantly lower levels of caregiver strain at one month compared to pre-discharge, and significantly less strain and depression symptoms at 3-month follow-up compared to pre-discharge. Non-significant reductions were observed in level of stress and anxiety across the follow-up time points. Independent group t tests found that female caregivers experienced greater strain than male caregivers at 3 months post-discharge, and caregivers who were immediate family members of the patient experienced greater anxiety than those who were spouses/partners of the patient at 1-month follow-up. Conclusions: The rate of depressive symptoms in caregivers of people with TBI was greater than the general population, and strain was prevalent during the transition period. The results suggest more specific caregiver support and preparation is needed before patient discharge from hospital, and that adequate time spent in rehabilitation is beneficial for caregiver wellbeing.
We sought to characterize patients who are referred from the emergency department (ED) to specialty clinics but do not complete the referral, and to identify reasons for their failure to follow up.
A prospective cohort study was carried out over 3 months of patients who were discharged from the ED of a teaching hospital with referral to internal medicine, cardiology or neurology clinics, but who did not complete the referral. Information on demographics, barriers to care and reasons for not completing the referral was obtained through a standardized telephone interview.
Of 171 ED referrals, 42 (24.6%) were not completed. Interviews were completed for 71.4% (30 patients). Of the nonattenders, 80% were functional in English and most had high school (73.1%) or university (60.7%) education. Virtually all (93.0%) interviewees could get to hospital by themselves or have someone take them. Only 42.9% (12 patients) understood why the emergency physician (EP) requested consultation, and 42.9% (12 patients) described EP instructions as poor or fair. Primary reasons for noncompletion of consult were patient choice (46.7%, 95% confidence interval [CI] 27.1%–66.2%), physical or social barriers (13.3%, 95% CI 0.0%–27.2%), communication failure (20%, 95% CI 4.0%–36.0%) and consultant's refusal of the consultation (20% [95% CI 4.0%–36.0%]). All consultant refusals were from one internal medicine clinic, representing 42% (8/19) of ED referrals to that clinic. None of the 6 patients interviewed who were declined consultation was aware that their consultation had been refused.
Patients discharged by the EP with referral to specialty clinics frequently do not complete the consultation. Causes for failure to follow up relate to patient decision, inadequate or poorly understood discharge information, and system factors. Institutional audits of patients who fail to complete follow-up may reveal unanticipated barriers to care.
Background: We explored phenotypic parameters of people with Huntington's disease who had been admitted to a psychiatric unit and then discharged, with a view to determining prognostic factors for discharge to higher levels of care.
Methods: A cross-sectional study was carried out on 19 patients admitted to a psychiatric unit with Huntington's disease. Data on the Unified Huntington's Disease Rating Scale (UHDRS) of behavior and function, global assessment of presence of depression and dementia as well as discharge outcomes were collated. Appropriate parametric and non-parametric statistical tests were applied.
Results: Fourteen patients were discharged to accommodation with the same level of care versus five who were discharged to a higher level of care. Having poor functioning in terms of activities of daily living predicted discharge to an increased level of care. Being depressed or having dementia did not forecast poor outcome. The total duration of admission was not related to UHDRS parameters.
Conclusions: Poor functioning on admission independently predicts the need for higher levels of care for patients who are admitted to a neuropsychiatric ward.
La dynamique des populations et la production du zooplancton ont été évaluées dans 3 retenues voisines (les lacs d'Aumar, Orédon et Aubert) et comparées aux résultats obtenus antérieurement dans le lac naturel de Port-Bielh (2 285 m) dont le zooplancton offrait une composition spécifique analogue (espèces dominantes : Polyarthra vulgaris, Mixodiaptomus laciniatus, Cyclops strenuus, Daphnia longispina).
Les 3 retenues diffèrent essentiellement par le régime thermique lié à leurs caractéristiques morphométriques et hydrologiques. L'ensemble de ces caractéristiques a permis de définir une série lacustre Port-Bielh-Aumar-Orédon-Aubert, caractérisée par un abaissement progressif du climat thermique et une instabilité croissante de l'environnement.
L'étude comparée du peuplement zooplanctonique en milieu naturel et en milieu perturbé, permet de préciser l'influence des modalités d'exploitation de ces retenues sur le développement de la communauté pélagique. En particulier, elle met en évidence pour la série lacustre considérée, un changement de structure de la communauté zooplanctonique, un appauvrissement spécifique de cette communauté, et une diminution progressive de la productivité de ces milieux.
To describe the characteristics and progress of the first 50 patients with severe and enduring mental illness who accessed inpatient rehabilitation services in Dublin North East Mental Health Service between 2001 and 2006.
Retrospective collection of data on the first 50 inpatients from case notes and staff interviews. Data included demographics, psychiatric history, results of rehabilitation interventions and assessment tools. The results were compiled and analysed using descriptive statistics.
Fifty patients were identified. The majority were male (68%) with a diagnosis of paranoid schizophrenia (60%). The levels of co-morbid alcohol and drug misuse were 40% and 30% respectively. Histories of verbal/physical aggression were found in 92% and impulsive behaviour in 70%. The majority of patients had a past history of being detained under the Mental Treatment Act (1945). High levels of co-morbid physical health problems were identified. New long-stay (NLS) patients showed a trend towards requiring the shortest admissions prior to being ready for discharge to lower levels of support.
One third of patients moved on to reside at lower support levels and accessed vocational training programmes following active inpatient rehabilitation interventions. However, there remained a cohort of patients who required prolonged inpatient admissions due to their high levels of disability. This study further highlights the need to ensure that a range of rehabilitation services from inpatient to supported community placement are provided to meet the needs of patients with severe and enduring mental illness with complex needs.