Outpatient Long-term Care Research Articles

Analysing the Need for Long-Term Care: Potential of Data from Long-Term Care Assessments of the Bavarian Medical Service for Public Health Research and Practice

Despite demographic changes, there is still no systematic and comparable differentiation of nursing care reporting on a small-scale level in Germany, where outpatient long-term care is depicted. This article presents findings of care assessment data of the Medical Service of Bavaria and draws conclusions for future reporting on nursing. For the analysis, anonymised initial long-term care assessments of the Bavarian Medical Service of 2019 were evaluated exemplarily using descriptive methods. The study describes the characteristics of persons with a care level recommendation, the distribution of care level categories, medical diagnoses and degree of independence in the areas of life. The persons assessed were on average 80 years old. At the time of the initial assessment, the largest proportion of persons with an assigned care level lived in an outpatient setting. Care level (PG) 1 (slight impairment of independence or abilities) was assigned to 35.1% of the insured, PG 2 (considerable impairment) to 43.1%, PG 3 (severe impairment) to 16.6%, PG 4 and 5 (most severe impairment) were each rarely assigned at the time of the initial assessment (3.9% and 1.4%, respectively). Medical diagnoses were dominated by gait and mobility disorders, unspecified dementia, heart failure and senility. In particular, there were impairments in the areas of 'mobility' and 'organisation of everyday life and social contacts'. The data available from the German Medical Service may be highly relevant to health research and policy and may provide a basis for planning interventions in long-term care.

Medical care and biomarker-based assessment of mortality in two cohorts of patients with chronic coronary syndrome 10 years apart

BackgroundThis study aimed to describe the characteristics and mortality of two cohorts of patients with chronic coronary syndrome (CCS) recruited with identical study designs in the same rehabilitation clinics but approximately 10 years apart.MethodsThe KAROLA cohorts included patients with CCS participating in an inpatient cardiac rehabilitation programme in Germany (KAROLA-I: years 1999/2000, KAROLA-II: 2009–2011). Blood samples and information on sociodemographic factors, lifestyle, and medical treatment were collected at baseline, at the end of rehabilitation, and after one year of follow-up. A biomarker-based risk model (ABC-CHD model) and Cox regression analysis were used to evaluate cardiovascular (CV) and non-CV mortality risk.ResultsWe included 1130 patients from KAROLA-I (mean age 58.7 years, 84.4% men) and 860 from KAROLA-II (mean age 60.4 years, 83.4% men). Patients in the KAROLA-I cohort had significantly higher concentrations of CV biomarkers and fewer patients were taking CV medications, except for statins. The biomarker-based ABC-CHD model provided a higher estimate of CV death risk for patients in the KAROLA-I cohort (median 3-year risk, 3.8%) than for patients in the KAROLA-II cohort (median 3-year risk, 2.7%, p-value for difference < 0.001). After 10 years of follow-up, 91 (8.1%) patients in KAROLA-I and 45 (5.2%) in KAROLA-II had died from a CV event.ConclusionsAdvances in disease management over the past 20 years may have led to modest improvements in pharmacological treatment during cardiac rehabilitation and long-term outpatient care for patients with CCS. However, modifiable risk factors such as obesity have increased in the more recent cohort and should be targeted to further improve the prognosis of these patients.

Einsatz digitaler Beschäftigung in der stationären und ambulanten Langzeitpflege bei Menschen mit Demenz und älteren Personen mit erhöhtem Pflegebedarf zum Erhalt kognitiver und kommunikativer Fähigkeiten

Background: At an older age and with increasing life expectancy, more and more people are affected by dementia. Individual, multifaceted solutions are needed to maintain and promote their cognitive abilities. In view of new technological possibilities, digital assistive applications for people with dementia are coming into focus. Method: Mixed-methods approach: The study included 16 persons over 64 years of age who had medically-diagnosed dementia or cognitive impairments and an increased need for care (from care level 2), were in an inpatient long-term care facility or a day care facility, and used the digital table system there for several weeks in individual and group activities. In addition, seven professionals from the four participating facilities with a focus on physiotherapy, occupational therapy, nursing and social care were recruited for expert interviews. Results: The digital activity with the table system used for people with dementia, cognitive impairments and an increased need for care is suitable for use in outpatient and inpatient long-term care. It was found to have positive effects, especially on the communicative abilities of the test persons. For people with severe forms of dementia, however, digital occupation is only recommended to a limited extent. Staff should always be present during activity. The test persons assessed the digital table system positively for the most part: 60% stated that they liked using the system frequently. For 80%, it was easy to learn how to use the table, but for 24% it also contained too many application options. The study participants found the digital table system's offerings attractive, stimulating, and original. The transparency of the system, on the other hand, was rated as rather difficult. Conclusion: Successful use of digital activities for people with dementia and those with an increased need for care can be supported by a flexible approach of the staff towards technological developments and a needs-based, pre-developed concept for engaging the target group, as well as sufficient time for its implementation. Keywords: digital activity, dementia, cognitive impairment, communication, assistive technologies, serious games, inpatient and outpatient long-term care

CASE CONCEPTUALIZATION AND TREATMENT OF ATYPICAL SYMPTOMATOLOGY OF OCD USING COGNITIVE BEHAVIOR THERAPY

Obsessive Compulsive Disorder is characterized by obsessional thinking, compulsive behavior and varying degrees of anxiety and depression. The course of OCD can be episodic or chronic with latter being considered as treatment resistant and high levels of dependency on mental health services. This case study describes the process of CBT in the long-term outpatient care of a young man with OCD. The client came with the chief complaints of repeated thoughts of losing home registry and checking behaviors to reduce the anxiety associated with these thoughts, with total duration of 22 years. Problems in social functioning and performance in work were encountered by the patient but still leading a compromised quality of life. Objective assessment tools (Y-BOCS &amp; BDI) were used to asses' severity of symptoms (anxiety and depression). A total number of 15 sessions were conducted once a week, each lasting 60-80 minutes. Results indicate considerable improvement in all outcome variables and maintenance of treatment gains. These findings provide evidence in support of potential usefulness of cognitive-behavioral interventions in the treatment of OCD

HALF OF OLDER ADULTS HOSPITALIZED WITH COVID-19 EXPERIENCE SYMPTOMS ONE YEAR LATER

Abstract Older adults hospitalized with severe COVID-19 are at higher risk of experiencing serious in-hospital outcomes and long-term health consequences following discharge. Declines in health and functional ability post-hospitalization are important infection-related outcomes. This study’s aim was to examine functional recovery one year following COVID-19 hospitalization. Twenty-one adults ≥60 years of age hospitalized with confirmed COVID-19 infection between 3/2020–5/2020 in Southeast Michigan completed a survey 9–15 months post-discharge including items from the Fried Frailty score, Short Form 36 Physical Assessment, PROMIS Dyspnea Scale, and the World Health Organization Disability Assessment Schedule. Mean age at hospital admission was 69 (standard deviation 7). Half of participants (52%) indicated they had too little energy to do the things they wanted to do, 52% (n=11) indicated moderate to severe shortness of breath when walking up two flights of stairs, and 43% (n=9) indicated they were limited a lot in walking several blocks. Additionally, 57% (n=12) indicated they were severely or extremely emotionally affected by their health due to their COVID-19 infection. Results were similar in only those ≥70 years (n=7). Our survey indicates that half of patients hospitalized with severe COVID-19 from the first infection wave in Southeast Michigan are significantly affected up to a year or more after their initial infection, and may benefit from long-term outpatient care. More research is needed to inform development of effective treatments for the long-term emotional and physical impacts of severe COVID-19.

Long-Term Outpatient Care and Rehospitalizations in Patients after Cardiac Electrotherapy Device Implantation.

Background and Objectives: Cardiovascular implantable electronic device (CIED) treatment is widely used in modern cardiology. Indications for this type of treatment are increasing. However, a significant proportion of CIED implantation patients require subsequent hospitalization for cardiovascular reasons. Older age and the associated complex clinical picture necessitate multidisciplinary outpatient specialist care for these patients. The aim of this study was to analyze the reasons for subsequent hospitalizations in the cardiology department and the impact of outpatient specialty care on these hospitalizations. To the best of our knowledge, there are no such studies in the available literature. Materials and Methods: This study was conducted on a population of patients treated with CIED. Reasons for subsequent hospitalizations were divided into clinically and statistically valid groups according to the main diagnosis. Using an electronic database, causes of hospitalization were determined based on this diagnosis. Using data on consultations at outpatient specialty clinics, a logistic regression model was created for the probability of subsequent hospitalization for cardiovascular causes according to the specialty of the clinic. Results: The 9-year follow-up included a population of 2071 patients treated with CIED. During the follow-up period, 508 patients (approximately 24.5%) required subsequent hospitalization for cardiovascular reasons. The most common leading causes were heart failure, atrial fibrillation, and coronary artery disease. The need for consultation at outpatient specialty clinics increased the likelihood of hospitalization. Moreover, the need to consult patients in nephrology outpatient, pulmonary disease outpatient, and orthopedic outpatient clinics was the most significant. Conclusions: The use of electronic implantable cardiovascular devices is a very important part of therapy in modern cardiology. The methods for their use are constantly being improved. However, they represent only one stage of cardiac treatment. After CIED procedures, patients require further care in both inpatient and outpatient specialty care settings. In this paper, we outline the reasons for subsequent hospitalizations and the importance of outpatient specialty care in this context. Effective organization of care after CIED procedures may be important in reducing the most expensive component of this care, that is, inpatient treatment.

The handling of psychotropic drugs in outpatient long-term care of older people : Part2: the perspective of outpatient care providers

Studies show risks in the psychopharmacological care of older people with long-term care needs. In developing recommendations on the handling of psychotropic drugs in outpatient long-term care, the perspective of care professionals has so far received only sporadic attention. The study aims to explore perspectives in outpatient care on the use of psychopharmaceuticals in the care of older people in need of long-term care. The importance of the topic, problems in dealing with it, priorities of measures as well as knowledge and distribution of instruments are examined. An online survey was used to interview personnel in leading positions in arandom sample of 20% (n = 2957) of the 15,138 outpatient long-term care facilities licensed with acare contract in 2019. Statistical data analysis and content analysis of answers to open questions was conducted. A total of 212 questionnaires was completed (7.2% response rate), 87.2% of the respondents evaluated the importance of dealing with psychotropic drugs as high and 46.2% were confronted with problems related to psychotropic drugs in their own work. Participants located problems predominantly with physicians (53.1%), but also with patients (19.6%), nursing staff (11.2%) and caring relatives (6.1%). The use of measures varied. Cooperation with physicians and-with less priority, but still important-the qualification of nursing staff and the involvement of caring relatives were named as central fields of action. The heterogeneity of experiences and initial conditions regarding the handling of psychotropic drugs in outpatient long-term care should be taken into account when developing corresponding recommendations for action and implementation concepts.

Soziale Ungleichheiten in der gesundheitlichen Versorgung der koronaren Herzkrankheit. Ergebnisse der GEDA-Studie 2014/2015

IntroductionLittle is known about social inequalities in outpatient long-term care of coronary heart disease (CHD) in Germany. MethodsRegression analyses are based on the responses of women and men who participated in the national cross-sectional study “German Health update” (GEDA) 2014/2015 and had self-reported CHD (N=920). Outpatient healthcare of CHD was analysed on the basis of the self-reported administration of antihypertensive and cholesterol-lowering drugs, and the frequency of general practitioner (GP) contacts. ResultsOn average, respondents visited their GP 7.5 times a year (mean). 46 % did not receive guideline-consistent treatment, i. e. both antihypertensive and cholesterol-lowering drugs. Respondents of lower social status consulted their GP more frequently (approx. two visits per year) than those of higher social status (AME: 1.94; 95% CI 0.56 to 3.31). Regarding treatment with antihypertensive and cholesterol-lowering drugs, there were no significant differences for either gender or social status. Nevertheless, the probability that respondents with increased levels of blood lipids or cholesterol took only one or none of the two medications recommended for long-term treatment of CHD was reduced by 54 percentage points (AME: –0,54; 95% CI –0,61 to –0,48). DiscussionThere are no social inequalities in the treatment of CHD patients with antihypertensive and cholesterol-lowering drugs, but inequalities exist in the frequency of visits to the GP who is more often consulted by the more socially disadvantaged patients. ConclusionWith about 7.5 consultations per year, CHD patients visit their general practitioner more often than average, but in about half of these patients the medication supply is less than optimal. This may indicate a deficit in the medical treatment of CHD that cannot be explained by social inequalities. A possible starting point for improving healthcare, especially for patients without other risk factors, is to focus more strongly on a guideline-based approach to prescribing medication for CHD patients.

Bedarfe der Langzeitpflege in der COVID-19-Pandemie

Das Virus SARS-CoV‑2 und die damit einhergehende Erkrankung COVID-19 stellen die Gesundheitssysteme weltweit vor große Herausforderungen. Besonders die vulnerable Gruppe pflegebedürftiger Menschen in der Langzeitpflege ist gefährdet, schwere Krankheitsverläufe zu erleiden oder an der Infektion zu versterben.In einer bundesweiten Querschnittsstudie wurden mittels einer Onlinebefragung die Situation und die Bedarfe stationärer und ambulanter Langzeitpflegeeinrichtungen während der SARS-CoV-2-Pandemie erfasst und analysiert.Konkret forderten Teilnehmende aus 531 Einrichtungen einheitliche Handlungsempfehlungen zu SARS-CoV‑2, ausreichende und finanzierbare Schutz- und Hygienematerialien, Reihentestungen in den Einrichtungen, fundierte Beratung bei der Umsetzung von Maßnahmen, einen konkreten Pandemieplan und unterstützende Öffentlichkeitsarbeit in den Medien. Dazu wurden eine höhere Vergütung der Pflegenden, eine bessere Personalausstattung und stärkere Wertschätzung der pflegerischen Profession gefordert.Um die vulnerable Gruppe pflegebedürftiger Menschen vor einer SARS-CoV-2-Infektion zu schützen, muss die Langzeitpflege stärker in den Fokus der gesundheitspolitischen Maßnahmen während der Pandemie gerückt werden.

Effect of Regional Long-Term Care Service Supply on Choice of Care Arrangement in Old Age

Depending on their place of residence, older persons have unequal access to long-term care (LTC) services. This article investigates how the county-level supply of inpatient and outpatient LTC services influences individual-level LTC choices of older persons. Administrative data on LTC service supply from the German Care Statistic are combined with representative survey data on the LTC choices of N = 1303 persons aged 80+ from the German Federal State North Rhine-Westphalia. Random utility models are applied to model the choice among three care arrangements: receiving inpatient care in an institutional setting (e.g., nursing home), receiving outpatient care in the community, and living in the community without receiving inpatient or outpatient care. The main findings are: Higher inpatient service supply increases the probability that older persons leave the community and enter institutional LTC. Higher outpatient service supply increases the probability that older persons choose to receive outpatient care in the community instead of entering institutional LTC. The results suggest that policy makers must consider the county-level LTC service supply when designing equitable LTC systems that meet the needs of older persons in a cost-effective way.

Outpatient quality of care for permanent postoperative hypoparathyroidism

Postoperative hypoparathyreoidism can cause severe symptoms, relevant sequelae and far reaching impairments of quality of life. Socio-economic effects are considerable. Individual follow-up of patients at risk could improve quality of care. We analysed quality of care for patients with hypoparathyreoidism after thyreoidectomy at our centre of endocrine surgery (Kompetenzzentrum DGAV) and tried to identify potentials for improvement. 420 consecutive patients underwent thyreoidectomy (patients with hyperparathyreoidism excluded) between 08/2012 and 08/2014, follow-up 8-32 months. Group I (study group): 197 patients with calcium (Ca) in blood serum on postoperative day 1 < 2,1 mmol/l and/or parathyroide hormone (PTH) < 15 pg/ml. Group II (control group): 223 patients with Ca ≥ 2 mmol/l and PTH ≥ 15 pg/ml on postoperative day 1. Outcome parameters at follow-up: Ca-, PTH-level, symptoms, quality of life and quality of care by general practitionor in long-term outpatient care (questionnaire). Participation rate at follow-up was 30,6 % (117/382). Rate of postopertive hypoparathyreoidism: 47 % temporary, 6 % permanent. Number of symptoms and perceived burden was identical in patients with hypoparathyreoidism compared to patients in the control group. Long-term outpatient postoperative care was performed in 96 % by general practitionors. No patient with a calcium level in blood serum ≤ 2,1 mmol/l was not on calcium and/or vitamin D medication at the time of follow-up. 33 % of patients with hypoparathyreoidism received insufficient calcium and/or vitamin D medication. 24 % of all 117 patients screened received calcium/or vitamin D medication despite normal blood levels and regular blood tests by general practitionors (rate 76 %) at the time of follow-up. We found features of under-, as well as of over-treatment by general practitionors in patients with postoperative hypoparathyreoidism. From this we deduct target parameters for improvement of outpatient long-term care after thyreoidectomy: 1. Close follow-up, 2. Sufficient calcium and/or vitamin D medication in all patients with postoperative hypoparathyreoidism, 3. On-time termination of medication in patients with normal postoperative parathyroid hormone levels.

Influence of new treatment modalities on adherence in glaucoma.

It is well known that glaucoma patients are not adherent to their therapeutic regimens. The issue of nonadherence is multifactorial and includes inadequate communication between doctors and patients, resulting in significant costs associated with enhanced disease progression. Therapeutic regimens are risk factors which often influences adherence rates. Thus, alternative treatment modalities, especially those risk factors that do not rely on patients' cooperation, may enable improvements in long-term outcomes of glaucoma in patient. The studies selected for this review were divided into new medications, especially advancements in pharmaceutical approaches to treat glaucoma and new ways of delivering the medication, new surgical methods, especially minimally invasive surgery methods for glaucoma, and new studies about adherence in glaucoma. Surprisingly, a very few studies on glaucoma medication or surgery addressed the concept of adherence. However, adherence is discussed in studies which consider psychological aspects of patients or communication issues between doctors and patients. Although these studies were performed in clinical settings, the issue of adherence is not addressed; despite it has significant effect on long-term outpatient care. A combination of both aspects, adherence and miscommunication, should be considered in studies.

Time trends in patients managed simultaneously in multiple hospital outpatient specialty clinics for chronic diseases: A register-based cross-sectional study.

Background:The increasing prevalence of patients with multimorbidity in the general population affects the health-care system. There is a lack of knowledge of the proportion of patients attending multiple hospital outpatient specialty clinics simultaneously.Objective:This study describes the development in the proportion of patients managed simultaneously in multiple hospital outpatient specialty clinics.Design:We obtained three cross-sectional samples from all of the hospitals in Denmark. The data set consists of adults (age 18+) in long-term outpatient care on January 1 in 2004, 2009, and 2014 with one or more of 50 consensus-selected chronic diseases. Descriptive statistics were used to examine and compare the proportion of patients treated simultaneously in multiple outpatient specialty clinics. We also investigated the most common combinations of outpatient specialty clinics.Results:In 2004, 176,786 patients with chronic diseases were registered as receiving outpatient care in Denmark. This figure increased to 246,542 patients in 2009 and 341,015 in 2014. The proportion of patients managed simultaneously in multiple outpatient specialty clinics was 4.0% in 2004, 5.5% in 2009, and 7.7% in 2014. The most common specialty clinic combination was endocrinology and cardiology, accounting for 12.1% in 2004, 11.5% in 2009, and 9.6% in 2014.Conclusions:The proportion of patients in multiple clinics nearly doubled over a 10-year period. While there were some common specialty clinic combinations in which patients were treated most often, there was also considerable variation. Further studies are needed to identify generic and disease-specific initiatives.

Institutional Pathways to Improve Care of Patients with Elevated Blood Pressure in the Emergency Department.

Hypertension (HTN) is the most prevalent cardiovascular disease and poses a major population level risk to long-term health outcomes. Despite this critical importance, and the widespread availability of effective and affordable medications, blood pressure (BP) remains uncontrolled in up to 50% of the diagnosed patients. This problem is exacerbated in communities with limited access to primary care, who often utilize hospital emergency departments (EDs) as their primary healthcare resource. Despite the ubiquity of patients presenting to EDs with severely elevated BP, a unified, evidence-based approach is not yet widely implemented, and both under- and overtreatment are common. The purpose of this review is to describe an approach towards institutional policy regarding asymptomatic HTN, in which we will translate the accepted principles of appropriate outpatient BP management to ED and inpatient settings. Results from the recent SPRINT trial, and the subsequent publication of the American Heart Association updated guidelines for the treatment of HTN, significantly lower both the diagnostic threshold and the treatment goals for hypertensive patients. This change will drastically increase the proportion of patients presenting to EDs with newly diagnosed and uncontrolled HTN. Several recent studies emphasize the safety in outpatient management of patients with severely elevated BP in the absence of acute end-organ damage and, conversely, the long- and intermediate-term risk associated with these patients. System-based approaches, particularly those led by non-physicians, have shown the greatest promise in reducing population level uncontrolled HTN. Evidence-based approaches, such as those described in emergency medicine and cardiology society guidelines, can guide appropriate management of ED and inpatient BP elevations. Translating these patient oriented guidelines into institutional policy, and maintaining provider adherence, is a challenge across healthcare institutions. We present here several examples of successful policies developed and implemented by the authors. While brief inpatient and ED encounters cannot replace long-term outpatient care, they have the potential to serve as a crucial inlet to health care and an opportunity to optimize care.

Evolution of the clinical profile of patients with acute heart failure treated in Spanish emergency departments

ObjectiveTo analyze the changes in epidemiology, outpatient and emergency department clinical care, and outcomes of patients treated for acute heart failure (AHF) in Spanish hospital emergency departments (HEDs) between 2007 and 2014. MethodA multicentre cohort study was conducted that consecutively included patients with AHF diagnosed in 9HEDs during 4 periods (2007, 2009, 2011 and 2014). The study analyzed the changes observed in 20 variables corresponding to baseline data, outpatient care and emergency care data and outcome data. ResultsA total of 4845 patients were included. There were significant changes in 13 variables: there was an increase in patients older than 80years (2007/2014: 45.9%/55.4%; p<.001) and a decrease in severe functional dependence (28.2%/19.7%; p<.001). In terms of long-term outpatient care, there was an increased use of beta-blockers (44.6%/57.8%; p=.002) and aldosterone antagonists (26.6%/37.7%; p<.05) among patients with reduced ejection fraction and an increase use of echocardiography (42.8%/56.2%; p=.001). The use of digoxin decreased (25.4%/16.9%; p=.005). In terms of emergency care, there was an increase in requests for troponins (54.6%/61.9%; p<.001), natriuretic peptides (7.8%/48.5%; p<.001) and the use of noninvasive ventilation (3.2%/6.9%; p=.004). Requests for endovenous perfusion drugs decreased (diuretics: 21.3%/10.4%; p<.001; nitrates: 21.3%/17.5%; p=.001; vasopressors: 4.2%/1.5%; p<.001). Finally, discharges directly from the emergency department without hospitalization increased (20.0%/25.9%; p<.001), and emergency department readmissions at 30days decreased (27.3%/17.6%; p=.007). Hospital mortality and mortality at 30days did not change. ConclusionsChanges in outcomes were detected during a 7-year period in patients with AHF treated in HEDs, with care that was more in line with the clinical guidelines. There are, however, areas for improvement. There was a noteworthy increase in outpatient follow-up without hospitalization and a reduction in HED readmissions.

Evolución del perfil clínico de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias españoles

ObjectiveTo analyse the changes in epidemiology, outpatient and emergency department clinical care, and outcomes of patients treated for acute heart failure (AHF) in Spanish hospital emergency departments (HEDs) between 2007 and 2014. MethodA multicentre cohort study was conducted that consecutively included patients with AHF diagnosed in 9HEDs during 4 periods (2007, 2009, 2011 and 2014). The study analysed the changes observed in 20 variables corresponding to baseline data, outpatient care and emergency care data and outcome data. ResultsA total of 4,845 patients were included. There were significant changes in 13 variables: there was an increase in patients older than 80years (2007/2014: 45.9%/55.4%; P<.001) and a decrease in severe functional dependence (28.2%/19.7%; P<.001). In terms of long-term outpatient care, there was an increased use of beta-blockers (44.6%/57.8%; P=.002) and aldosterone antagonists (26.6%/37.7%; P<.05) among patients with reduced ejection fraction and an increase use of echocardiography (42.8%/56.2%; P=.001). The use of digoxin decreased (25.4%/16.9%; P=.005). In terms of emergency care, there was an increase in requests for troponins (54.6%/61.9%; P<.001), natriuretic peptides (7.8%/48.5%; P<.001) and the use of noninvasive ventilation (3.2%/6.9%; P=.004). Requests for endovenous perfusion drugs decreased (diuretics: 21.3%/10.4%; P<.001; nitrates: 21.3%/17.5%; P=.001; vasopressors: 4.2%/1.5%; P<.001). Finally, discharges directly from the emergency department without hospitalization increased (20.0%/25.9%; P<.001), and emergency department readmissions at 30days decreased (27.3%/17.6%; P=.007). Hospital mortality and mortality at 30days did not change. ConclusionsChanges in outcomes were detected during a 7-year period in patients with AHF treated in HEDs, with care that was more in line with the clinical guidelines. There are, however, areas for improvement. There was a noteworthy increase in outpatient follow-up without hospitalisation and a reduction in HED readmissions.

After initial treatment for primary breast cancer: information needs, health literacy, and the role of health care workers.

After a short hospital stay of just some days follows long-term outpatient care for breast cancer patients. The aim of the study is to describe the information needs of breast cancer outpatients and to get in touch with aspects of health literacy, as well as contact various health care workers. In a multicenter study, patients were asked about their information needs 10 weeks after surgery. The analysis on hand includes data about 1248 female patients. In addition to descriptive analyses identifying the most prevalent information needs, logistic regression analyses were calculated to identify factors associated with these. The results show that information needs of breast cancer outpatients are mainly in "follow-up after acute treatment", "coping with long-term side effects", and "heredity of breast cancer". In addition to sociodemographic patient characteristics, perceived helpful contacts with various health care workers as well as a satisfactory patient's level of health literacy reduced the probability of unmet information needs. Breast cancer outpatients have numerous information needs. In addition to provide information at the right time regarding a specific disease phase, it is important that health professionals' support affected breast cancer patients in coping with the new situation.

Complications Resulting from Taking Ear Impressions

In 2012, we carried out a study in a large sample to understand the secondary injuries caused during the taking ear impressions for hearing aids. This study is a follow-up of previous research conducted in 1986 (285 medical institutions) and 1999 (98 medical institutions). We posted a questionnaire survey to the otolaryngology departments of 3,257 medical institutions. The response rate to the questionnaire was 62.9% (2,050 of the 3,257 institutions), and the results indicated that 301 of the 2050 institutions (14.7%) had experience with secondary injuries, with a total of 460 cases reported. In 342 of the 460 cases (74.3%), the secondary injuries occurred at hearing-aid dealerships, followed by 67 cases (14.6%) at affiliated medical institutions, and 51 cases (11.1%) in other locations, including other medical institutions, rehabilitation counseling centers, and educational institutions. The most common type of secondary injury (298 cases, 64.8%) was caused by the presence of foreign bodies in the ear, which in turn was a result of complications occurring during the removal of residual ear impression material. Of these 298 cases, 32 required excision of the foreign bodies and surgical intervention under general anesthesia. The remaining 10 cases exhibited isolated tympanic membrane perforation without foreign body-related complications. Furthermore, 146 cases (31.7%) developed bleeding and otitis externa following removal of the ear impression, and there were reports of cases with bleeding that required long-term outpatient care and treatment. Therefore, since retention of a foreign body in the ear and tympanic membrane perforation can occur even in patients without a history of surgery or prior otologic history, adjustment of hearing aids requires prior otorhinolaryngological examination. Furthermore, because of the risk of secondary injury when taking ear impressions, this procedure must be performed with caution under the guidance of an otolaryngologist.

The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: Executive summary

Institutional Affiliations Co-chairs Feldman D: Minneapolis Heart Institute, Minneapolis, Minnesota, Georgia Institute of Technology and Morehouse School of Medicine; Pamboukian SV: University of Alabama at Birmingham, Birmingham, Alabama; Teuteberg JJ: University of Pittsburgh, Pittsburgh, Pennsylvania Task force chairs Birks E: University of Louisville, Louisville, Kentucky; Lietz K: Loyola University, Chicago, Maywood, Illinois; Moore SA: Massachusetts General Hospital, Boston, Massachusetts; Morgan JA: Henry Ford Hospital, Detroit, Michigan Contributing writers Arabia F: Mayo Clinic Arizona, Phoenix, Arizona; Bauman ME: University of Alberta, Alberta, Canada; Buchholz HW: University of Alberta, Stollery Children’s Hospital and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Deng M: University of California at Los Angeles, Los Angeles, California; Dickstein ML: Columbia University, New York, New York; El-Banayosy A: Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Elliot T: Inova Fairfax, Falls Church, Virginia; Goldstein DJ: Montefiore Medical Center, New York, New York; Grady KL: Northwestern University, Chicago, Illinois; Jones K: Alfred Hospital, Melbourne, Australia; Hryniewicz K: Minneapolis Heart Institute, Minneapolis, Minnesota; John R: University of Minnesota, Minneapolis, Minnesota; Kaan A: St. Paul’s Hospital, Vancouver, British Columbia, Canada; Kusne S: Mayo Clinic Arizona, Phoenix, Arizona; Loebe M: Methodist Hospital, Houston, Texas; Massicotte P: University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada; Moazami N: Minneapolis Heart Institute, Minneapolis, Minnesota; Mohacsi P: University Hospital, Bern, Switzerland; Mooney M: Sentara Norfolk, Virginia Beach, Virginia; Nelson T: Mayo Clinic Arizona, Phoenix, Arizona; Pagani F: University of Michigan, Ann Arbor, Michigan; Perry W: Integris Baptist Health Care, Oklahoma City, Oklahoma; Potapov EV: Deutsches Herzzentrum Berlin, Berlin, Germany; Rame JE: University of Pennsylvania, Philadelphia, Pennsylvania; Russell SD: Johns Hopkins, Baltimore, Maryland; Sorensen EN: University of Maryland, Baltimore, Maryland; Sun B: Minneapolis Heart Institute, Minneapolis, Minnesota; Strueber M: Hannover Medical School, Hanover, Germany Independent reviewers Mangi AA: Yale University School of Medicine, New Haven, Connecticut; Petty MG: University of Minnesota Medical Center, Fairview, Minneapolis, Minnesota; Rogers J: Duke University Medical Center, Durham, North Carolina

A Descriptive Review of Neuropathic-Like Pain After Burn Injury

This study reviews the natural history of neuropathic-like pain after burn injury. We undertook a retrospective chart review during a 24-month period of patients treated at an outpatient burn center. The medical records of patients with neuropathic-like pain complaints, including the sensation of pins and needles, burning, stabbing, shooting, or "electric" sensations, were included for analysis. Medical and demographic data were collected. We identified 72 patients for inclusion in the study. The age was 44 +/- 2 years (mean +/- SEM), and TBSA burned was 18 +/- 3%. The first complaint of neuropathic-like symptoms was at 4.3 +/- 0.5 months after injury. Documentation of improvement in the symptoms occurred at 7.0 +/- 0.8 months. Symptoms persisted for 13.1 +/- 2.2 months after the injury. Patients were followed for 14.5 +/- 2.2 months. Documented initial pain severity score was 7 +/- 1 of 10. Typical exacerbating factors included temperature change, dependent position, light touch, and weight-bearing activities. Common alleviating factors included rest, massage, compression garment use, and elevation. Treatment regimens often included gabapentin (38%) and steroid injections (21%). Hypertrophic scarring (43%), pruritus (40%), and psychiatric diagnoses (36%) were common associated problems. There is a patterned natural history for neuropathic-like pain after burn injury. This clinical entity involves significant pain complaints and persists, on average, for greater than 1 year after injury, which underscores the importance of long-term outpatient care after burn injury. Furthermore, an understanding of the natural history will assist clinicians in prognosticating and caring for burn survivors with pain after wound closure.