Can AM-PAC "6-Clicks" Inpatient Functional Assessment Scores Strengthen Hospital 30-Day Readmission Prevention Strategies?

Background Prevention of unplanned hospital readmissions remains a priority in the US healthcare sector. Patient functional status has evolved as an important factor in identifying patients at risk for unplanned readmissions and poor predischarge functional performance has been shown to be predictive of increased readmission risk. Yet, patient functional status appears to be underutilized in readmission prediction models. Methods To examine the impact of inpatient functional status (mobility and activity performance) on unplanned 30-day hospital readmissions at two tertiary care hospitals, retrospective cohort analysis was performed on electronic health record data from adult inpatients (N = 26,298) having undergone completed functional assessments during their index hospitalization. Primary outcomes were functional assessment scores and unplanned all-cause patient readmission within 30 days following hospital discharge. Secondary analysis stratified the assessment by discharge destination. Functional assessment scores from the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" Basic Mobility Short Form or Daily Activity Short Form were extracted along with patient demographics, admission diagnoses, comorbid conditions, and hospital readmission risk score.  Results Adjusting for age, sex, and comorbidity, lower AM-PAC "6-Clicks" Basic Mobility and Daily Activity scores resulted in higher readmission rates when each score was considered separately. When both scores were considered, only Daily Activity scores were significant.  Conclusion Patients with lower Basic Mobility and Daily Activity scores are at a higher risk for readmission. The relative importance of AM-PAC "6-Click" scores on short-term readmission depends on discharge destination. Timely identification of patient mobility and activity performance may lead to earlier intervention strategies to reduce readmissions.

Early Progressive Mobilization of Patients with External Ventricular Drains: Safety and Feasibility.

BACKGROUND/OBJECTIVE: Early mobilization of critically ill patients has been shown to improve functional outcomes. Neurosurgery patients with an external ventricular drain (EVD) due to increased intracranial pressure often remain on bed rest while EVD remains in place. The prevalence of mobilizing patients with EVD has not been described, and the literature regarding the safety and feasibility of mobilizing patients with EVDs is limited. The aim of our study was to describe the outcomes and adverse events of the first mobilization attempt in neurosurgery patients with EVD who participated in early functional mobilization with physical therapy or occupational therapy. METHODS: We performed a single-site, retrospective chart review of 153 patients who underwent placement of an EVD. Hemodynamically stable patients deemed appropriate for mobilization by physical or occupational therapy were included. Mobilization and activity details were recorded. RESULTS: The most common principal diagnoses were subarachnoid hemorrhage (61.4%) and intracerebral hemorrhage (17.0%) requiring EVD for symptomatic hydrocephalus. A total of 117 patients were mobilized (76.5%), and the median time to first mobilization after EVD placement in this group of 117 patients was 38 h. Decreased level of consciousness was the most common reason for lack of mobilization. The highest level of mobility on the patient's first attempt was ambulation (43.6%), followed by sitting on the side of the bed (30.8%), transferring to a bedside chair (17.1%), and standing up from the side of the bed (8.5%). No major safety events, such as EVD dislodgment, occurred in any patient. Transient adverse events with mobilization were infrequent at 6.9% and had no permanent neurological sequelae and were mostly headache, nausea, and transient diastolic blood pressure elevation. CONCLUSION: Early progressive mobilization of neurosurgical intensive care unit patients with external ventricular drains appears safe and feasible.

Peripheral nerve blocks and postoperative physical therapy: a single-institution survey of physical therapists' preferences and opinions.

BACKGROUND AND AIMS: Our aim was to ascertain the opinions and preferences of physical therapists with regard to use of peripheral nerve blocks and their impact on the recovery of patients undergoing total joint replacement. METHODS: We conducted an anonymous 24-question survey of 20 full-time inpatient physical therapists at a single tertiary care medical center. RESULTS: One respondent indicated they never work with patients who have undergone total joint replacement surgery. Nineteen questionnaires were included in the final analysis. Questions omitted by respondents or with write-in answers were not included in the analysis. A majority of respondents (15 [78.9%]) agreed nerve blocks somewhat to greatly improve a patient's pain after total joint replacement surgery. Most respondents answered that nerve blocks somewhat to greatly impede a patient's ability to participate in physical therapy (14 [73.6%]) and make therapy somewhat to very difficult for them as physical therapists (16 [84.2%]). When asked about specific surgeries, (17/18 [94.4%]) and (14/18 [77.8%]) of respondents would prefer that their patients receive periarticular infiltration or no block at all after total knee arthroplasty or total hip arthroplasty, respectively. All respondents (19 [100%]) answered that they thought lower extremity nerve blocks increased a patient's risk of falling after surgery. CONCLUSIONS: According to the physical therapists we surveyed, nerve blocks impede patient recovery and increase the risk of falls, despite their positive impact on pain control. When considering surgery for themselves, therapists indicated they would not want a nerve block.

A quantitative screening-level approach to incorporate chemical exposure and risk into alternative assessment evaluations.

As the general public and retailers ask for disclosure of chemical ingredients in the marketplace, a number of hazard screening tools were developed to evaluate the so-called "greenness" of individual chemical ingredients and/or formulations. The majority of these tools focus only on hazard, often using chemical lists, ignoring the other part of the risk equation: exposure. Using a hazard-only focus can result in regrettable substitutions, changing 1 chemical ingredient for another that turns out to be more hazardous or shifts the toxicity burden to others. To minimize the incidents of regrettable substitutions, BizNGO describes "Common Principles" to frame a process for informed substitution. Two of these 6 principles are: "reduce hazard" and "minimize exposure." A number of frameworks have emerged to evaluate and assess alternatives. One framework developed by leading experts under the auspices of the US National Academy of Sciences recommended that hazard and exposure be specifically addressed in the same step when assessing candidate alternatives. For the alternative assessment community, this article serves as an informational resource for considering exposure in an alternatives assessment using elements of problem formulation; product identity, use, and composition; hazard analysis; exposure analysis; and risk characterization. These conceptual elements build on practices from government, academia, and industry and are exemplified through 2 hypothetical case studies demonstrating the questions asked and decisions faced in new product development. These 2 case studies-inhalation exposure to a generic paint product and environmental exposure to a shampoo rinsed down the drain-demonstrate the criteria, considerations, and methods required to combine exposure models addressing human health and environmental impacts to provide a screening level hazard and exposure (risk) analysis. This article informs practices for these elements within a comparative risk context to improve alternatives assessment evaluation and decision making. Integr Environ Assess Manag 2017;13:1007-1022. © 2017 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals, Inc. on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Very early mobilization in stroke patients treated with intravenous recombinant tissue plasminogen activator.

BACKGROUND: There are limited prospective data on the relative safety of very early mobilization of stroke patients after intravenous recombinant tissue plasminogen activator (IV rtPA) in stroke patients. We hypothesized that very early patient mobilization within 24 hours after IV rtPA administration for acute ischemic stroke would be safe and feasible. METHODS: The study was a prospective observational safety and feasibility study involving very early mobilization of stroke patients by physical therapy/occupational therapy within 24 hours after IV rtPA administration for treatment of ischemic stroke. A premobilization safety checklist was completed before mobilization to ensure hemodynamic stability. We assessed adverse safety events, including changes in patient symptoms, changes in vital signs, and bleeding complications. RESULTS: Eighteen patients were enrolled in the study, and informed consent was obtained. One hundred percent of patients were evaluated with a premobilization safety checklist; 72.2% (13 of 18) were mobilized without any adverse event. Eighty-nine percent (42 of 47) of mobilization activities were tolerated without an adverse response. One patient was orthostatic, and 1 patient had transient worsening of hemiparesis. No patient had intracranial bleeding or permanent worsening of neurologic deficits. CONCLUSIONS: Very early mobilization within 24 hours of ischemic stroke for patients who receive IV rtPA appears to be relatively safe and feasible in most patients. Patients who are mobilized within 24 hours of IV rtPA require detailed neurologic and vital sign monitoring.

Derivation of human Biomonitoring Guidance Values for chlorpyrifos using a physiologically based pharmacokinetic and pharmacodynamic model of cholinesterase inhibition.

A number of biomonitoring surveys have been performed for chlorpyrifos (CPF) and its metabolite (3,5,6-trichloro-2-pyridinol, TCPy); however, there is no available guidance on how to interpret these data in a health risk assessment context. To address this gap, Biomonitoring Guidance Values (BGVs) are developed using a physiologically based pharmacokinetic and pharmacodynamic (PBPK/PD) model. The PBPK/PD model is used to predict the impact of age and human variability on the relationship between an early marker of cholinesterase (ChE) inhibition in the peripheral and central nervous systems [10% red blood cell (RBC) ChE inhibition] and levels of systemic biomarkers. Since the PBPK/PD model characterizes variation of sensitivity to CPF in humans, interspecies and intraspecies uncertainty factors are not needed. Derived BGVs represent the concentration of blood CPF and urinary TCPy associated with 95% of the population having less than or equal to 10% RBC ChE inhibition. Blood BGV values for CPF in adults and infants are 6100 ng/L and 4200 ng/L, respectively. Urinary TCPy BGVs for adults and infants are 2100 µg/L and 520 µg/L, respectively. The reported biomonitoring data are more than 150-fold lower than the BGVs suggesting that current US population exposures to CPF are well below levels associated with any adverse health effect.

Quantitation of 4,4'-methylene diphenyl diisocyanate human serum albumin adducts.

4,4'-Methylene diphenyl diisocyanate (herein 4,4'-MDI) is used in the production of polyurethane foams, elastomers, coatings, adhesives and the like for a wide range of commercial products. Occupational exposure to MDI levels above current airborne exposure limits can elicit immune mediated hypersensitivity reactions such as occupational asthma in sensitive individuals. To accurately determine exposure, there has been increasing interest in developing analytical methods to measure internal biomarkers of exposure to MDI. Previous investigators have reported methodologies for measuring MDI diamine metabolites and MDI-Lysine (4,4'-MDI-Lys) adducts. The purpose of this study was to develop and validate an ultra performance liquid chromatography isotope dilution tandem mass spectrometry (UPLC-ID/MS/MS) quantitation method via a signature peptide approach to enable biomonitoring of 4,4'-MDI adducted to human serum albumin (HSA) in plasma. A murine, anti-4,4'-MDI monoclonal IgM antibody was bound to magnetic beads and utilized for enrichment of the MDI adducted HSA. Following enrichment, trypsin digestion was performed to generate the expected 414 site (primary site of adduction) 4,4'-MDI-adducted HSA signature peptide that was quantified by UPLC-ID/MS/MS. An Agilent 6530 UPLC/quadrupole time of flight MS (QTOF) system was utilized for intact adducted protein analysis and an Agilent 6490 UPLC/MS/MS system operated in multiple reaction monitoring (MRM) mode was utilized for quantification of the adducted signature peptide biomarker both for in chemico and worker serum samples. Worker serum samples were initially screened utilizing the previously developed 4,4'-MDI-Lys amino acid method and results showed that 12 samples were identified as quantifiable for 4,4'-MDI-Lys adducts. The signature peptide adduct approach was applied to the 12 worker samples identified as quantifiable for 4,4'-MDI-Lys adducts. Results indicated no positive results were obtained above the quantification limit by the signature peptide approach. If the 414 site of lysine adduction accounted for 100% of the 4,4'-MDI adductions in the signature peptide adduct approach, the three highest quantifiable samples by the 4,4'-MDI-Lys method should have at least been detectable by the signature peptide method. Results show that although the 4,4'-MDI signature peptide approach is more selective, it is 18 times less sensitive than the 4,4'-MDI-Lys method, thus limiting the ability to detect adduct levels relative to the 4,4'-MDI-Lys amino acid method.

The use of biomonitoring data in exposure and human health risk assessment: benzene case study.

Abstract A framework of "Common Criteria" (i.e. a series of questions) has been developed to inform the use and evaluation of biomonitoring data in the context of human exposure and risk assessment. The data-rich chemical benzene was selected for use in a case study to assess whether refinement of the Common Criteria framework was necessary, and to gain additional perspective on approaches for integrating biomonitoring data into a risk-based context. The available data for benzene satisfied most of the Common Criteria and allowed for a risk-based evaluation of the benzene biomonitoring data. In general, biomarker (blood benzene, urinary benzene and urinary S-phenylmercapturic acid) central tendency (i.e. mean, median and geometric mean) concentrations for non-smokers are at or below the predicted blood or urine concentrations that would correspond to exposure at the US Environmental Protection Agency reference concentration (30 µg/m(3)), but greater than blood or urine concentrations relating to the air concentration at the 1 × 10(-5) excess cancer risk (2.9 µg/m(3)). Smokers clearly have higher levels of benzene exposure, and biomarker levels of benzene for non-smokers are generally consistent with ambient air monitoring results. While some biomarkers of benzene are specific indicators of exposure, the interpretation of benzene biomonitoring levels in a health-risk context are complicated by issues associated with short half-lives and gaps in knowledge regarding the relationship between the biomarkers and subsequent toxic effects.

Relevance of drinking water as a source of human exposure to bisphenol A.

A comprehensive search of studies describing bisphenol A (BPA) concentrations in drinking water and source waters (i.e., surface water and groundwater) was conducted to evaluate the relevance of drinking water as a source of human exposure and risk. Data from 65 papers were evaluated from North America (31), Europe (17), and Asia (17). The fraction of drinking water measurements reported as less than the detection limit is high; 95%, 48%, and 41%, for North America, Europe, and Asia, respectively. The maximum quantified (in excess of the detection limit) BPA concentrations from North America, Europe, and Asia are 0.099 µg/l, 0.014 µg/l, and 0.317 µg/l. The highest quantified median and 95th percentile concentrations of BPA in Asian drinking water are 0.026 µg/l and 0.19 µg/l, while high detection limits restricted the determination of representative median and 95th percentile concentrations in North America and Europe. BPA in drinking water represents a minor component of overall human exposure, and compared with the lowest available oral toxicity benchmark of 16 µg/kg-bw/day (includes an uncertainty factor of 300) gives margins of safety >1100. Human biomonitoring data indicate that ingestion of drinking water represents <2.8% of the total intake of BPA.

Risk assessment for consumer exposure to toluene diisocyanate (TDI) derived from polyurethane flexible foam.

Polyurethanes (PU) are polymers made from diisocyanates and polyols for a variety of consumer products. It has been suggested that PU foam may contain trace amounts of residual toluene diisocyanate (TDI) monomers and present a health risk. To address this concern, the exposure scenario and health risks posed by sleeping on a PU foam mattress were evaluated. Toxicity benchmarks for key non-cancer endpoints (i.e., irritation, sensitization, respiratory tract effects) were determined by dividing points of departure by uncertainty factors. The cancer benchmark was derived using the USEPA Benchmark Dose Software. Results of previous migration and emission data of TDI from PU foam were combined with conservative exposure factors to calculate upper-bound dermal and inhalation exposures to TDI as well as a lifetime average daily dose to TDI from dermal exposure. For each non-cancer endpoint, the toxicity benchmark was divided by the calculated exposure to determine the margin of safety (MOS), which ranged from 200 (respiratory tract) to 3×10(6) (irritation). Although available data indicate TDI is not carcinogenic, a theoretical excess cancer risk (1×10(-7)) was calculated. We conclude from this assessment that sleeping on a PU foam mattress does not pose TDI-related health risks to consumers.

A reanalysis of the evidence for increased efficiency in benzene metabolism at airborne exposure levels below 3 p.p.m.

An analysis of monitoring data on workers in Tianjin, China, reported a 9-fold increase in the production of benzene metabolites per unit exposure as air concentrations declined from 88.9 to 0.03 p.p.m. The increase is attributed to an enhanced efficiency of benzene metabolism at lower air concentrations. This finding, however, is not consistent with other studies demonstrating that adsorbed benzene is almost completely metabolized at airborne levels ranging from <1 to 70 p.p.m. In this article (i) the modeling performed in Kim et al. is repeated and the model predictions are reproduced; (ii) the impacts of technical issues in the corrections for background levels of metabolites, accounting for biases in the regression modeling, and the uncertainties introduced by the use of a calibration model to estimate benzene air levels for certain workers are evaluated and (iii) alternative methods of correcting for background levels of metabolites are examined. The new analysis indicates that findings of increased production are probably smaller and are highly uncertain, 4.8 fold [0.1-18] (mean and [95% confidence limits]). Defining background levels as either the levels in all workers with no occupational exposures or in workers with predicted air levels of <0.03 p.p.m. results in estimates of 2.4 fold [<0.1-15] and 3.3 fold [<0.1-19] increases, respectively. Based on this reanalysis, the Tianjin data appear to be too uncertain to support any conclusions of a change in the efficiency of benzene metabolism with variations in exposure.

Public health evaluation of cadmium concentrations in liver and kidney of moose (Alces alces) from four areas of Alaska.

Liver and/or kidney samples were collected from 139 hunter-killed moose from four areas of Alaska during 1986. The concentration of cadmium in organ tissue was determined by direct-current plasma atomic emission spectrometry. All results are reported as mug/g wet weight. Concentrations of cadmium in liver ranged from 0.06 microg/g to 9.0 microg/g; in the kidney cortex they ranged from 0.10 microg/g to 65.7 microg/g. Cadmium levels were significantly associated with location and age. The highest geometric mean liver (2.11 microg/g) and kidney cortex (20.2 microg/g) cadmium concentrations were detected in moose harvested near Galena, Alaska. Limited dietary information from Alaska and Canada indicates that the intake of moose liver or kidney does not exceed, in most individuals, the World Health Organization recommendations for weekly cadmium consumption of 400 microg to 500 microg. Additionally, human biomonitoring data from Canada and Alaska indicate exposure to cadmium is low except for individuals who smoke cigarettes. Given the nutritional and cultural value of subsistence foods, the Alaska Division of Public Health continues to support the consumption of moose liver and kidney as part of a well-balanced diet. Human biomonitoring studies are needed in Alaska to determine actual cadmium exposure in populations with a lifelong history of moose liver and kidney consumption.

Human biomonitoring to optimize fish consumption advice: reducing uncertainty when evaluating benefits and risks.

National fish consumption advisories that are based solely on assessment of risk of exposure to contaminants without consideration of consumption benefits result in overly restrictive advice that discourages eating fish even in areas where such advice is unwarranted. In fact, generic fish advisories may have adverse public health consequences because of decreased fish consumption and substitution of foods that are less healthy. Public health is on the threshold of a new era for determining actual exposures to environmental contaminants, owing to technological advances in analytical chemistry. It is now possible to target fish consumption advice to specific at-risk populations by evaluating individual contaminant exposures and health risk factors. Because of the current epidemic of nutritionally linked disease, such as obesity, diabetes, and cardiovascular disease, general recommendations for limiting fish consumption are ill conceived and potentially dangerous.