To compare the 30-day readmission predictive power of in-hospital walking activity and in-hospital activities of daily living (ADLs) in older acutely ill patients. In addition, we sought to identify ...preliminary walking thresholds that could support the targeting of interventions aimed at minimizing rehospitalizations.
Prospective, observational clinical cohort study. Step counts during hospitalization were assessed via accelerometry. ADL function was assessed within 48 hours of admission.
Acute care hospital.
One hundred sixty-four ambulatory persons aged 65 years and older admitted to the hospital from the community with an acute medical illness.
Not applicable.
Readmission back to the index hospital (yes vs no) within 30 days of discharge.
Twenty-six patients (15.8%) were readmitted within 30 days of discharge. Walking activity during hospitalization was more strongly and significantly associated with 30-day readmission (odds ratio=0.90; 95% confidence interval, 0.82-0.98) than ADL function (odds ratio=0.45; 95% confidence interval, 0.14-1.45) after adjusting for relevant readmission risk factors. The predictive accuracy (area under the curve) was highest for models that included walking activity and changed little with the addition of ADLs. A walking threshold of 275 steps or more per day identified patients at reduced 30-day readmission risk.
Walking activity was a stronger predictor of readmission than ADLs. Monitoring patient activity during hospitalization may provide clinicians with valuable information on early readmission risk not captured by measures of ADLs. Further study is needed to replicate these findings and monitor walking activity posthospitalization to further advance our understanding of readmission risk.
Purpose: To explore the mobility-related preferences among stroke survivors and caregivers following post-acute rehabilitation at inpatient or skilled nursing facilities.
Methods: In this ...cross-sectional study; semi-structured, qualitative interviews of stroke survivors (n = 24) and informal caregivers (n = 15) were conducted. The participants were recruited from the community.
Results: Comparative content analysis was used to identify themes by two independent coders. The survivors (68 years) and caregivers (58 years) mentioned mobility-related consequences including inability to walk, balance, drive, and transfer; and increased falls. The survivors (63%) and caregivers (73%) also mentioned the use of assistive devices. The common rehabilitation activities included: walking (62%); followed by standing and mobility; strength and balance; and wheelchair skills. Some stroke survivors were dissatisfied as their rehabilitation was not patient-centered. Frequently mentioned outcome preferences by survivors were ability to walk (88%), move, and balance. They also wanted to acquire assistive devices to move independently. Caregivers were concerned with the survivor's safety and wanted them to drive (53%), prevent falls, have home accommodations, and transfer independently. Caregivers (40%) also expressed the importance of receiving realistic information.
Conclusions: This study suggests a need to consider the stroke survivors' and caregivers' mobility outcome preferences to improve the patient-centered rehabilitation care.
Implications for Rehabilitation
Stroke survivors and caregivers tend to differ in their outcome preferences.
Caregivers expressed concern for transfers, driving, fall prevention, home modifications, and wished for realistic information.
Incorporating stroke survivors and their families' perspectives during rehabilitation may enhance patient-centered outcomes.
Previous research has demonstrated that using a multicomponent approach to ankle injury preventions can significantly reduce ankle injuries; however, these studies lack specific intervention ...recommendations.
To evaluate the exercise components of prevention programs on ankle injuries specifically in high school athletes. Secondary objectives were to assess the overall effectiveness of prevention programs on ankle injuries in this population and how compliance and education may impact success.
A total of 5 databases were searched through September 26, 2022.
Study inclusion criteria included randomized control trials (RCTs) investigating exercise interventions in high school athletes aged 13 to 19 years, participation in sports competition, reporting of injury incidence, and specific exercise interventions used.
Systematic review and meta-analysis.
Level 1.
Pooled overall ankle injury incidence rate ratio and 95% CIs were calculated using random-effects meta-analysis.
A total of 10 studies were included, of which 9 used multicomponent exercise interventions and 1 used only balance training. Of the 10 studies, 3 demonstrated statistically significant reduction in ankle injuries. When data from all 10 studies were pooled and analyzed, there was a statistically significant overall reduction (incidence rate ratio, 0.74; 95% CI 0.60-0.91) in ankle injuries when comparing intervention groups with controls.
The most effective injury prevention programs included multiple components, emphasized strengthening and agility exercises, and promoted high adherence to the intervention. The importance of coach and player education on how and why to perform an injury prevention program as well as the frequency and duration of programs was also important. Exercise-based injury prevention programs may reduce ankle injury incidence in youth athletes by 26% when pooling data from a multitude of sport types/settings.
The proposed Centers for Medicare & Medicaid Services (CMS) 30-day readmission risk standardization models for inpatient rehabilitation facilities establish readmission risk for patients at admission ...based on a limited set of core variables. Considering functional recovery during the rehabilitation stay may help clinicians further stratify patient groups at high risk for hospital readmission.
The purpose of this study was to identify variables in the full administrative medical record, particularly in regard to physical function, that could help clinicians further discriminate between patients who are and are not likely to be readmitted to an acute care hospital within 30 days of rehabilitation discharge.
This study used an observational cohort with a 30-day follow-up of Medicare patients who were deconditioned and had medically complex diagnoses and who were receiving postacute inpatient rehabilitation in 2010 to 2011.
Patients in the highest risk quartile for readmission (N=25,908) were selected based on the CMS risk prediction model. Hierarchical generalized linear models were built to compare the relative effectiveness of motor functional status ratings in predicting 30-day readmission. Classification and regression tree analysis was used to create a hierarchical order among predictors based on variable importance in classifying patients based on readmission status.
Approximately 34% of patients in the high-risk quartile were readmitted within 30 days. Functional outcomes and rehabilitation length of stay were the best predictors of 30-day rehospitalization. A 3-variable algorithm classified 4 clinical subgroups with readmission probabilities ranging from 28% to 75%.
Although planned readmissions were accounted for in the outcome, potentially preventable readmissions were not distinguished from unpreventable readmissions.
For older patients who are deconditioned and have medically complex diagnoses admitted to postacute inpatient rehabilitation, information on functional status measures that are easily monitored by health care providers may improve plans for care transition and reduce the risk of hospital readmission.
Bacterial biofilm formation is a complex developmental process involving cellular differentiation and the formation of intricate 3D structures. Here we demonstrate that exposure to ferric chloride ...triggers rugose biofilm formation by the uropathogenic Escherichia coli strain UTI89 and by enteric bacteria Citrobacter koseri and Salmonella enterica serovar typhimurium . Two unique and separable cellular populations emerge in iron-triggered, rugose biofilms. Bacteria at the air–biofilm interface express high levels of the biofilm regulator csgD , the cellulose activator adrA , and the curli subunit operon csgBAC . Bacteria in the interior of rugose biofilms express low levels of csgD and undetectable levels of matrix components curli and cellulose. Iron activation of rugose biofilms is linked to oxidative stress. Superoxide generation, either through addition of phenazine methosulfate or by deletion of sodA and sodB , stimulates rugose biofilm formation in the absence of high iron. Additionally, overexpression of Mn-superoxide dismutase, which can mitigate iron-derived reactive oxygen stress, decreases biofilm formation in a WT strain upon iron exposure. Not only does reactive oxygen stress promote rugose biofilm formation, but bacteria in the rugose biofilms display increased resistance to H ₂O ₂ toxicity. Altogether, we demonstrate that iron and superoxide stress trigger rugose biofilm formation in UTI89. Rugose biofilm development involves the elaboration of two distinct bacterial populations and increased resistance to oxidative stress.
The purpose of this systematic review was to summarize recent evidence on the efficacy of behavioral interventions for the management of urinary incontinence (UI) among women in nursing homes.
...Systematic review of the literature. For this review, behavioral interventions were defined as those that included some form of physical exercise or behavior modification such as scheduled toileting.
A search of MEDLINE/PubMed, CINAHL, Scopus, and Cochrane Library electronic databases was conducted seeking randomized controlled trials published since 2010 in female participants residing in long-term care facilities (nursing homes, skilled nursing facilities) and diagnosed with UI. Inclusion criteria were studies that addressed the effects of voiding regimens, lower extremity strengthening, functional training, food and fluid management, and pelvic floor muscle training. Independent reviewers extracted relevant data and assessed methodological quality using the PEDro scale.
Five studies (pooled sample, N = 399) met inclusion criteria; mean age of participants was 81.1 ± 6.8 years; 85% were female. The PEDro scores ranged from 6 to 9; only 2 studies included residents with cognitive impairment. Interventions included voiding strategies, increasing physical activity, functional mobility training, pelvic floor muscle training, fluid management, and multicomponent combinations of approaches. Three of the 5 studies were multicomponent interventions and 2 focused on a single intervention. Outcomes included objective measures of incontinent episodes and subjective assessments of UI severity.
Behaviorally based interventions can be successful in improving UI among nursing residents with and with no cognitive impairment.
Future studies should examine logistic and labor costs associated with sustaining behavioral interventions using nursing home staff and investigate the effects of these therapies using appropriate quality-of-life metrics for this population.
Little is known about older patient's mobility soon after discharge home from an acute hospitalization. We examined daily postdischarge mobility levels as marker of overall health and response to ...in-hospital treatment in older medicine patients.
One hundred and eleven ambulatory men and women aged 65 years and older hospitalized with an acute medical illness and discharged to home were studied. Patients received an ankle-worn accelerometer during hospitalization and wore it continually for up to 1 week after discharge. Total number of steps taken per day was assessed. The primary outcome was all-cause 30-day readmission.
Thirteen (11.7%) participants were readmitted within 30 days of discharge. There was a significant association between mean daily steps taken postdischarge and 30-day readmission (odds ratio = 0.85, 95% confidence interval = 0.72-0.99, and p = .04; odds ratio and confidence intervals were calculated for 500-step intervals). Though not statistically significant in the fully adjusted model (odds ratio = 0.83, 95% confidence interval = 0.71-1.02, and p = .08), mean daily steps was the strongest predictor among known readmission risk factors. The least active participants postdischarge were significantly more likely to be older (p = .02), be not married (p = .02), use a cane or walker prior to admission (p < .01), have longer lengths of hospital stay (p = .02), and be readmitted (p = .05).
Mobility level soon after discharge home shows promise as a simple physical biomarker of overall health and risk of 30-day readmission in older patients.
Thoracic hyperkyphosis is a common condition that progresses with aging and has been associated with impaired functional performance, increased risk of falls, and even mortality. Previous studies to ...improve posture primarily used exercise for durations of 3 months or longer. The purpose of this pilot study was to examine the feasibility of a manual therapy intervention in community-dwelling older adults over a 4-week time frame that is comparable to the typical clinical setting, to test the appropriateness and procedures for the measurement of posture and function in the older population with hyperkyphosis, and to collect preliminary data to describe change in posture and function measures.
Twenty-four participants with hyperkyphosis or forward head posture were recruited, and 22 participants completed this pilot study. Feasibility was measured based on attendance, tolerance, safety, and retention. Issues with measurement procedures were recorded. The intervention included manual therapy and exercise 3 times a week for 4 weeks to target spinal and peripheral joint stiffness, muscle lengthening, and muscle activation. Outcomes included height, kyphotic index (KI), Block Test, Acromion to Table (ATT), Timed Up and Go (TUG), 5 times sit-to-stand (5XSTS), Functional Reach (FR), 2-minute walk test (2MWT), and Patient-Specific Functional Scale (PSFS). Data collected at visits 1, 6, and 12 were analyzed using 1-way repeated-measures multivariate analysis of variance.
Measurement and intervention protocols were found to be feasible. A significant effect for the aggregate dependent variables change over time was found. Univariate analysis of each dependent variable showed significance except for FR. All postural measures (height, KI, Block Test, and ATT) significantly improved statistically. The KI and ATT exceed the minimal detectable change for clinical significance. Function showed statistical improvements in the TUG, 5XSTS, 2MWT, and PSFS. Clinical significance was reached with the PSFS. Seven of 9 measures showed a statistically significant change in just 2 weeks.
This pilot study suggests that manual therapy and exercise applied to older adults shows promise for improvement in measures of posture and functional performance in a clinically feasible 4-week time frame.
To examine how similar summary scores of physical functioning using the FIM can represent different patient clinical profiles.
Retrospective cohort study.
Inpatient rehabilitation facilities.
...Medicare fee-for-service beneficiaries (N=765,441) discharged from inpatient rehabilitation.
Not applicable.
We used patients' scores on items of the FIM to quantify their level of independence on both self-care and mobility domains. We then identified patients as requiring "no physical assistance" at discharge from inpatient rehabilitation by using a rule and score-based approach.
In those patients with FIM self-care and mobility summary scores suggesting no physical assistance needed, we found that physical assistance was in fact needed frequently in bathroom-related activities (eg, continence, toilet and tub transfers, hygiene, clothes management) and with stairs. It was not uncommon for actual performance to be lower than what may be suggested by a summary score of those domains.
Further research is needed to create clinically meaningful descriptions of summary scores from combined performances on individual items of physical functioning.
The objective of this study was to determine the prevalence of increased fall risk among women presenting to a large pelvic health center using a screening method compatible with the busy clinic ...environment and to identify factors associated with increased risk.
A retrospective medical records review was conducted on consecutive treatment-seeking women presenting to a Urogynecology & Pelvic Health Center over 6 months. The Centers for Disease Control and Prevention, Stopping Elderly Accidents, Deaths, and Injuries fall risk screening tool was included among the intake questionnaires all patients completed before their scheduled appointments. Relevant sociodemographic and clinical measures were abstracted from the electronic medical record.
Three hundred and forty-eight women completed the fall screen. One hundred and twenty-four (36%) screened positive for increased fall risk. Mean age was 58.7 ± 15.8 years. An age threshold of 68 years best discriminated between those who were and were not identified as at risk. There was a gradient of association between number of urinary symptoms and prevalence of increased fall risk. Patients with 3 or more urinary symptoms were most likely to screen positive (1: odds ratio OR, 1.51 0.86-2.66; 2: OR, 1.62 0.99-2.64; 3 or more: OR, 1.84 1.07-3.17) after adjusting for other know fall risk factors.
The prevalence of increased fall risk in this patient population is high and highest in women with multiple urinary symptoms. The Stopping Elderly Accidents, Deaths, and Injuries screening tool was a feasible and nonintrusive screening method for identifying increased fall risk during routine patient care. Fall risk and concern about falling should be taken into consideration when deciding management strategies for urinary problems.
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