Using telemedicine for older adults with multiple comorbid conditions is a potential area for growth in health care. Given this older, ailing population, providers should discuss end-of-life care ...with patients.
To determine the relationship between telemonitoring and hospice enrollment compared to usual care among older adults with chronic health problems.
This was a secondary evaluation of a randomized controlled trial. The trial was performed at an academic medical center. Patients who were over the age of 60 and had a high risk of hospitalization and emergency department visits were recruited to the study. The primary outcome was hospice enrollment, and the secondary outcome was the mean number of days in hospice. The data were analyzed using Chi-squared tests and time-to-event analysis.
The average age of the cohort was 80.3 years. Nine patients (9.6%) in the telemonitoring group were enrolled in hospice care, whereas four patients (4.0%) in the usual care group were enrolled (P = 0.12). The mean number of days in hospice was 57.9 (SD ± 99.2) for the telemonitoring group, and 119.3 (SD ± 123.8) for the usual care group (P = 0.36). There was no significant difference regarding time to hospice referral.
In this pilot analysis, there were no differences noted between groups in the number of patients that entered into hospice or the amount of time they stayed in hospice care. This was a small trial, and the power to detect a difference was 36%. It was encouraging that twice the number of patients enrolled in hospice care in the telemonitoring group compared to usual care despite the insignificant finding. Further research may determine the effect of telemonitoring upon hospice referral.
Hemodialysis (HD) is routinely offered to patients with end-stage renal disease in the United States who are ineligible for other renal replacement modalities. The frequency of HD among the US ...population is greater than all other countries, except Taiwan and Japan. In US, patients are often dialyzed irrespective of age, comorbidities, prognosis, or decision-making capacity. Determination of when patients can no longer dialyze is variable and can be dialysis-center specific. Determinants may be related to progressive comorbidities and frailty, mobility or access issues, patient self-determination, or an inability to tolerate the treatment safely for any number of reasons (e.g., hypotension, behavioral issues). Behavioral issues may impact the safety of not only patients themselves, but also those around them. In this article the authors present the case of an elderly patient on HD with progressive cognitive impairment and combative behavior placing him and others at risk of physical harm. The authors discuss the medical, ethical, legal, and psychosocial challenges to care of such patients who lack decision-making capacity with a focus on variable approaches by regions and culture. This manuscript provides recommendations and highlights resources to assist nephrologists, dialysis personnel, ethics consultants, and palliative medicine teams in managing such patients to resolve conflict.
The ABCs of Asthma Control Thorsteinsdottir, Bjorg; Volcheck, Gerald W.; Madsen, Bo Enemark ...
Mayo Clinic proceedings,
2008, Letnik:
83, Številka:
7
Journal Article
Recenzirano
The new asthma guidelines have introduced impairment and risk assessments into the management of asthma. Impairment assessment is based on symptom frequency and pulmonary function, whereas risk ...assessment is based on exacerbation frequency and severity. These 2 measures determine the initial severity of asthma in the untreated patient as well as the degree of control in asthma once treatment has been initiated. The focus on asthma control is important because the attainment of control correlates with a better quality of life and reduction in health care use. We describe 4 easy steps to achieving asthma control in the ambulatory practice setting: (1) a standardized assessment of asthma symptoms using a 5-question assessment tool called the Asthma Control Test, (2) a simple mnemonic that provides a systematic review of the comorbidities and clinical variables that contribute to uncontrolled asthma, (3) directed patient education, and (4) a schedule for ongoing care. Most if not all patients can achieve good control of their asthma with optimal care through an active partnership with their health care professionals.
A 26-year-old primigravida, with no history of hypertension, presented at 20 weeks of gestation with severe pre-eclampsia. A pelvic ultrasound revealed intrauterine fetal death, probably caused by ...placental abruption. The pregnancy was terminated by induction with oxytocin, followed by a vaginal breech delivery. The patient remained hypertensive for 8 weeks after delivery.
Physical examination, laboratory investigation, renal angiogram and renal-vein renin sampling.
An atrophic right kidney secondary to an occluded right renal artery, probably caused by dissected fibromuscular dysplasia; a contralateral high-grade stenosis secondary to fibromuscular dysplasia.
Right nephrectomy and angioplasty of the left renal artery.
Abdominal wall cellulitis in the morbidly obese Thorsteinsdottir, Bjorg; Tleyjeh, Imad M.; Baddour, Larry M.
Scandinavian journal of infectious diseases,
2005, Letnik:
37, Številka:
8
Journal Article
Currently, almost two-thirds of the US population is either overweight or obese. In addition to non-infectious complications, obesity predisposes to infections, including lower extremity cellulitis. ...Although cases of abdominal wall cellulitis in the morbidly obese occur, to date there has been no formal address of this syndrome in the literature. We therefore reviewed our clinical experience of abdominal wall cellulitis complicating morbid obesity.
A retrospective database search was performed to identify patients with both cellulitis and morbid obesity who were seen at the Mayo Clinic between January 1998 and August 2003. Clinical and microbiologic data were collected for these patients.
Of the 260 cases of cellulitis identified, 24 (9.2%) had morbid obesity and abdominal wall cellulitis. The mean age of the 24 patients was 47 (range 22-70) y and over two-thirds of them were females. Their mean body mass index (BMI) was 62.3 (range 39.6-108.6). 17 (70.8%) had a remote history of abdominal surgery. 16 patients required 23 hospitalizations. Five patients developed cellulitis complications and 7 (29.1%) patients had recurrent bouts of cellulitis during the study period.
Abdominal wall cellulitis is a unique infectious complication in patients with morbid obesity. Further study is needed to better define the pathogenesis of this illness to develop strategies in treatment and prevention.
•Identifying subsets of older adults at risk for adverse outcomes is important.•Construct validity of the interRAI ED-screener was compared to established instruments.•We found the interRAI ED ...screener was easy to use and predicted adverse outcomes.•Identifying the older adults likely to benefit from geriatric service is recommended.•Effectively screening older adults at ED might minimize readmissions.
The interRAI Emergency Department-Screener (ED-screener) is a risk stratification instrument incorporating functional and social aspects to identify older adults in EDs. The aim was to assess the construct validity and utility of the ED-screener in comparison with more established instruments.
The ED-screener, Triage Risk Screening Tool (TRST) and Identification of Seniors at Risk (ISAR) were administered to older ED-patients. Construct validity was assessed by correlation with TRST and ISAR. The ED-screener scores that corresponded to the established cut-offs for ISAR and TRST were assessed with linear regression. The sensitivity and specificity of the ED-screener for mortality at 4-months were calculated.
Two hundred patients were included (mean age 78.5 years, 44% male). Majority (85%) lived at home, 43% lived alone and 53% received home care. The scores of 3.02 and 3.01 on ED-screener corresponded to the cut-off score of 2 on the other instruments. The correlation of the ED-screener with ISAR and TRST was 0.56 and 0.41 respectively. A score of 3 on the ED-screener was 100% sensitive and 28% specific for 4-month mortality.
These findings provide support for the construct validity of the ED-screener and its ability to predict outcomes in its intended setting.
PDF
