Identification of pseudobulbar affect symptoms in the nursing home setting: Development and assessment of a screening tool.

Pseudobulbar Affect (PBA) is a neurologic condition characterized by involuntary outbursts of crying and/or laughing disproportionate to patient mood or social context. Although an estimated 9% of nursing home residents have symptoms suggestive of PBA, they are not routinely screened. Our goal was to develop an electronic screening tool based upon characteristics common to nursing home residents with PBA identified through medical record data. Nursing home residents with PBA treated with dextromethorphan hydrobromide/quinidine sulfate (n = 140) were compared to age-, gender-, and dementia-diagnosis-matched controls without PBA or treatment (n = 140). Comparative categories included diagnoses, medication use and symptom documentation. Using a multivariable regression and best decision rule analysis, we found PBA in nursing home residents was associated with chart documentation of uncontrollable crying, presence of a neurologic disorder (e.g., Parkinson's disease), or by the documented presence of at least 2 of the following: stroke, severe cognitive impairment, and schizophrenia. Based on these risk factors, an electronic screening tool was created.

Expanding STEM opportunities through inclusive STEM-focused high schools.

Inclusive STEM high schools (ISHSs) (where STEM is science, technology, engineering, and mathematics) admit students on the basis of interest rather than competitive examination. This study examines the central assumption behind these schools-that they provide students from subgroups underrepresented in STEM with experiences that equip them academically and attitudinally to enter and stay in the STEM pipeline. Hierarchical modeling was applied to data from student surveys and state longitudinal data records for 5113 students graduating from 39 ISHSs and 22 comprehensive high schools in North Carolina and Texas. Compared to peers from the same demographic group with similar Grade 8 achievement levels, underrepresented minority and female ISHS students in both states were more likely to undertake advanced STEM coursework. Hispanics in Texas and females in both states expressed more STEM career interest in Grade 12 if they attended an ISHS. Positive relationships between ISHS attendance and grade point average were found in the total sample and each subgroup in North Carolina. Positive ISHS advantages in terms of test scores for the total student sample were found for science in both states and for mathematics in Texas. For the various student subgroups, test score differences favored the ISHS samples but attained statistical significance only for African Americans' science achievement scores in the Texas study.

Clinical and Functional Characteristics of Nursing Facility Residents with Opioid-Induced Constipation.

OBJECTIVE: Our goal was to determine the prevalence, clinical characteristics, and treatment differences of opioid-induced constipation (OIC) in older adults with noncancer pain compared with opioid-treated patients without OIC. DESIGN: Retrospective database analysis. SETTING: United States nursing facilities: Patients, Participants, facility residents. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Minimum data set and prescription claims, pain, impaired cognition, falls, delirium, and drug treatment. RESULTS: We found an OIC prevalence of 8.9%. Nursing facility residents with OIC are more likely to have severe pain (31.3% vs. 29%; P < 0.001), pain in the last 5 days (71.2% vs. 69.2%; P < 0.001), almost constant pain (18.1% vs.13.3%; P < 0.001), and pain interfering with daily activities (36.1% vs. 30%; P < 0.001). Strong opioids were more likely prescribed and the duration of use was longer than in non-OIC nursing facility residents. Cognitive impairment (56.3% vs. 49.8%; P < 0.001), fall rate (4.8% vs. 2.5%; P = 0.023), delirium indicators (confusion assessment method; P < 0.001), urinary incontinence (59.1% vs. 54.9%; P < 0.001), depression (66.5% vs. 61.6%; P < 0.001), and depression severity score (4.7% vs. 4.3%; P < 0.001) were higher in nursing facility residents with OIC. Nursing facility residents with OIC had a higher percentage of concomitantly prescribed anticholinergic medications (76.7% vs. 70.0%; P < 0.001) and a higher mean anticholinergic burden score (1.4% vs. 1.1%; P < 0.001). Over-the-counter laxatives were used more often than prescription laxatives: polyethylene glycol (43%), docusate (31.1%), and senna/sennosides (23%) vs. lactulose (18.1%) and lubiprostone (2.2%). CONCLUSION: Nursing facility residents with OIC experience suboptimal pain relief, additional anticholinergic adverse drug-related effects, and a decreased quality of life.

Challenges in the Pharmacological Management of Nursing Home Residents with Overactive Bladder or Urinary Incontinence.

OBJECTIVES: To determine the proportion of nursing home (NH) residents (NHR) with overactive bladder (OAB) or urinary incontinence (UI) with potential pharmacodynamic contraindications to antimuscarinic treatment because of concomitant anticholinergic medications or acetylcholinesterase inhibitors (AChEIs) and nonpharmacological limitations to antimuscarinic treatment. DESIGN: Cross-sectional retrospective analysis. SETTING: U.S. skilled nursing facilities. PARTICIPANTS: Nursing home residents with a diagnosis of OAB or UI. MEASUREMENTS: Linked and deidentified pharmacy claims and Minimum Data Set (MDS) 3.0 records (October 1, 2010 to September 30, 2012). RESULTS: Of NHRs, 71.3% received at least one anticholinergic medication. Medications that can cause or worsen UI were used commonly. AChEIs and antimuscarinic treatment were prescribed concurrently in 24% of NHRs with OAB or UI. NHRs with OAB or UI were more likely to have concurrent moderate to severe cognitive impairment (MSCI) (70.1%) than those without (29.9%) (P < .001). NHRs with or without OAB or UI and with MSCI were more likely to be treated with an anticholinergic medication than those without MSCI (P = .001). When NHRs with MSCI, severe mobility impairment (SMI), and anticholinergic medication and AChEI use were excluded, only a small proportion of NHRs were potential candidates for antimuscarinic treatment (6.6% with OAB or UI, 6.2% with UI). CONCLUSIONS: This study advances understanding of the challenges in prescribing antimuscarinic treatment safely and appropriately in elderly NHRs with a high prevalence of drug interactions, underlying MSCI, and SMI.

Clinical Burden and Nonpharmacologic Management of Nursing Facility Residents with Overactive Bladder and/or Urinary Incontinence.

OBJECTIVE: To identify clinical characteristics of residents with a diagnosis of overactive bladder (OAB) and/or urinary incontinence (UI) to determine the prevalence of comorbidities, severe mobility impairment (SMI), moderate-to-severe cognitive impairment (MSCI), and a toileting program and the response to that program. DESIGN: Cross-sectional retrospective analysis. SETTING: Skilled nursing facilities. PATIENTS, PARTICIPANTS: Residents with a diagnosis of OAB and/or UI and an age range, and gender frequency-matched 1:1 control cohort without OAB and/or UI. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): De-identified Minimum Data Set data 3.0 records (October 1, 2010, to September 30, 2012). RESULTS: Of the 175,632 residents, 65% had a diagnosis of UI and 1% had a diagnosis of OAB. Those with UI and/or OAB were more likely to have MSCI (mean Brief Inventory of Mental Status score 10.2 ± 4.5 vs. 12.5 ± 3.6; P = 0.001) and SMI (49.4% vs. 26.4%; P < 0.001), multiple comorbid conditions, falls and falls with injury, hip fractures (5.5% vs. 4.9%; P < 0.001), urinary tract infections (21.4% vs. 16.5%; P = 0.001), and moisture-associated skin damage (5.2% vs. 2.6%; P = 0.001) than the control cohort. Toileting programs were attempted more often (17.0% vs. 5.1%; P < 0.001) in those with UI and/or OAB but were only minimally successful, with 4.2% having decreased wetness and 0.9% being completely dry. CONCLUSION: Residents with UI and/or OAB exhibit a higher burden of MSCI, SMI, and comorbidities than do residents without these diagnoses. Nonpharmacologic therapies such as toileting programs should be a primary focus in the nursing facility.

Risk Factors, Clinical Characteristics, and Treatment Differences Between Residents With and Without Nursing Home- and Non-Nursing Home-Acquired Clostridium difficile Infection.

BACKGROUND: The incidence of Clostridium difficile infection (CDI) in nursing home residents is believed to be high because of the prevalence of predisposing factors such as decreased immune response, multiple comorbidities, medications, increased risk of infection, close proximity of residents, and recent hospitalization. Yet, specific information on CDI in this population is scarce.  OBJECTIVES: To investigate differences in clinical and demographic characteristics, treatment, and underlying comorbidities in residents who acquired CDI preadmission (non-nursing home-acquired [NNH-Acquired]) compared with those who acquired CDI after admission to a nursing home (nursing home-acquired [NH-Acquired]) and matched controls. METHODS: We conducted a retrospective case-control study of CDI in nursing home residents with a cross-sectional and longitudinal aspect of linked and de-identified pharmacy claims and Minimum Data Set data (MDS) 2.0 records from October 1, 2009, to September 30, 2010. The control group was frequency matched 1:1 for gender, race, and age range to residents with CDI.  RESULTS: Of 195,498 residents, 5,044 (2.6%) had a diagnosis of CDI. Compared with controls, CDI patients had less severe cognitive impairment (P less than 0.01) and more severe functional impairment (P less than 0.01), incontinence (P less than 0.01), and diarrhea (P less than 0.01). They were more likely to (a) have diabetes, stroke, heart failure, cancer, renal failure, and infections; (b) be treated with antibiotics, corticosteroids, megestrol, and proton pump inhibitors; and (c) be discharged to the hospital (29.3% vs. 14.7%, P = 0.001) than controls. NNH-Acquired CDI was 3 times more prevalent than NH-Acquired CDI. Most residents with NNH-Acquired CDI (85.0%) came from acute care hospitals and were more likely to have heart disease, cancer, and infections, while those with NH-Acquired CDI tended to have more cognitive impairment, reliance on staff for activities of daily living, incontinence, and stroke. Thirty-day retreatment rates for NH-Acquired CDI and NNH-Acquired CDI with metronidazole were 72.7% and 68.4%, and with vancomycin were 83.9% and 69.3%, respectively. The facility (Medicare Part A) was the payer for 93.6% of NNH-Acquired CDI and 75% of NH-Acquired CDI treatment; Medicare Part D was the prevalent secondary payer for NNH-Aquired CDI (19.4%) and NH-Acquired CDI (37.5%). CONCLUSIONS: Residents with CDI had more comorbidities, and the NNH-Acquired group bore a higher burden of illness, resulting in differing treatment patterns and outcomes than the NH-Acquired CDI group.

Type 2 diabetes mellitus treatment patterns in U.S. nursing home residents.

BACKGROUND: The prevalence of type 2 diabetes mellitus (diabetes) in nursing home residents (NHRs) is increasing, concurrently with obesity and other comorbid conditions. NHR would benefit greatly from antidiabetic medications that would improve glycemic control and give a lower risk of hypoglycemia but that do not contribute to weight gain in obese individuals. OBJECTIVE: To examine the prescription patterns to NHRs with diabetes, including the use of newer injectable therapies such as glucagon-like peptide-1 (GLP-1) receptor agonists. METHODS: Treatment patterns of diabetes in NHR were analyzed using Minimum Data Set records and prescription claims from the Omnicare Senior Health Outcomes data repository (May 2011-September 2012). RESULTS: The prevalence of diabetes in this population of 229,283 NHRs was 35.4%. Among the 44,665 NHRs with diabetes and prescription claims data, the prevalence of obesity (40.3%) and multiple comorbidities (100%) was high. Approximately 20% of the NHRs with diabetes were aged <65 years. Overall, 20% of NHRs had diabetes that was untreated with medications during the study period. Insulin was the mainstay of treatment (>80%), followed by oral agents (54%). GLP-1 receptor agonist use was low (0.5%) and associated with poor treatment persistence. CONCLUSION: Considerations other than glycemic control may drive prescribing decisions, contrary to recommendations from the American Diabetes Association, American Medical Directors Association, and European Association for the Study of Diabetes.

Osteoporosis prevalence and characteristics of treated and untreated nursing home residents with osteoporosis.

OBJECTIVES: Our primary objective was to describe the prevalence of osteoporosis (OP) diagnosis in nursing home residents (NHRs). Secondary objectives included assessment of pharmacologic therapies and risk of fracture in NHRs with OP, as well as differentiating clinical characteristics of treated versus untreated male and female NHR with OP. Finally, we sought to evaluate persistence and compliance rates in NHRs treated with OP and determine the prevalence of severe renal impairment in NHRs with OP treated with a bisphosphonate. DESIGN: Retrospective cohort analysis. SETTING: US NH. PARTICIPANTS: NHRs with a Minimum Data Set (MDS) 3.0 record in the Omnicare Senior Health Outcomes (OSHO) data repository during the time period of October 1, 2011, to September 30, 2012. MEASUREMENTS: A patient was considered to have an OP diagnosis if MDS item I3800 indicated the NHR had OP or if the MDS record contained ICD-9-CM codes 733.0x. An expanded definition of OP diagnosis was explored, in which an NHR with a previous fracture (MDS items I3900, I4000, J1700C=1) was also considered to have OP. OP pharmacologic therapies were extracted from the pharmacy claims data and included alendronate, calcitonin salmon, denosumab, ibandronate, raloxifene, risedronate, and teriparatide. Using MDS items, cognitive impairment (Brief Instrument for Mental Status, Cognitive Performance Scale) and functional impairment (composite activities of daily living) were assessed. Using MDS and prescription claims data, high risk of fracture (at least 2 of the following: age ≥75 years, female gender, previous fracture, history of falls, and use of a bisphosphonate) was assessed. Persistence was indicated by continuous use of therapy without a gap of more than 60 days, compliance was calculated using the medication possession ratio, and creatinine clearance (Clcr) was calculated using a modified Cockcroft-Gault equation. RESULTS: The prevalence of OP in NHRs was 13.5%. Using the expanded OP definition, the prevalence of OP increased to 24.2%. Among NHRs with OP (n = 23,666), the mean age was 82.5 and 85.1% were female; 36.8% had gastroesophageal reflux disease or ulcer. Per the definition of high risk for fracture based on older age, female gender, prior fracture, fall history, and use of bisphosphonates, 89.0% of NHRs with OP met the criteria. Additionally, 10.8% had hip fracture, and 15.8% had other fracture. Overall, few NHRs with OP received active treatment: one-third received pharmacologic therapy, of which 73.5% received an oral bisphosphonate. Those with a history of hip fracture had similar treatment rates (31.7%) to those without (32.0%) (P = .804), whereas those with a history of other fracture were more likely to be treated (35.9%) than those without (31.2%) (P = .001). Two-thirds of residents with OP had moderate/severe cognitive impairment, and these residents were less likely to receive OP therapy than those without (P = .001). Persistence with pharmacologic therapy in NHR with a full year of pharmacy data (n = 1399) was higher for raloxifene (82.9%), with calcitonin salmon and bisphosphonates being similar, and the few NHRs who received teriparatide and denosumab were lower. Of the NHRs who received bisphosphonates for whom there was creatinine clearance data, 57% had a Clcr lower than 35 mL/min. CONCLUSION: The recognized prevalence of OP in NHRs using MDS records was low, but consistent with previous reports. Among those with a documented diagnosis of OP, approximately 89% of NHRs with OP were at high risk of fracture and only one-third were treated with active pharmacologic therapy. For those treated, persistence and compliance was suboptimal, but higher with oral therapies. More than half of NHRs with OP treated with bisphosphonates had Clcr of less than 35 mL/min, suggesting alternative forms of therapy should be considered. For all of these reasons, the opportunity exists to improve the care and medication use of residents with OP who are at high risk of fracture.

Blood pressure control in continuous flow left ventricular assist devices: efficacy and impact on adverse events.

BACKGROUND: Continuous flow (CF) left ventricular assist devices (LVAD) are afterload sensitive and therefore pump performance is affected by hypertension. In addition, poorly controlled hypertension may increase the risk of aortic insufficiency (AI) and stroke. Blood pressure regimens after CF LVAD have not been studied and their impact on rates of AI and stroke are unknown. METHODS: Patients who had CF LVAD at a single center and were supported greater than 30 days were included. Blood pressure was monitored at home by Doppler. Outpatient management of blood pressure was conducted according to a predefined institutional protocol (target mean arterial pressure ≤ 80 mm Hg). RESULTS: A total of 96 patients were included. At the end of follow-up, 25 patients were not on an antihypertensive drug, of these 9 died. Of the 74% receiving antihypertensives, 54% required 1 medication, 34% were on 2, 10% were on 3, and 3% were on 4 or more. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (85% of patients on an antihypertensive) and beta blockers (30%) were the most commonly prescribed medications. There was a significantly higher neurologic event rate in those on no antihypertensives compared with those on antihypertensives (p = 0.009). Only 3% of patients with no or mild AI at baseline progressed to develop moderate or greater AI after a mean of 201 days of follow-up. CONCLUSIONS: Blood pressure control can be achieved in patients with CF LVADs, with the majority of patients requiring only 1 or 2 antihypertensives.

Bariatric surgery for a patient with a HeartMate II ventricular assist device for destination therapy.

A patient with a HeartMate II left ventricular assist device who had a body mass index of 52 needed gastric bypass surgery in order to qualify for a heart transplant. Unlike previous experience in which the surgery was performed at the implant hospital, the gastric bypass surgery in this case was performed at a bariatric center of excellence that was a separate facility from the implant hospital. The artificial heart program of the University of Pittsburgh Medical Center worked with the bariatric center of excellence in scheduling the gastric bypass surgery using a multidisciplinary team approach at 2 hospitals to coordinate safe, high-quality patient care in a unique situation.

The 3' untranslated region of human vimentin mRNA interacts with protein complexes containing eEF-1gamma and HAX-1.

Previously, we have shown that the vimentin 3' untranslated region (3'UTR) contains a highly conserved region, which is sufficient for the perinuclear localization of a reporter mRNA. This region was shown to specifically bind protein(s) by band shift analyses. UV-cross-linking studies suggest these proteins are 46- and 35-kDa in mass. Here, we have used this sequence as 'bait' to isolate RNA binding proteins using the yeast three-hybrid method. This technique relies on a functional assay detecting bona fide RNA-protein interaction in vivo. Three cDNA isolates, HAX-1, eEF-1gamma and hRIP, code for proteins of a size consistent with in vitro cross- linking studies. In all cases, recombinant proteins were capable of binding RNA in vitro. Although hRIP is thought to be a general mRNA binding protein, this represents an unreported activity for eEF-1gamma and HAX-1. Moreover, HAX-1 binding appears to be specific to vimentin's 3'UTR. Both in vivo synthesized eEF-1gamma and HAX-1 proteins were 'pulled out' of HeLa whole cell extracts by binding to a RNA affinity column comprised of vimentin's 3'UTR. Moreover, size-fractionation of extracts results in the separation of large complexes containing either eEF-1gamma or HAX-1. Thus, in addition to their known functions, both eEF-1gamma and HAX-1 are RNA binding proteins, which suggests new roles in mRNA translation and/or perinuclear localization.