Exploring Delirium's Heterogeneity: Association Between Arousal Subtypes at Initial Presentation and 6-Month Mortality in Older Emergency Department Patients.

OBJECTIVES: To determine how delirium subtyped by level of arousal at initial presentation affects 6-month mortality. DESIGN: This was a preplanned secondary analysis of two prospective cohort studies. SETTING: Academic tertiary care emergency department (ED). PARTICIPANTS: 1,084 ED patients who were 65 years old or older. MEASUREMENTS: At the time of enrollment, trained research personnel performed the Confusion Assessment Method for the Intensive Care Unit and the Richmond Agitation Sedation Score to determine delirium and level of arousal, respectively. Patients were categorized as having no delirium, delirium with normal arousal, delirium with decreased arousal, or delirium with increased arousal. Death was ascertained by medical record review and the Social Security Death Index. Cox proportional hazard regression was used to analyze the association between delirium arousal subtypes and 6-month mortality. RESULTS: Delirium with normal arousal was the only subtype that was significantly associated with increased 6-month mortality (hazard ratio [HR]: 3.1, 95% confidence interval [CI]: 1.3-7.4) compared with the no delirium group after adjusting for confounders. The HRs for delirium with decreased and increased arousal were 1.4 (95% CI: 0.9-2.1) and 1.3 (95% CI: 0.3-5.4), respectively. CONCLUSIONS: Delirious ED patients with normal arousal at initial presentation had a threefold increased hazard of death within 6 months compared with patients without delirium. There was a trend towards increased hazard of death in delirious ED patients with decreased arousal, but this relationship did not reach statistical significance. These data suggest that subtyping delirium by arousal may have prognostic value but requires confirmation with a larger study.

Defining Safety in the Nursing Home Setting: Implications for Future Research.

Currently, the Agency for Healthcare Research and Quality (AHRQ) Common Format for nursing homes (NHs) accommodates voluntary reporting for 4 adverse events: falls with injury, pressure ulcers, medication errors, and infections. In 2015, AHRQ funded a technical brief to describe the state of the science related to safety in the NH setting to inform a research agenda. Thirty-six recent systematic reviews evaluated NH safety-related interventions to address these 4 adverse events and reported mostly mixed evidence about effective approaches to ameliorate them. Furthermore, these 4 events are likely inadequate to capture safety issues that are unique to the NH setting and encompass other domains related to residents' quality of care and quality of life. Future research needs include expanding our definition of safety in the NH setting, which differs considerably from that of hospitals, to include contributing factors to adverse events as well as more resident-centered care measures. Second, future research should reflect more rigorous implementation science to include objective measures of care processes related to adverse events, intervention fidelity, and staffing resources for intervention implementation to inform broader uptake of efficacious interventions. Weaknesses in implementation contribute to the current inconclusive and mixed evidence base as well as remaining questions about what outcomes are even achievable in the NH setting, given the complexity of most resident populations. Also related to implementation, future research should determine the effects of specific staffing models on care processes related to safety outcomes. Last, future efforts should explore the potential for safety issues in other care settings for older adults, most notably dementia care within assisted living.

Ambulatory care sensitive emergency department use among low-cost medical home patients.

Rates of hospitalization for ambulatory care sensitive conditions (ACSC, non-emergent or primary-care-treatable) are indicators of access to and effectiveness of primary care. An assessment of Bridges to Care (BTC), a program that links Nashville's uninsured population to a medical home, was performed by surveying 76 of 756 patients presenting to the Vanderbilt emergency department (ED) between January and March 2007. Rates of ACSCs among BTC patients were not different than those of the uninsured/non-BTC or insured. A 20-item telephone survey showed that reasons for using EDs for ACSCs were not different between BTC and non-BTC patients. More BTC than non-BTC patients cited cost of healthcare as a problem that needed to be improved (p = 0.04). BTC patients have similar ACSC rates when compared to both uninsured/non-BTC and insured patients, and it is likely that cost remains a factor in their accessing healthcare services.

Educational impact of the neonatal resuscitation program in low-risk delivery centers in a developing country.

OBJECTIVE: To evaluate the effectiveness of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP) in improving knowledge, skills, and self-efficacy of nurse midwives in low-risk delivery clinics in a developing country. STUDY DESIGN: We used the content specifications of the NRP material applicable to college-educated nurse midwives working in low-risk clinics in Zambia to develop performance and self-efficacy evaluations focused on principles of resuscitation, initial steps, ventilation, and chest compressions. These evaluations were administered to 127 nurse midwives before and after NRP training and 6-months later. RESULTS: After training, written scores (knowledge evaluation) improved from 57%+/-14% to 80%+/-12% (mean+/-SD; P< .0001); performance scores (skills evaluation) improved the most from 43%+/-21% to 88%+/-9% (P< .0001); self-efficacy scores improved from 74%+/-14% to 90%+/-10% (P< .0001). Written and performance scores decreased significantly 6 months after training, but self-efficacy scores remained high. CONCLUSIONS: As conducted, the NRP training improved educational outcomes in college-educated practicing nurse midwives. Pre-training knowledge and skills scores were relatively low despite the advanced formal education and experience of the participants, whereas the self-efficacy scores were high. NRP training has the potential to substantially improve knowledge and skills of neonatal resuscitation.

The actions of BDNF on dendritic spine density and morphology in organotypic slice cultures depend on the presence of serum in culture media.

We have previously shown that brain-derived neurotrophin factor (BDNF) increases dendritic spine density and the proportion of stubby spines in apical dendrites of CA1 pyramidal neurons of hippocampal slice cultures maintained in serum-free media. We show here that serum withdrawal causes an increase in the proportion of thin spines and a decrease in the fraction of stubby spines, without changing the overall density of dendritic spines. When slices are maintained in serum-containing media, BDNF also increased spine density but had the opposite effect on spine morphology: it increased the proportion of mushroom and thin spines and decreased the proportion of stubby spines. Intriguingly, slices maintained in serum media showed a lower p75NTR-to-TrkB expression level than serum-free slices, even after BDNF exposure. The differential actions of BDNF on spine morphology depending on the presence of serum in culture media, together with the difference in neurotrophin receptor expression are reminiscent of opposing functional signaling by p75NTR and Trk receptors, and reveal a complex modulation of dendritic morphology by BDNF signaling.