Long-term Facilities Research Articles

Could Towel bath reduce aggressiveness in patient with dementia? Results from a crossover trial

BACKGROUND: Bathing is one of the most intimate activities during which persons with dementia are cared for. The literature suggests that 20-40% of patients with cognitive impairment, hospitalized in long-term facilities, may react with aggressive behaviours. AIM: To evaluate the efficacy of the towel bath technique in reducing agitation, aggression, and discomfort in nursing home residents with dementia. MATERIALS AND METHODS: An Inteentional crossover study was conducted; a convenience sample of patients with dementia, was enrolled. Aggressive behaviors were evaluated using the italian version of the Care Recipient Behavior Assessment (CAREBA- ita). RESULTS: 71 resident were enrolled. Towel Bath technique showed a reduction in episodes of aggression and in the execution time of the procedure with a statistically significant difference (p < 0.05). CONCLUSIONS: The technique Towel bath provides a viable alternative to traditional bath to reduce aggression in patients with dementia.

Trends, Prevalence, and Outcomes of Sudden Cardiac Arrest Post Cardiac Transplant: A Nationwide 16-Year Study.

Heart transplantation is the most effective long-term therapy for end-stage heart disease. There is limited data related to sudden cardiac arrest (SCA) in postheart transplant recipients. We aimed to describe the trends, and rate of SCA following heart transplantation and thereby identify clinical predictors as well as outcomes of SCA in patients post-transplant. We queried the National Inpatient Sample (NIS) with administrative codes for SCA and heart transplant. We assessed baseline differences between SCA and non-SCA admissions, with hazard ratios adjusted for age, gender, CCI, and race. Multivariable logistic regression models were generated to identify the independent predictors for SCA. There was a total of 30,020 hospitalizations of heart transplant recipients between 1999 and 2014 in the United States and among these 1,953 patients (6.5%) suffered SCA with an increasing trend of admissions for SCA. Among the patients who suffered from SCA, 18.83% died during the same hospitalization, 19.29% were discharged to a long-term facility, and 61.38% were discharged home. Multivariate analysis demonstrated that conduction system disorders (Hazard ratio [95% confidence interval]; 7.1 [4.5-11.1]), female gender (HR:1.2 [1.1-1.3]), diabetes (HR:1.4 [1.2-1.6]), and hypertension (HR:1.2 [1.1-1.4]) were the strongest predictors for SCA. SCA hospitalizations occur in 6.5% of patients post cardiac transplant and have been increasing from 1999 to 2014. Conduction block, graft rejection, female gender, hypertension, diabetes are independent predictors for SCA in heart transplant recipients.

Predictive Value of Emergency Designation on Outcomes of Moribund Patients

Background: Anesthesiologists are increasingly encountering sicker patients that require potentially life-saving surgical interventions, and assess risk using the American Society of Anesthesiology Physical Status (ASA PS) classification system. Here, we examined long-term mortality along with hospital length of stay (LoS) and discharge disposition for survivors in ASA PS 5 and 5E patients.Methods: Adult surgeries were extracted from New York-Presbyterian Hospital/Weill Cornell Medical Center’s Electronic Medical Record (EMR) for cases between January 1, 2013 and December 31, 2017; outcomes were collected from EMRs and the Social Security Death Index Master File.Results: 194,947 cases were identified. Mortality correlated with increasing ASA PS; the same trend was observed within both emergent and non-emergent sub-populations. Two hundred seventy-six cases were identified as 5/5E. This patient population had a higher rate of mortality at 30 days than at 48 hours (25.9% vs. 13.4%, respectively, p < 0.01); there was no difference between survivor functions at 30 or 90 days (p = 0.63, p = 0.09, respectively). Survivors within the 5 or 5E subpopulations did not have significantly different LoSs. Further, survivors after 90 days typically had a disposition of hospice, long-term facilities, inpatient rehabilitation, or self-discharged.Conclusions: Mortality increases with increases in ASA PS classifications. There is no difference in outcomes for 5 vs 5E at 30- or 90-day postoperatively. Similarly, emergency status did not play a role in LoS. Most 5 or 5E patients are not discharged home but to another facility. These outcomes should be considered during the informed consent process in this high-risk surgical population.

Family-oriented interventions in long-term care residential facilities for older people: A scoping review of the characteristics and outcomes.

Family-oriented interventions in long-term care (LTC) residential facilities are heterogenous in design, characteristics, and outcomes. To synthesize characteristics (e.g., type, provider, and duration) and outcomes of family-oriented interventions in LTC residential facilities. We followed the JBI methodology and searched seven databases for quantitative, qualitative, and mixed method studies that reported family-oriented interventions in LTC residential settings for older people; defined in this review as ≥60 years. Interventions that included residents, resident families, health professionals, or any combinations of these three were included if the study reported post-intervention assessment of at least one family-related outcome. Thirteen studies met the inclusion criteria. Interventions were found to be multifaceted, and education was the most common element. Nurses were the most common intervenors, and most interventions had more than one target (residents, resident families, or staff). Most outcomes were related to family involvement, satisfaction with care, quality of life, communication, symptom management, and shared decision making, and none of the studies reported a negative impact. Family-oriented interventions were associated with high care quality and better resident-staff-family partnership. Staff education and staff-family conversation are relatively cheap interventions to help family involvement, facilitate shared decision-making, and improve family satisfaction.

The history of seed banking and the hazards of backup.

Seeds and other plant materials in seed and gene bank collections are rarely considered adequately conserved today unless genetically identical duplicate samples have been created and safely stored elsewhere. This paper explores the history of seed banking to understand how, why and with what consequences copying collections came to occupy this central place. It highlights a shift in the guiding metaphor for long-term preservation of seed collections, from banking to backup. To understand the causes and consequences of this shift in metaphor, the paper traces the intertwined histories of the central long-term seed storage facility of the United States (opened in 1958) and the international seed conservation system into which that facility was integrated in the 1970s. This account reveals how changing conceptions of security, linked to changing economic, political and technological circumstances, transformed both the guiding metaphors and the practices of seed conservation in these institutions. Early instantiations of long-term cold storage facilities vested security in robust infrastructures and the capacities of professional staff; between the 1960s and 1990s, this configuration gave way to one in which security was situated in copies rather than capacities. This observation ultimately raises questions about the security promised and achieved through present-day infrastructures for crop genetic resources conservation.

Directed Hypercapnia for Weaning From ECMO to Mechanical Ventilation—Progress or Just a Process?

In this issue of The Annals of Thoracic Surgery, Kluis and colleagues1Kluis A. Shih E. Squiers J.J. et al.Directed hypercapnia as a strategy to wean extracorporeal membrane oxygenation in COVID-19 pneumonia.Ann Thorac Surg. 2022; 114: e307-e309Abstract Full Text Full Text PDF Scopus (1) Google Scholar report a single-institution experience with 5 cases of severe COVID-19 acute respiratory distress syndrome (ARDS) with hypercarbic respiratory failure using directed hypercapnia as a strategy to wean patients from venovenous extracorporeal membrane oxygenation (ECMO). The authors instituted a directed hypercapnia approach in combination with metabolically compensated respiratory acidosis to terminate long-term ECMO support and to reduce associated morbidity and mortality. Five patients were successfully weaned off ECMO. One patient with preexisting kidney disease requiring renal replacement therapy ultimately died of refractory acidosis and sepsis. ECMO duration ranged from 56 to 167 days, highlighting the extended duration of support. More than 13,000 cases of COVID-19 requiring ECMO have been reported to the Extracorporeal Life Support Organization registry with a 47% in-hospital mortality.2Extracorporeal Life Support OrganizationELSO live registry dashboard of ECMO patient data.https://www.elso.org/Registry/ELSOLiveRegistryDashboard.aspxDate accessed: March 20, 2022Google Scholar Early use of ECMO for COVID-19 resulted in poor outcomes, with many clinicians discouraging this application.3Henry B.M. Lippi G. Poor survival with extracorporeal membrane oxygenation in acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19): pooled analysis of early reports.J Crit Care. 2020; 58: 27-28Crossref PubMed Scopus (144) Google Scholar As the pandemic progressed, ECMO use increased rapidly, and more recent data suggest similar outcomes to non-COVID ARDS.4Barbaro R.P. MacLaren G. Boonstra P.S. et al.Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry.Lancet. 2020; 396: 1071-1078Abstract Full Text Full Text PDF PubMed Scopus (420) Google Scholar Much of the management of ECMO and mechanical ventilation has been extrapolated from non-COVID ARDS populations. Whereas most centers use lung-protective ventilation, there are no standard guidelines for ventilator management in this setting. Institutional demands and experiences often dictate the pathway of care. The authors report an ECMO weaning protocol that successfully liberated patients from this high-risk, resource-intensive therapy, allowing discharge from a tertiary center to long-term acute rehabilitation facilities. At the individual patient level, this may translate into decreases in the morbidity and mortality associated with prolonged ECMO. At the health system level, the economic and resource allocation benefits associated with freeing up intensive care beds, staff, and resources could be immense. This protocol could be particularly valuable during high infectivity periods when the health system is significantly strained. Certain considerations temper enthusiasm for widespread adoption of this protocol. Individualized care is essential, and recovery is the primary aim. As reported, all survivors remain on assist-control ventilation, and long-term outcomes, including prospects for eventual ventilator liberation, are unknown. Patients may have been better served with sedative reduction, extubation, and ambulation on ECMO. In addition, proponents of directed hypercapnia must ensure that protocols do not restrict evaluation for lung transplantation. Outcomes from ECMO bridging to transplantation have improved because of better patient selection and protocolized management approaches. As highlighted in a recent US nationwide analysis published in the New England Journal of Medicine, lung transplantation is an important option for refractory COVID-19 ARDS or post-COVID fibrosis, with promising early outcomes including 95% 3-month survival in more than 200 recipients.5Roach A. Chikwe J. Catarino P. et al.Lung transplantation for Covid-19–related respiratory failure in the United States.N Engl J Med. 2022; 386: 1187-1188Crossref PubMed Scopus (24) Google Scholar Notwithstanding, there will likely be a role for directed hypercapnia in this population, which will be further delineated as more research is performed. Directed Hypercapnia as a Strategy to Wean Extracorporeal Membrane Oxygenation in COVID-19 PneumoniaThe Annals of Thoracic SurgeryVol. 114Issue 5PreviewCoronavirus disease 2019 pneumonia with respiratory failure refractory to maximum medical therapy has been successfully managed with venovenous extracorporeal membrane oxygenation. This report describes a process of using directed hypercapnia in 5 patients to wean them from prolonged extracorporeal support secondary to refractory hypercarbic respiratory failure. Full-Text PDF

SARS-CoV-2 cases reported from long-term residential facilities (care homes) in South Africa: a retrospective cohort study

BackgroundGlobally, long-term care facilities (LTCFs) experienced a large burden of deaths during the COVID-19 pandemic. The study aimed to describe the temporal trends as well as the characteristics and risk factors for mortality among residents and staff who tested positive for SARS-CoV-2 in selected LTCFs across South Africa.MethodWe analysed data reported to the DATCOV sentinel surveillance system by 45 LTCFs. Outbreaks in LTCFs were defined as large if more than one-third of residents and staff had been infected or there were more than 20 epidemiologically linked cases. Multivariable logistic regression was used to assess risk factors for mortality amongst LTCF residents.ResultsA total of 2324 SARS-CoV-2 cases were reported from 5 March 2020 through 31 July 2021; 1504 (65%) were residents and 820 (35%) staff. Among LTCFs, 6 reported sporadic cases and 39 experienced outbreaks. Of those reporting outbreaks, 10 (26%) reported one and 29 (74%) reported more than one outbreak. There were 48 (66.7%) small outbreaks and 24 (33.3%) large outbreaks reported. There were 30 outbreaks reported in the first wave, 21 in the second wave and 15 in the third wave, with 6 outbreaks reporting between waves. There were 1259 cases during the first COVID-19 wave, 362 during the second wave, and 299 during the current third wave.The case fatality ratio was 9% (138/1504) among residents and 0.5% (4/820) among staff. On multivariable analysis, factors associated with SARS-CoV-2 mortality among LTCF residents were age 40–59 years, 60–79 years and ≥ 80 years compared to < 40 years and being a resident in a LTCF in Free State or Northern Cape compared to Western Cape. Compared to pre-wave 1, there was a decreased risk of mortality in wave 1, post-wave 1, wave 2, post-wave 2 and wave 3.ConclusionThe analysis of SARS-CoV-2 cases in sentinel LTCFs in South Africa points to an encouraging trend of decreasing numbers of outbreaks, cases and risk for mortality since the first wave. LTCFs are likely to have learnt from international experience and adopted national protocols, which include improved measures to limit transmission and administer early and appropriate clinical care.

Caregivers facing violence in long-term care setting: A cross analysis of incident reports and caregivers speech.

Workplace violence is frequent, especially in long-term care, but often unreported. The aim of this study is to identify workers experiences and coping strategies when they face physical aggression from residents and assess the value of incident reports for violence follow-up. This mixed method study is based on incident reports collected over 3 years from two different long-term care geriatric facilities in France and thematic analysis of 20 semi-structured interviews of nurses and nursing assistants. The reported frequencies of physical aggression among respondents range from none to daily aggression. Only 76 incident reports were submitted. Aggressions were under-reported by caregivers who often felt guilty for not having avoided them. Coping strategies included banalization and seeking support from colleagues. Incident reports can constitute a warning signal for the management team but are not a reliable tool for workplace violence follow-up. Our study emphasizes the complexity of workplace violence prevention in long-lerm care settings. Proposals can be formulated to train and support caregivers, but a shift from a task-oriented organisation to a patient-centred approach seems necessary to reduce violence. Situations to be reported should be better defined, aggression reporting encouraged and judgmental attitudes toward reports discouraged.

Pathway to Hospice: How Has Place of Care before Hospice Changed with the Growth of Hospice in the United States?

Background: Hospice use among Medicare decedents increased from 21.6% in 2000 to 51.6% in 2019. Whether this growth has been accompanied by more referrals to hospice directly from the community is not known. Objective: To assess trends in place of care before hospice enrollment. Design: Retrospective cohort from 2011 to 2018. Subjects: Medicare decedents age ≥66 years. Measure: Location of care before hospice enrollment in the last 90 days of life, defined as: the community with and without home health, short- or long-term nursing facility, or inpatient hospital. A county-level random effects model examined changes in enrollment from the community after adjusting for admitting diagnosis, age, race/ethnicity, sex, and Medicaid participation. Results: Among hospice enrollees (N = 7,650,933), 27.7% transitioned to hospice from the community, 31.8% transitioned from the hospital, and 10.1% transitioned after short- or long-term nursing facility stay. Rates of enrollment to hospice from the community remained stable from 35.1% in 2011 to 34.3% in 2018. After adjustment, the proportion enrolling in hospice from the community decreased by 1.2% (95% confidence interval -1.0% to 1.4%). Place of care before hospice enrollment in 2018 varied by hospice admitting diagnosis, with patients with cancer more likely to enroll from the community (39.5%) and patients with cerebrovascular accidents from the hospital (53.2%). Prior place of care varied by state, with Florida having the highest rate of the enrollment following hospitalization (47.8%). Conclusion: Despite the growth of hospice, the site of care before hospice enrollment has remained relatively stable and was strongly influenced by region.

Abstract 272: Infective Endocarditis Of Unicuspid-unicommisural Aortic Valve

Approximately, 75% of patients with infective endocarditis have underlying structural heart disease at the time of diagnosis. Aortic valve disease is associated with up to a quarter of patients, with aortic regurgitation being the most common abnormality. A unicuspid aortic valve (UAV) is an extremely rare congenital anomaly with a prevalence of 0.02%. We present a unique case of UAV with a devastating association. Case Summary: A 32-year-old male intravenous drug abuser presented with weakness after 18-hours of symptom onset. He was afebrile but tachycardic, with left-sided hemiparesis and sensory loss. Brain CT-scan revealed a hypodensity within the right cerebral hemisphere, a CTA of head-neck revealed an acute right MCA infarct with malignant cerebral edema. Due to deteriorating clinical condition, he was intubated for airway protection and underwent emergent hemi-craniectomy. Blood cultures grew enterococcus faecalis. Transthoracic echocardiogram showed abnormal aortic valve with severe regurgitation. Transesophageal echocardiography (TEE) demonstrated unicuspid unicommissural aortic valve with a small mobile echodensity attached to the left ventricular outflow tract aspect. Decision Making: He received a 6-weeks course of ceftriaxone and vancomycin with negative repeat blood cultures. Given poor clinical state, he was deemed poor candidate for valve replacement and was discharged to long-term rehabilitation facility. Four-months later, he was re-admitted with fevers. Repeat TEE demonstrated multiple aortic valve vegetations. He subsequently underwent successful minimally invasive aortic valve replacement. Conclusion: Unicuspid unicommisural aortic valve is an extremely rare condition that can be complicated by aortic stenosis more often than regurgitation. Infective endocarditis has been reported in 11% among UAV patients and can lead to valvular destruction with severe regurgitation which can be catastrophic in some patients

MP02-07 THE IMPACT OF COVID-19 AND TELEMEDICINE ON EMPIRIC UTI TREATMENT IN WOMEN

You have accessJournal of UrologyCME1 May 2022MP02-07 THE IMPACT OF COVID-19 AND TELEMEDICINE ON EMPIRIC UTI TREATMENT IN WOMEN Madeline Epsten, Jennifer Ferraro, Fareesa Khan, Cynthia Brincat, and Kristin Jacobs Madeline EpstenMadeline Epsten More articles by this author , Jennifer FerraroJennifer Ferraro More articles by this author , Fareesa KhanFareesa Khan More articles by this author , Cynthia BrincatCynthia Brincat More articles by this author , and Kristin JacobsKristin Jacobs More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002514.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary tract infection (UTI), one of the most common reasons women seek acute care, is responsible for 15% of all community-prescribed antibiotics. The effects of the pandemic and telemedicine on UTI treatment are largely unknown. Here, we evaluated the impact of Covid-19 and telemedicine on empiric UTI treatment in women. We hypothesized that increased use of telemedicine during the pandemic would increase the rate of empiric UTI treatment. METHODS: This is a retrospective cohort study of treatment patterns of female patients aged 18-65 using ICD-10 codes for acute cystitis with (N30.00) and without (N30.01) hematuria during the first 6 months of the pandemic (March 2020 – August 2020) versus the 6 months preceding the pandemic (September 2019 – February 2020). Our primary outcome was presence of empiric antibiotic treatment, defined by treatment based on clinical picture with or without pending urine testing. Secondary analysis included determining which antibiotics were most commonly prescribed and treatment adjustment. To reach 80% power to detect a 10% difference with p≤0.05, we included 222 patients. Exclusion criteria included inpatient encounter, long-term facility residence, urinary procedure in last 2 weeks, previous UTI treatment within 30 days. RESULTS: The average age of participants was 42 years. Fifty-two percent were white, 23% Black, and 23% Hispanic. No demographic differences existed between cohorts. During the pandemic, 36.6% of UTI encounters were conducted via telemedicine, compared to 1.5% pre-pandemic (p<.0001). The rate of empiric treatment increased from 58.2% pre-pandemic to 70.5% during the pandemic (p=.055). The rate of treatment based on clinical picture with no pending urine testing was significantly higher during the pandemic (p<.0001). Nitrofurantoin or trimethoprim/sulfamethoxazole was used in 79% of patients prescribed an antibiotic. The overall rate of treatment adjustment was 17.1%; there was no significant difference by time period. CONCLUSIONS: Covid-19 dramatically increased telemedicine utilization by women with UTI symptoms. Empiric treatment approached significance and confirmatory urine testing was done significantly less during the pandemic. Given the importance of antibiotic stewardship, it is important to further characterize telemedicine’s impact on treatment of this common condition. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e12 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Madeline Epsten More articles by this author Jennifer Ferraro More articles by this author Fareesa Khan More articles by this author Cynthia Brincat More articles by this author Kristin Jacobs More articles by this author Expand All Advertisement PDF DownloadLoading ...

Changes in long-term care certification rate and related factors in municipalities affected by the heavy rain disaster in July 2018

Objectives The purpose of this study was to determine the change in the certification rate for long-term care (LTC) in the municipalities affected by the heavy rain disaster in July 2018, and to clarify the relationships between the change in the LTC certification rate and the damage situation and regional characteristics.Methods The subjects were 108 municipalities to which the Disaster Relief Act was applied. Interrupted time series analyses were conducted of the monthly LTC certification rate for a total of 37 months from July 2016 to July 2019, and the changes in the LTC, mild LTC (requiring support 1 and 2), moderate LTC (requiring long-term care 1 to 3), and severe LTC (requiring long-term care 4 and 5) certification rates after the disaster were determined. Multinomial logistic regression analyses were performed to clarify the relationship between trends of changes in the LTC certification rate after the disaster, the damage situation (number of damaged houses, number of dead and missing), and the regional characteristics (population rate of people aged 65 and over, population density, taxable income, population per public health nurse, capacity of long-term care insurance facilities, number of hospital beds, number of clinics, specific health examination implementation rate, and specific health guidance implementation rate).Results The LTC and mild LTC certification rates showed significant increases in the month of the disaster and changes in trends after the disaster. The change in the post-disaster trend of the moderate LTC certification rate was significantly lower. The severe LTC certification rate showed a significant increase only in the month of the disaster; however, there was no significant change seen in the post-disaster trend. The downward change in the trend of the moderate LTC certification rate was negatively related to the population rate of people aged 65 and over, and positively related to the number of clinics. No significant associations of the LTC, mild LTC, and severe LTC certification rates with any of the variables related to the disaster situation and regional characteristics were found.Conclusion The results of this study suggest that the demand for long-term care insurance services may increase as a result of disasters experienced by elderly requiring mild LTC certification who have a relatively high degree of independence.

Community based integrated care systems and long-term care health facility in Onomichi area

利用者を中心として地域連携の先駆けをしている尾道市医師会介護老人保健施設が在宅復帰施設としての役割を果たしているかどうか3年間の退所者と病院搬送者を対象として検討した．在宅復帰率は在宅（家庭）からの入所に比し退所は7％増加，在宅復帰の最大阻害要因である病院からの入所者に比べ入院退所は9.3％減少し22％，搬送理由は発熱，呼吸困難，意識障害など，疾患では呼吸器感染症が最多であった．

Factors Associated with Food Form in Long-Term Care Insurance Facilities.

We examined factors related to dietary intake status (food form) of long-term care facility (LTCF) residents to identify factors related to proper food form choice for older individuals requiring nursing care. We surveyed 888 residents from 37 LTCFs in Japan. We evaluated basic information (age, sex, body mass index [BMI]), food form (swallowing-adjusted diet class), Barthel Index (BI), Clinical Dementia Rating (CDR), simply evaluated eating and swallowing functions, the number of present/functional teeth, oral diadochokinesis, repetitive saliva swallowing test (RSST), and modified water swallowing test. To clarify factors associated with food form, participants who had good nutrition by oral intake were categorized into the dysphagic diet (DD) and normal diet (ND) groups. Multi-level analyses were used to detect oral functions associated with food form status. Among objective assessments, BMI (odds ratio [OR] 0.979, 95% confidence interval [CI] -0.022- to 0.006, p = 0.001), BI (OR 0.993, 95% CI -0.007 to -0.004, p < 0.001), CDR 3.0 (OR 1.002, 95% CI 0.002‒0.236, p = 0.046), present teeth (OR 0.993, 95% CI -0.007 to -0.001, p = 0.011), functional teeth (OR 0.989, 95% CI -0.011 to -0.005, p < 0.001), and RSST (OR 0.960, 95% CI -0.041 to -0.007, p = 0.006) were significantly associated with DD vs ND discrimination. Simple evaluations of coughing (OR 1.056, 0.054‒0.198, p = 0.001) and rinsing (OR 1.010, 0.010‒0.174, p = 0.029) could also discriminate food form status. These simple evaluations provide insight into the discrepancies between food form status and eating abilities of LTCF residents. Periodic evaluations by the nursing caregiver may help to prevent aspiration by older individuals with dysphagia.

Healthcare-associated infections in Veterans Affairs acute-care and long-term healthcare facilities during the coronavirus disease 2019 (COVID-19) pandemic.

To assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare-associated infections (HAIs) reported from 128 acute-care and 132 long-term care Veterans Affairs (VA) facilities. We compared central-line-associated bloodstream infections (CLABSIs), ventilator-associated events (VAEs), catheter-associated urinary tract infections (CAUTIs), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridioides difficile infections and rates reported from each facility monthly to a centralized database before the pandemic (February 2019 through January 2020) and during the pandemic (July 2020 through June 2021). Nationwide VA COVID-19 admissions peaked in January 2021. Significant increases in the rates of CLABSIs, VAEs, and MRSA all-site HAIs (but not MRSA CLABSIs) were observed during the pandemic in acute-care facilities. There was no significant change in CAUTI rates, and C. difficile rates significantly decreased. There were no significant increases in HAIs in long-term care facilities. The COVID-19 pandemic had a differential impact on HAIs of various types in VA acute care, with many rates increasing. The decrease in CDI HAIs may be due, in part, to evolving diagnostic testing. The minimal impact of COVID-19 in VA long-term facilities may reflect differences in patient numbers and acuity and early recognition of the impact of the pandemic on nursing home residents leading to increased vigilance and optimization of infection prevention and control practices in that setting. These data support the need for building and sustaining conventional infection prevention and control strategies before and during a pandemic.

Asymptomatic COVID-19 in the elderly: dementia and viral clearance as risk factors for disease progression.

SARS-CoV-2 infected individuals ≥60 years old have the highest hospitalization rates and represent >80% fatalities. Within this population, those in long-term facilities represent >50% of the total COVID-19 related deaths per country. Among those without symptoms, the rate of pre-symptomatic illness is unclear, and potential predictors of progression for symptom development are unknown. Our objective was to delineate the natural evolution of asymptomatic SARS-CoV-2 infection in elders and identify determinants of progression. We established a medical surveillance team monitoring 63 geriatric institutions in Buenos Aires, Argentina during June-July 2020. When an index COVID-19 case emerged, we tested all other eligible asymptomatic elders ≥75 or >60 years old with at least 1 comorbidity. SARS-CoV-2 infected elders were followed for 28 days. Disease was diagnosed when any COVID-19 manifestation occurred. SARS-CoV-2 load at enrollment, shedding on day 15, and antibody responses were also studied. After 28 days of follow-up, 74/113(65%) SARS-CoV-2-infected elders remained asymptomatic. 54% of pre-symptomatic patients developed hypoxemia and ten pre-symptomatic patients died. Dementia was the only clinical risk factor associated with disease(OR 2.41(95%CI=1.08, 5.39). In a multivariable logistic regression model, dementia remained as risk factor for COVID-19 severe disease. Furthermore, dementia status showed a statistically significant different trend when assessing the cumulative probability of developing COVID-19 symptoms(log-rank p=0.027). On day 15, SARS-CoV-2 was detectable in 30% of the asymptomatic group while in 61% of the pre-symptomatic(p=0.012). No differences were observed among groups in RT-PCR mean cycle threshold at enrollment(p=0.391) and in the rates of antibody seropositivity(IgM and IgG against SARS-CoV-2). In summary, 2/3 of our cohort of SARS-CoV-2 infected elders from vulnerable communities in Argentina remained asymptomatic after 28 days of follow-up with high mortality among those developing symptoms. Dementia and persistent SARS-CoV-2 shedding were associated with progression from asymptomatic to symptomatic infection.

DEGRADATING CONCRETE AND REINFORCED CONCRETE BUILDING STRUCTURES AND LONG-TERM STRUCTURES

The problems of degradation of concrete and reinforced concrete constructions of buildings and constructions of long operation are formulated on the basis of the performed field researches and its urgency is noted in the work. The authors analyzed a number of works on this problem. In particular, the results of technical diagnostics of many buildings and structures, both newly built and long-term operation, are described. The necessity of periodic technical diagnostics is noted. Based on these studies, the main factors that significantly affect the reduction of load-bearing capacity of reinforced concrete structures of buildings and structures are summarized and found that they are as follows: design errors, defects and shortcomings of construction and operational shortcomings of buildings and structures. Also, using modern technologies and materials, the authors identified the benefits of their use for repair and restoration of concrete and reinforced concrete structures at a number of long-term facilities. Relevant conclusions have been formulated on research and repair works. It is established that to prevent loss of load-bearing capacity of structures for long-term operation it is necessary to study the degradation and residual life of load-bearing capacity of structures, their reliability and durability, which were exposed to aggressive air, soil and water. It is established that the reason for the decrease in the strength of concrete beams, which were operated in an aggressive environment, was the error in the design of corrosion protection of structures. Reinforcement and injection filling of dry cracks, crevices and hidden cavities and stratifications and other corrosion damage of beams and slabs with the use of fluid polyurethane compositions, which allowed to extend the service life of structures. It is established that the use of the Polymer Cement Concrete system with the use of glued composite materials ensured the further normal operation of the monolithic reinforced concrete floor of the technical floor of the residential building. Recommendations for the sequence of operations in the repair of reinforced concrete structures of buildings and structures of long-term operation.

Prognosis of Chronically Ventilated Patients in a Long-Term Ventilation Facility: Association with Age, Consciousness and Cognitive State.

Background: The number of adults requiring prolonged mechanical ventilation (PMV) including those with cognitive impairment or disorders of consciousness is escalating. We aimed to compare in a long-term acute care hospital (LTACH) mortality and length of stay (LOS) among three age groups (40-59y, 60-79y, ≥80y) of hospitalized PMV patients, and according to consciousness and cognitive state at admission. Methods: We obtained data from the health records of 308 adults aged ≥40 years requiring PMV hospitalized at a Chronic Ventilator Dependent Unit in a LTACH between 01/01/2015 to 06/30/2019 and followed-up until discharge or death or until 12/31/2019. Results: At admission to LTACH, 42.2% of PMV patients were in a vegetative state/ minimally conscious state (VS/MCS); 32.5% were severely cognitively impaired, 11.0% were mildly to moderately cognitively impaired, 12.3% had no cognitive impairment, and 1.9% had intellectual disability/psychiatric disorder. In-LTACH LOS (months) decreased from 34.6 ± 42.6 at age 40-59y, 19.1 ± 22.3 at 60-79y to 14.4 ± 19.3 at age ≥80y (p = .006). In-LTACH mortality was 30.6% for 40-59y, 41.1% for 60-79y and 54.8% for age ≥80y. In-LTACH LOS (months) was 23.8 ± 30.7 for VS/MCS, 15.1 ± 19.5 for the severely cognitively impaired, 10.0 ± 12.8 for mild to moderate cognitive impairment and 18.9 ± 21.9 for those without cognitive impairment (p = .02). In-LTACH mortality was 50.8% for VS/MCS, 58.0% for the severely cognitively impaired, 26.5% for mild to moderate cognitive impairment and 13.2% for those without cognitive impairment (p < .001). Conclusion: In this population requiring PMV, mortality and in-LTACH LOS worsened with age. In-LTACH LOS was longest for VS/MCS patients, who had a mean survival of about two years, followed by those without cognitive impairment and then those with severe cognitive impairment. Mortality was associated with worse consciousness and cognitive state. These findings highlight the importance of discussing end-of-life decisions with patients and family members regarding resuscitation/intubation and the long-term management of these patients.

A study on texture stability and the biaxial creep behavior of as-hydrided CWSR Zircaloy-4 cladding at the effective stresses from 55 MPa to 65 MPa and temperatures from 300 °C to 400 °C

The creep rupture of high burnup used nuclear fuel (> 45 GWD/MTU) cladding is regarded as one of the failure mechanisms during long-term dry storage. A high amount of zirconium hydride in the cladding matrix would degrade the mechanical properties of the cladding especially leading to delayed hydride cracking. To better understand the influence of zirconium hydride on the biaxial thermal creep performance and the crystalline texture stability of Zircaloy-4 cladding, the pressurized tube technique is applied to test the durability of the as-hydrided material. Tests were performed on as-received Zircaloy-4 tubular specimens as well as-hydrided ones with targeted 300 wt parts per million (wppm) or 750 wppm hydrogen. The biaxial creep experiments were conducted at temperatures from 300 °C to 400 °C and at equivalent stresses at mid-wall from 55 MPa to 65 MPa. The hydridation process prior to creep tests induces the formation of FCC δ-hydride platelets along the circumferential direction of the tube. This alignment and phase structure of hydride show no significant change after biaxial creep tests. The creep strain-rate negatively depends on the hydrogen content. The synchrotron wide-angle X-ray diffraction (WAXD) technique and electron backscatter diffraction (EBSD) analysis were applied for the study of the crystallographic orientation relationship. zirconium-to-hydride grain orientation follows Shoji–Nishiyama crystallographic relationship. This relationship is stable before and after creep deformation. These results of creep performance and texture stability of Zircaloy-4 claddings can help support the design basis of interim and long-term dry storage facilities.

Emergency medical care for multiple sclerosis: A five-year population study in the Campania Region (South Italy)

Background: Emergency hospital admissions are common in multiple sclerosis (MS), and can highlight unmet medical needs. Objectives: To evaluate burden, predictors and outcomes of MS emergency admissions. Methods: This is a population-based study, conducted in the Campania Region (South Italy) from 2015 to 2019, using hospital discharge records, drug prescriptions and outpatients. The risk of emergency hospital admissions and the likelihood of worse outcomes were evaluated using the Cox regression and multinomial logistic regression models, respectively, in relation to age, sex, disease-modifying treatments (DMTs), comorbidities and adherence. Results: We recorded 1225 emergency admissions for 1001 patients (out of 5765 prevalent MS patients), overall costing 4,143,764.67 EUR. The risk of emergency admissions increased with age (hazard ratio (HR) = 1.02; 95% confidence interval (CI) = 1.01, 1.03; p < 0.01) and comorbidities (HR = 1.62; p < 0.01), and decreased in patients using DMTs (interferon beta/peg-interferon beta/glatiramer acetate HR = 0.19; p < 0.01; teriflunomide/dimethyl-fumarate/fingolimod HR = 0.18; p < 0.01, and alemtuzumab/cladribine/natalizumab/ocrelizumab HR = 0.21; p < 0.01), and with higher adherence (HR = 0.18; 95% CI = 0.13, 0.26; p < 0.01). Following emergency admission, older age was associated with probability of death (n = 63) (odds ratio (OR) = 1.06; p < 0.01) and discharge to long-term facility (n = 65) (OR = 1.03; p = 0.01). Conclusion: With 17% people with MS requiring emergency medical care over 5 years, improved management of DMTs and comorbidities could potentially reduce their medical, social and financial burden.