By FREIDA FRISARO
One morning last summer, Tony Smith slipped a multicolor tutu over his scrubs in the pre-op ward of a South Florida hospital to grant the wish of a young patient heading to surgery.
A photo of the tutu-clad Smith quickly became a hit online and within weeks, Tutu Tuesday was born at Joe DiMaggio Children's Hospital.
"That day, it was all about making a patient feel comfortable. Having me put on the tutu made her feel better," said Smith, an operating room assistant who has worked at the Hollywood, Florida, hospital for almost five years. "I never knew I would have that much impact. I didn't expect it to go viral."
But it did. Once employees saw the shot, they started asking Lotsy Dotsy — resident clown and unofficial keeper of the tutu — for their own frilly skirts to wear. Department by department, hospital staff adopted Tutu Tuesday.
It begins outside the hospital named for a baseball legend, where visitors are greeted by a valet whose tutu clashes with his normal uniform — shorts and a baseball jersey.
"People laugh and ask why I'm wearing a skirt," said John Aristizabal, who takes good-natured kidding as he parks cars. "It's all for the kids, to catch a smile."
On Tutu Tuesday, smiles are contagious.
Inside the hospital, tutus are everywhere. Doctors, nurses, technicians and receptionists don the colorful layers of tulle, decorated with polka dots and fancy bows as they go about the business of tending to patients. Even Nutmeg, the in-house therapy dog, has a specially designed pink tutu. Hospital administrators also play along, wearing tutus over their business suits.
Smith said he could have never imagined that such a simple act would catch on.
"It's for the patients," Smith said. "Just seeing you in a tutu brightens their day, and it can keep them from thinking about what's really going on."
That's exactly what pediatric anesthesiologist Dr. Bob Kaye has been doing for years. He's worn a variety of funny hats and wigs to help ease the fears of his young patients. Now he's added a tutu to his routine and has found that his patients and their parents like the distraction.
"If you can dress in a way that it not threatening and silly, maybe, and make the medical professional look not like the last person who gave them a shot in the doctor's office, then it's a lot easier to feel comfortable with them," he said. "I think it's an ice breaker."
On a Tuesday morning in March, Laurel Barnett and her 13-year-old daughter Julia arrived about 5:45 a.m. for surgery.
"Of course, not having any coffee and then coming in and seeing everyone in tutus is quite amusing," Barnett said. "It's not what you expected to see. It does give children a sense of relief that these people are not only here to help them, but there to have fun as well. It kind of takes their mind off of things."
Smith says he's not bothered at all by the stares and giggles as he makes his way through the hospital's corridors every Tuesday. He even offered his tutu to 12-year-old Brayden Wilmsmeyer, who along with his 10-year twin sisters Leah and Lexi spent spring break getting respiratory treatment at Joe DiMaggio.
The twins had borrowed tutus from two nurses for an impromptu photo session.
"Remember, you are a real man," Smith told Brayden as he pulled the tutu over his pants. "Don't let anyone tell you otherwise just because you're wearing a tutu."
After roughly 40 years, U.S. health regulators are seeking data to see if the cocktail of ingredients in antiseptics used in hospitals, clinics and nursing homes are as safe and effective as they were once considered.
The Food and Drug Administration said on Thursday it is asking manufacturers for more data, including on absorption, potential hormonal effects and bacterial resistance of thehe 'active' ingredients in antiseptics, to see if they are still appropriate for use in a health care setting.
Since the review of health care antiseptics in the 1970s, things have changed, the FDA noted, alluding to a shift in frequency of use, hospitals' infection control practices, technology and safety standards. (1.usa.gov/1EUrzCd)
An independent panel of experts to the FDA raised similar concerns last year. In 2013, the regulator issued a warning to manufacturers, saying it was aware of at least four deaths and multiple infections caused by over-the-counter antiseptics. (1.usa.gov/1DNxOSp)
Commonly used active ingredients in health care antiseptics include alcohol and iodine. Data suggests that, for at least some of these ingredients, the systemic exposure is higher than previously thought, the agency noted.
"We're going to try to answer their questions in great detail as called for, but we believe the FDA already has sufficient data on these products," said Brian Sansoni, a spokesman for American Cleaning Institute (ACI), a trade association for the cleaning products industry.
The ACI represents antiseptic ingredient and product makers such as Gojo Industries Inc, the maker of Purell hand sanitizers; Dial Corp, a unit of Germany's Henkel (HNKG_p.DE); Ecolab Inc and Steris Corp.
The FDA said no health care antiseptics were going to be pulled off shelves as of now, and that their review excluded home-use antiseptics such as antibacterial soap and hand sanitizers.
The new data request relates only to health care antiseptics covered by the over-the-counter monograph, a kind of "recipe book" covering acceptable ingredients, doses, formulations and labeling. Once a final monograph is implemented, companies can market their product without having to go through the FDA.
Companies will have one year to submit the data, which the FDA will evaluate before determining if the OTC monograph needs to be revised.
"We're concerned if the FDA takes maybe a too narrow view regarding the safety and effectiveness data – depending how the final rule ends up – they could take effective products or ingredients off the shelves," Sansoni said.
Written by Markus MacGill
3D printing has come to the rescue of severe cases of a childhood disease in which the windpipe is softened, leading to collapse of the airway and breathing failure. Previously lacking any adequate intervention, tracheobronchomalacia has found an innovative fix in three babies whose condition presented them with little chance of reaching young childhood.
Researchers at the University of Michigan's C.S. Mott Children's Hospital in Ann Arbor say the three boys have become the "first in the world to benefit from groundbreaking 3D-printed devices" to stent their airways in such a way as to allow the supports to keep up with their growth.
A follow-up of all three patients published in the journal Science Translational Medicine shows the personalized bioresorbable splint implants have worked with "promising results."
Pediatric tracheobronchomalacia (TBM) sees excessive collapse of the airways during breathing that can lead to life-threatening cardiopulmonary arrests (halted heart and breathing).
The cartilage supporting the airway can strengthen as children with the condition grow, the study paper goes on to explain, but severe cases of the disease require aggressive treatment - and those children are at "imminent risk of death."
Before this new approach to provide an early treatment option for TBM, the only conventional therapies available also carried life-threatening complications of their own.
Babies needed tracheostomy tube placement with mechanical ventilation, requiring prolonged hospitalization, and complications often led to cardiac and respiratory arrest. For example, the rate of respiratory arrest owing to tube occlusion runs as high as 43% of pediatric tracheostomy procedures a year.
Survivors: Kaiba, Ian and Garrett
But none of the newly developed 3D-printed devices have caused any complications for the three children treated, including Kaiba, who at 3 months old was the first to receive the new technology, 3 years ago. The stents were also inserted into 5-month-old Ian and 16-month-old Garrett.
Designed to accommodate airway growth while preventing external compression over a period of time before bioresorption, the technology allows for the particular problem of radial expansion of the airway over the critical period of growth. "If a child can be supported through the first 24 to 36 months of tracheobronchomalacia, airway growth generally results in a natural resolution of this disease," write the authors.
Senior author Dr. Glenn Green, associate professor of pediatric otolaryngology at C.S. Mott, says: "Before this procedure, babies with severe tracheobronchomalacia had little chance of surviving. Today, our first patient Kaiba is an active, healthy 3-year-old in preschool with a bright future." Dr. Green adds:
"The device worked better than we could have ever imagined. We have been able to successfully replicate this procedure and have been watching patients closely to see whether the device is doing what it was intended to do.
We found that this treatment continues to prove to be a promising option for children facing this life-threatening condition that has no cure."
Dr. Green describes in the video below how he and his colleagues at the University of Michigan worked on finding the solution.
Dr. Green strives enthusiastically for the lives of babies born with the condition, which he says in a post on the hospital's Hail to the little victors blog is often misdiagnosed as treatment-resistant asthma. He adds that it is a rare congenital condition affecting about 1 in 2,200 births, and the severe cases are even rarer, with most children growing out of the milder cases by 2 or 3 years of age.
"Kaiba's parents, April and Bryan, were left watching helplessly each time he stopped breathing, praying that something would change and doctors' predictions that he would never leave the hospital again weren't true," writes Dr. Green in 2013.
The 3D-printed splints were computational image-based designed to be customizable so that the following parameters could be made bespoke to the individual patient's anatomy on "the submillimeter scale:"
- Inner diameter, length and wall thickness of the device
- Number and spacing of suture holes.
Not being a closed cylinder, the design of the tubes gave an opening to allow placement but also expansion of the radius as the airways grew. All the inserts placed around the airways were made of polycaprolactone, a polymer that harmlessly dissolves in the body at a rate to allow the technology time to support the growing cartilage.
For Garrett's bespoke device on his left bronchus, the opening had a spiral shape to it, to allow a device to be fitted concurrently around, and grow with, his right bronchus, too.
Freedom from intensive care treatments
The Michigan team also share findings showing that the success of the devices meant the young children were able to come off of ventilators and no longer needed paralytic, narcotic and sedating drugs.
There were improvements in multiple organ systems and problems that had prevented the babies from absorbing food, so now they could be free of intravenous therapy.
The research doctors had received urgent approval from the US Food and Drug Administration to do the procedures, but it is early days for the strategy to become routine for babies with TBM. The case report published today was not designed to test the safety of the devices - so it may yet be possible that rare complications are found to result from treatment in some cases. Dr. Green says:
"The potential of 3D-printed medical devices to improve outcomes for patients is clear, but we need more data to implement this procedure in medical practice."
The specialist surgeon performing the operations, Dr. Richard Ohye, head of pediatric cardiovascular surgery at C.S. Mott, believes the cases provide the groundwork for a potential clinical trial in children with less-severe forms of TBM.
Before surgeons stitched a kidney from a 32-year-old former Marine into his abdomen in March, Mark Kim spent almost two years on dialysis. He had lot of time to think while hooked up to the machine, three times a week, as it pumped his blood out of his body, purified it and pumped it back in. Sometimes he found himself mulling over how odd it was that a new kidney — the one thing he needed most — was something money couldn’t buy.
When his kidneys first failed him, all sorts of people offered to donate one: his neighbor, his two 20-something nieces, two old friends, his sister. But none could follow through, mostly because of incompatible blood types. Such supply-and-demand mismatches can cause prices to skyrocket in a normal market, and indeed, Kim heard hints about the organ’s economic value along the way. Once, at a backyard barbecue, a woman whispered to him that her mother purchased a kidney on the black market for $100,000.
Despite the crushing demand, the sale of kidneys is banned in every country in the world except Iran. In the U.S., more than 100,000 people with renal failure are on the list for a deceased-donor kidney, typically waiting between four and five years. Last year, 4,270 people died waiting. Few but free-market absolutists would argue for repealing the 1984 law banning the organ trade in the U.S., but most would agree something should be done to increase the supply of kidneys for transplant. In a sense, though, there’s already a global glut: While we are born with two kidneys, we can function just fine with one. The problem is that they’re stuck inside of us.
Kim would have continued to wait on the national list, despite having several willing donors, were it not for a company called BiologicTx. Thanks to its software, Kim was able swap his sister’s kidney for the Marine’s kidney. The Marine, a woman named Liz Torres, gave up her kidney to ensure that her mother got a kidney, which came from a young social worker, Ana Tafolla Rios, who was a better match. Rios passed hers along to secure one for her ailing mother from Keith Rodriguez, a young man from Fresno. He let go of his to procure one for his mom, Norma, a 52-year-old dental assistant with polycystic kidney disease. All these people underwent surgery over two days in March at the California Pacific Medical Center in San Francisco, in what is called a kidney-transplant chain. The software programs driving such chains create something like a marketplace for organs — but one where supply and demand are balanced not through pricing but through altruism.
A law-abiding American in need of a kidney has two options. The first is to wait on the national list for an organ donor to die in (or near) a hospital. The second is to find a person willing to donate a kidney to you. More than half the time, such donor-and-recipient pairs are incompatible, because of differences in blood type or the presence, in the donor’s blood, of proteins that might trigger the recipient’s immune system to reject the new kidney. The genius of the computer algorithms driving the kidney chains is that they find the best medical matches — thus increasing the odds of a successful transplant — by decoupling donors from their intended recipients. In the United States, half a dozen of these software programs allow for a kind of barter market for kidneys. This summer, doctors will most likely complete the last two operations in a record-breaking 70-person chain that involved flying donated kidneys on commercial airlines to several hospitals across the country.
Garet Hil, the founder and chief executive of the National Kidney Registry, the largest kidney-chain exchange program in the world, has a background in financial services, not medicine. He borrowed concepts from the brokerage industry when developing the registry’s algorithm. Hil founded the organization after the emotionally grueling experience of obtaining a kidney for his 10-year-old daughter. After seven family members, including Hil and his wife, volunteered to donate theirs, all seven were found to be a poor match. (Eventually they found a compatible cousin.)
Each chain starts with a completely altruistic donor, someone who expects nothing in return. In the case of the San Francisco chain, that person was Zully Broussard, a 55-year-old mental-health nurse who works in a prison. Broussard lost her 21-year-old son to bone-cartilage cancer in 2001. Then, in 2013, her husband died of colon cancer. “I know what it is to want an extra hour, an extra day, with someone you love,” she told me. Directed by the algorithm, Broussard’s kidney ended up inside a complete stranger, a 26-year-old factory worker, Oswaldo Padilla, with a 6-year-old daughter, setting off the 12-person chain that included Kim and his sister and ended with an interior designer named Verle Breschini.
Economists call an arrangement like this a matching market. “It is not fundamental to economic theory to assume people are selfish,” Alvin E. Roth, an economist who teaches at Stanford University, told me. Roth won the Nobel Prize in economics in 2012 for his work using game theory to design matching markets, which pair unmatched things in mutually beneficial ways — students with public schools and doctors with hospitals. In such markets, money does not decide who gets what. Instead, these transactions are more akin to elaborate courtships.
The classic example of a matching market is the college-admissions process. Every year, tens of thousands of students apply to Harvard University. But just because a student wants a spot in the freshman class and can afford tuition does not mean he gets in. Harvard must also wanthim to attend. In the case of kidney exchange, this matchmaking happens at a microcellular level. White blood cells contain genetic markers, proteins that help our immune systems distinguish between our bodies and foreign invaders. The more closely a transplant recipient’s genetic markers match a donor’s, the more likely the body is to adopt that foreign kidney as its own rather than attacking it.
All these genetic variables mean that linking unrelated donors and recipients requires the kind of computational heft humans can’t manage with pen and paper. For example, BiologicTx currently has 72 people in a computer database waiting to give or receive a kidney. Run the software to find biologically compatible matches among those 72 people, and you get 105,716 possible configurations — some long chains, others short. Some people in the database have no possible matches. Others, genetically blessed, have thousands of potential matching options within the pool. The software ranks those possible pairings based on hundreds of different immunological, genetic and demographic criteria, while also aiming to create longer chains of harder-to-match people which will ultimately result in more transplants.
Last year in the United States, 544 kidneys were transplanted through these paired exchange programs, and many other countries are beginning to adopt them. Surgeons in Poland, Italy and Argentina completed their first chains last year. As more donor-and-recipient pairs enroll, the chains can accommodate increasingly complicated transactions. In December, for example, a transplant surgeon at U.C.L.A. removed the kidney from a grandfather who donated on behalf of his young grandson. The boy suffers from chronic kidney disease, but his doctors have determined he does not yet require a transplant. The grandfather feared that if he waited the five or 10 years until the boy needed the kidney, he would be too old to donate. So the boy and his grandfather joined the National Kidney Registry, using the grandfather’s kidney to kick off a chain, thereby securing a kidney for the boy, who will be the last recipient in another chain at some unspecified future date.
Mark Kim had his operation two months ago, and ever since, people have been telling him that his voice seems different, that somehow he sounds more alive. And at a biological level, every cell in his body feels better. But that vitality extends beyond his physical well-being. He is now one link in a visceral chain of sacrifice and benefit. It feels, to him, a little bit like kinship.
By Jacque Wilson and Deborah Brunswick
It was just another day with another massive allergic reaction.
She can always tell when one is coming on. "I just get this overwhelming sense of -- they call it impending doom." Her labradoodle, Moose, starts alerting, licking her hands frantically.
"I'll feel like I'm being stabbed in the stomach, and then it gets hard to breathe and my throat and tongue start swelling. And we have to treat it really fast."
On that particular day in March, multiple EpiPens didn't slow the reaction. The paramedics who arrived to take Brynn to Greenville Memorial Hospital, or "Hotel Greenville" as she likes to call it, knew her well. When she asked for her security blanket, they knew to hand her her smartphone.
"New day, new crisis," Brynn quips as she tells the story, as if it's about her first day of college or a shopping trip gone wrong. It might as well be. When you're allergic to life, a near-death experience is no big deal.
Center of attention
Less than a week after her trip to the hospital, Brynn, 21, is back at home in Easley, South Carolina. She lies on her back, her head near the foot of her bed, chattering away as her mom changes the access to her chest port.
Melissa Duncan, a paralegal by day, dons a mask and surgical gloves before disinfecting the area around the tube that's connected to Brynn's jugular vein. The disinfectant burns, and Brynn's blood pressure hits 150/102. Her heart rate rockets to 128.
"The meds we have to give her to keep her alive, she reacts to," Melissa says, shaking her head. "Never in a million years did I think I would be doing this. "
Brynn was seemingly a normal kid -- until she wasn't. Yes, she was a fussy baby. Yes, she got sick often as a child, Melissa muses out loud -- but what kid doesn't? Brynn was also incredibly energetic, always the center of attention. Her father, Barry, jokingly rues the day she learned to talk. She started taekwondo at the age of 9 and had her black belt by the time she was 11. That was the same year doctors diagnosed Brynn with IBS, or irritable bowel syndrome.
"She's always been --" Melissa Duncan pauses.
"High maintenance!" Brynn fills in with a laugh.
It wasn't until shortly before her 16th birthday in 2010 that Brynn had her first serious allergic reaction. The next two years became a blur of sick days and doctors' appointments.
Brynn saw specialist after specialist. The gastrointestinologist diagnosed her with gastroparesis, or partial paralysis of the stomach muscles. A cardiologist said she had POTS, or Postural Orthostatic Tachycardia Syndrome -- meaning that when she stood up for longer than a few minutes, her blood pressure dropped, leaving her light-headed and nauseated. A Wake Forest doctor diagnosed her with Ehlers-Danlos syndrome, a connective tissue disorder that causes fragile skin and overly flexible joints.
After doing hours of research, Melissa, Barry and Brynn came up with their own diagnosis: mast cell disease. They found a specialist online, Dr. Lawrence Afrin, who at the time was working in Charleston. They waited nearly nine months to see him, but hearing him confirm their suspicions was life-changing.
Mast cells are the regulators of your immune system. They're the ones that release histamine when a bug bites, or when you come into contact with an allergen. They basically sound the alarm that lets the rest of your immune system know something is wrong.
Until recently, the only mast cell disease doctors had identified was mastocytosis, which is characterized by "abnormal proliferation and activation" of the body's mast cells -- meaning there are way too many and they act in strange ways.
But in the last few years doctors such as Afrin have started to recognize that there are many different layers to mast cell disease. For instance, Brynn has mast cell activation syndrome, meaning her mast cells act strangely, but they're not growing in number.
"It's like I'm living in a 24/7 allergic reaction," Brynn explains simply.
Fruit, vegetables, milk, soy, nuts, smoke, perfume, the sun -- you name it, Brynn is allergic to it. But it's not really about the specifics; the allergens change depending on how "angry" her mast cells are that day, she says. On good days, she can eat small amounts of plain meat or mashed potatoes. On bad days, even using her feeding tube causes her extreme pain.
Not everyone with mast cell activation syndrome has it as bad as Brynn does. "Oh God, no," Afrin says when asked. "No, no, no, no."
But mast cells are located in your connective tissue, including your skin and the lining of your stomach and intestine. They can affect every system in the body, Afrin says, so the disease is capable of causing all the symptoms Brynn experiences.
You have to ask yourself, he says: "Is this poor patient so uniquely unlucky to have acquired so many different, independent problems? Or is it more likely that there is just one thing going on?"
Of course, having a diagnosis didn't make living with mast cell disease any easier.
In 2012, Brynn was admitted to the hospital 30 times. She started having seizures and episodes of dystonia -- painful, violent muscle contractions that are "scary to see and scary to experience." On multiple occasions, doctors have had to put casts on her legs to prevent her joints from bending in the wrong direction.
"I've seen doctors and nurses step back, kind of like 'What is this?'" Barry Duncan says.
Every time she went to the ER, Brynn was given a large dose of steroids to calm the inflammation. She's now steroid dependent -- and likely will be for life.
"We could be here for days, and you still would not understand all the inner workings of Brynn and all of her medical issues," Melissa Duncan says. "But I think the underlying one is the mast cell disease, which is a beast, and continues to become a bigger beast, day by day."
Living in a bubble
Brynn spent her 19th birthday in the hospital. An allergic reaction made her miss a zip lining trip for her 20th. On December 31, her 21st birthday, when many young adults would be out celebrating the legal drinking age with friends, she was at home still recuperating from Christmas. She had joined the holiday festivities by eating a special pizza -- made with fake bread and fake cheese.
"It's nasty," Barry Duncan says with a laugh. "It's the worst pizza you've ever tasted." But "for her, the worst pizza you've ever had ... tastes really good."
Brynn dreams about real stuffed crust pizza sometimes. And mozzarella sticks. Occasionally she lets her spunky attitude drop, and you see that she understands the effect her illness has on those around her.
Her parents have spent weeks sleeping in cramped hospital chairs. Her younger siblings have missed vacations and school ceremonies; they've learned how to inject Brynn with an EpiPen, and how to hold her limbs still during a dystonia episode.
"There's a lot of guilt that goes along with having a chronic illness," Brynn says. "You feel like a burden. And people can tell you you're not, but no matter what, in your head, you feel that you are."
She has moments when she gets jealous of her high school friends who are doing all the things she can't -- attending college, moving out, finding boyfriends. She and her new friends, others with chronic illnesses she met online, have a saying: "Single and ready to mingle -- as long as you have good health insurance."
And with a giggle, the dark moment passes. Skyping with her friends keeps her spirits up. She's prolific on Instagram, with more than 5,300 followers, and writes regularly on her blog, which is called "Brynn's Bubble."
"A lot of people with this disease ... do, in a sense, have to live in a bubble, because it's really difficult to get the symptoms under control," Brynn says. "You spend a lot of time alone. And it can be very isolating. But thanks to social media, I haven't felt alone."
Over the last two years, Brynn and her family have made progress in managing her disease. She was one of the first patients in the nation to be put on a continuous IV of antihistamine. Intravenous immune globulin, or IVIG, therapy, when a healthy donor's plasma is used to boost a patient's immune system, cut in half the number of drugs she needs.
Of course, she still needs a lot -- a compounding pharmacy delivers a box to her house once or twice a week. The meds make her brain foggy. She punctuates conversations with "Where'd that thought go?" But that doesn't stop her from talking. She plans to keep talking until mast cell disease receives the attention she feels it deserves.
"'You don't look sick' -- that's one of the comments that I get a lot. Or they say, 'At least it's not cancer,' and that's another hard one, because these illnesses can be just as devastating," Brynn says. "The difference is they're not understood. And the only way to change that is to somehow bring awareness to it."
Early in her taekwondo career, Brynn's instructor told her that she could win a match before it even began -- just by staring down the opponent. She plans to fight mast cell disease the same way.
Alexandra Wilson Pecci
Hospitals have a broader responsibility to elderly trauma patients than just the time spent within their walls, and should consider updating their strategies to ensure the best outcomes for these patients, research suggests.
Elderly trauma patients are increasingly likely to be discharged to skilled nursing facilities, rather than inpatient rehabilitation facilities (IRF), finds a study in The Journal of Trauma and Acute Care Surgery published in the April issue.
Discharge to skilled nursing facilities for trauma patients has, however, been associated with higher mortality compared with discharge to inpatient rehabilitation facilities or home.
Researchers wanted to "better characterize trends in trauma discharges and compare them with a population that is equally dependent on post-discharge rehabilitation." They not only examined trauma discharges, but also discharges of stroke patients, who have been taking up more inpatient rehabilitation facility beds.
Using data from 2003–2009 data from the National Trauma Data Bank and National Inpatient Sample, the retrospective cohort study found that elderly trauma patients were 34% more likely to be discharged to a skilled nursing facility and 36% less likely to be discharged to an inpatient rehabilitation facility. By comparison, stroke patients were 78% more likely to be discharged to an inpatient rehabilitation facility.
This is despite the findings of a 2011 JAMA study of patients in Washington State showing that "Discharge to a skilled nursing facility at any age following trauma admission was associated with a higher risk of subsequent mortality."
The Journal of Trauma and Acute Care Surgery study notes that "elderly trauma patients are the fastest-growing trauma population," which leads to the question: Where should hospitals be investing their money and time to ensure the best outcomes for these patients?
"I think hospitals should be investing in post-acute care discharge planning," says Patricia Ayoung-Chee, MD, MPH, Assistant Professor, Surgery, NYU School of Medicine, and lead author of the study. "What's the best post-acute care facility for patients? And it may end up needing to be individualized."
She says reimbursement and insurance factors have "played more of a role than anybody sort of thought about" in discharges, rather than what is always necessarily best for patients.
For example, to be classified for payment under Medicare's IRF prospective payment system, at least 60% of all cases at inpatient rehab facilities must have at least one of 13 conditions that CMS has determined typically require intensive rehabilitation therapy, such as stroke and hip fracture.
"I think the unintended consequence is that we may be discharging patients to the best post-acute care setting, but we also may not be," Ayoung-Chee said by email, and that question "is only now being looked at in-depth."
She says hospitals should think about truly appropriate discharge planning upfront.
For instance, at admission, hospitals can find out who the patient lives with, or what their social support system is like. If they have a broken dominant hand after a fall, will they be able to get help with their groceries? Do they live alone? Will they be able to use the bathroom?
Caring for patients also doesn't end when patients leave the hospital, she adds. Hence the study's title: "Beyond the Hospital Doors: Improving Long-term Outcomes for Elderly Trauma Patients."
Ayoung-Chee says the next step in her research is to look at a more longitudinal picture, following individual patients to see what factors play into their function or lack of function.
But hospitals can do some of that work on a smaller scale, with internal audits to determine which facilities have the best post-acute care outcomes. For instance, they could spend time examining which facilities had fewer readmissions compared to others, as well as how long it took patients to get home and their how satisfied they were with their care.
Other research is also trying to determine which facilities are best for elderly trauma patients. For instance, a second study, also published in The Journal of Trauma and Acute Care Surgery, shows that geriatric trauma patients have improved outcomes when they are treated at centers that manage a higher proportion of older patients.
One of the overarching takeaways from Ayoung-Chee's research is the idea that hospitals have a broader responsibility to patients than just the time spent within their walls.
"What we do doesn't just end upon patient discharge. If we truly want to get the biggest bang from our buck, we're going to have to think about the entire continuum," she says.
That could range from working to prevent falls that can cause elderly trauma, to seeing patients through all of the appropriate care needed to expect a good functional outcome. Good healthcare for elderly trauma patients should extend beyond the parameters of morbidity and mortality, and toward returning patients to their original functional status and, ultimately, independence, says Ayoung-Chee.
"Our long-lasting effect as healthcare providers isn't just what we do in the hospital," she says. "And we have to start thinking outside."
Medication errors continue to plague the clinical community and even rare cases of mistakes can make a big splash in the news. And for a good reason: we all expect to be treated than harmed when receiving medical care. A new device is currently in the third round of pilot testing, including at major retail pharmacies and Purdue University, that may help avoid prescription errors altogether. The IdentRx system from PerceptiMed, a Mountain View, California firm, optically analyzes every single pill that will be given to a patient to make sure it precisely matches each prescription.
It is the only device that visually inspects each pill, recognizing the manufacturer imprints on them all. The system confirms that the pills themselves, and not only the container bottles, match the issued prescriptions, hopefully preventing errors just before the pills are handed to the patients.
Written by James McIntosh
Obesity is a serious public health problem in the US and can affect anyone regardless of age. In particular, childhood obesity prevalence remains high. As well as compromising a child's immediate health, obesity can also negatively influence long-term health dramatically. Unfortunately, some racial and ethnic groups are affected by obesity much more than others.
For example, the US Department of Health and Human Services Office of Minority Health (OMH) report that African-American women have the highest rates of being overweight or obese, compared with other racial or ethnic groups in the US.
Approximately 4 out of 5 African-African women were found to be overweight or obese and, in 2011, African-American women were 80% more likely to be obese than non-Hispanic white women.
Researchers have identified that disparities in obesity prevalence can be found just as readily among children as among adults. It is alarming that these disparities exist to begin with, but more so that they exist so early in life for so many.
In this Spotlight feature, we take a brief look at the prevalence of childhood obesity in the US and the disparities in childhood obesity prevalence that exist among different racial and ethnic groups. We will examine what factors may contribute to this disparity and what action can be taken to remedy the situation.
A growing problem
"Obesity is the terror within," states Dr. Richard Carmona, the former Surgeon General. "Unless we do something about it, the magnitude of the dilemma will dwarf 9-11 or any other terrorist attempt."
These are strong words, but they illustrate the scope of the obesity problem. According to the Centers for Disease Control and Prevention (CDC), in 2009-2010, over a third (35.7%) of adults in the US were obese.
On average, childhood obesity in the US has not changed significantly since 2003-2004, and overall, approximately 17% of all children and adolescents aged 2-19 years are obese - a total of 12.7 million.
There are a number of immediate health problems that childhood obesity can lead to, including:
- Respiratory problems, such as asthma and sleep apnea
- High blood pressure and cholesterol
- Fatty liver disease
- Increased risk of psychological and social problems, such as discrimination and low self-esteem
- Joint problems
- Type 2 diabetes.
In the long term, obese children are much more likely to grow up to be obese as adults than children with healthy weights. Not only that, but the obesity experienced by these children is likely to be more severe, leading to further and more extreme health problems.
Significant disparities exist in obesity prevalence between different racial and ethnic groups. The CDC report the following obesity prevalence percentages among different youth demographics:
- Hispanic youth - 22.4%
- Non-Hispanic black youth - 20.2%
- Non-Hispanic white youth - 14.1%
- Non-Hispanic Asian youth - 8.6%.
From these figures taken from 2011-2012, we can see that levels of obesity among Hispanic and non-Hispanic black children and adolescents are significantly above average.
When the parameters are extended to include overweight children as well, the disparity persists. Around 38.9% of Hispanic youth and 32.5% of non-Hispanic black youth are either overweight or obese, compared with 28.5% of non-Hispanic white youth.
In 2008, Dr. Sonia Caprio, from the Yale University School of Medicine, CN, and colleagues wrote an article published in Diabetes Care in which they examined the influence of race, ethnicity and culture on childhood obesity, and what their implications were for prevention and treatment.
"Obesity in children is associated with severe impairments in quality of life," state the authors. "Although differences by race may exist in some domains, the strong negative effect is seen across all racial/ethnic groups and dwarfs any potential racial/ethnic differences."
However, if there are specific factors contributing to these disparities that can be addressed, the numbers involved suggest that attention should be paid to them. The long-term health of thousands of children in the US is at stake.
"Rarely is obesity in children caused by a medical condition," write the National Association for the Advancement of Colored People (NAACP) in their childhood obesity advocacy manual. "It occurs when more calories are eaten than calories burned."
The NAACP outline a number of factors that contribute to increases in childhood obesity, including:
- The development of neighborhoods that hinder or prevent outdoor physical activity
- Failure to adequately educate and influence families about good nutrition
- Ignored need for access to healthy foods within communities
- Limited physical activity in schools
- Promotion of a processed food culture.
The CDC report that childhood obesity among preschoolers is more prevalent in those who come from lower-income families. It is likely that this ties in with the disparity with obesity prevalence among different racial and ethnic groups.
"There are major racial differences in wealth at a given level of income," write Caprio, et al. "Whereas whites in the bottom quintile of income had some accumulated resources, African-Americans in the same income quintile had 400 times less or essentially none."
Fast food and processed food is widely available, low cost and nutritionally poor. For these reasons, they are often associated with rising obesity prevalence among children. According to Caprio, et al., lower-cost foods comprise a greater proportion of the diet of lower-income individuals.
If adults need to work long hours in order to make enough money to support their families, they may have a limited amount of time in which to prepare meals, leading them to choose fast food and convenient processed food over more healthy home-cooked meals.
Living in high-poverty areas can also mean that children have limited access to suitable outdoor spaces for exercise. If the street is the only option available to children in which to play, they or their parents may prefer them to stay inside in a safer environment.
Hispanic youth and non-Hispanic black youth are more likely to come from lower-income families than non-Hispanic white youth. According to The State of Obesity, white families earn $2 for every $1 earned by Hispanic or non-Hispanic black families.
Over 38% of African-American children aged below 18 and 23% of Latino families live below the poverty line. This statistic suggests that the effects of living with a low income that increase the risk of obesity may be felt much more by African-American and Latino families and their children.
Not only do these socioeconomic factors increase the risk of obesity among these demographic groups but equally obesity can compromise a family's economic standing.
The NAACP point out that families with obese children spend more money on clothing and medical care. Additionally, as obese and overweight girls frequently start puberty at a younger-than-average age, there is a possibility that their risk of adolescent pregnancy is also higher.
Alongside these socioeconomic factors, a number of additional factors exist that may be linked to an increased prevalence of childhood obesity among Hispanic and non-Hispanic black youth.
The NAACP give one such example, stating that one component of body image is how a person believes others view them or accept their weight:
"This also poses unique challenges in African-American communities because of cultural norms that accept, uplift and at times reward individuals who are considered 'big-boned,' 'P-H-A-T, fat,' or thick.'"
Cultural norms such as these may lead to parents remaining satisfied with the weight of their children or even wanting them to be heavier, even if they are at an unhealthy weight. Other sociological studies have also suggested that among Hispanic families, women may prefer a thin figure for themselves but a larger one for their children, according to Caprio, et al.
As well as being influenced by socioeconomic status, the type of foods eaten by children can be influenced by the cultural traditions of their families.
"Food is both an expression of cultural identity and a means of preserving family and community unity," write Caprio, et al. "While consumption of traditional food with family may lower the risk of obesity in some children (e.g., Asians), it may increase the risk of obesity in other children (e.g., African-Americans)."
As mentioned earlier, the promotion of a processed food culture may be a contributing factor to childhood obesity. As fast food companies target specific audiences, favoring cultural forms associated with a particular race or ethnicity could increase children's risk of being exposed to aggressive marketing.
Caprio, et al., report that exposure to food-related television advertising - most frequently fast food advertising - was found to be 60% among African-American children.
The amount of television that is watched may contribute as well; one study conducted by the Kaiser Family Foundation observed that African-American children watched television for longer periods than non-Hispanic white children.
A number of these cultural factors are associated with socioeconomic factors. African-American children may be more likely to watch television for longer, for example, if they live in areas where opportunities for playing safely outside are limited.
What can be done?
This subject area is far too detailed to do justice to in an article of this size, but these brief observations suggest that there should be ways in which the disparity in childhood obesity between racial and ethnic groups can be addressed.
Having more safe spaces to walk, exercise and play in low-income areas would give children a better opportunity to get the exercise need to burn the required number of calories each day. Improving the availability of and access to healthy food would give families more options when it came to maintaining a healthy, balanced diet.
The NAACP state that low-income neighborhoods have half as many supermarkets as the wealthiest neighborhoods, suggesting that for many low-income families, accessing healthy food can be a challenge.
These problems are ones that would need to be solved by local government and businesses that have influence over the planning and development of public living spaces.
Caprio, et al. propose that a "socioecological" framework should be adopted to guide the prevention of childhood obesity. Such a framework would involve viewing children "in the context of their families, communities, and cultures, emphasizing the relationships among environmental, biological and behavioral determinants of health."
This approach would require large-scale collaboration, involving peer support, the establishment of supportive social norms and both the private and public sector working together.
"For health care providers to have a meaningful interaction about energy intake and energy expenditure with children/families, providers should have training in cultural competency in order to understand the specific barriers patients face and the influence of culture and society on health behaviors," the authors suggest.
In order for this disparity to be adequately addressed, a lot of work will need to be done. Not only might certain cultural norms need to be altered, but most importantly, environments will need to be provided in which children will have the opportunity to live as healthy lives as possible.
BY SEAN DENT
Pens that don’t work? Socks that cut off your circulation? Cheap key chains? Yep, those sound like some Nurses Week gift failures to me!
I have some suggestions for gifts I think every nurse would appreciate for Nurses Week. Here are two major ones (you can thank me later!):
A real lunch break
- You know, the kind of lunch break that involves leaving the nursing unit, or even leaving the premises all together. The kind where you actually taste your meal instead of inhaling it on the go. Maybe even a full hour-long lunch so we could enjoy the food we eat and take our time getting back on shift.
IOU: A time out
- A certificate that allows you the ability to just call a time out. I’m talking stopping everything, putting your hands in the air and taking a “Calgon moment.” No explanation necessary, just produce the IOU. We should be able to use this IOU whenever the need arises. You could even put an expiration date on it, although I doubt it would take long to use this one up.
Here are a few more random ideas for gifts:
- A valet ticket for parking
- A free lunch (or more than one)
- IOU: One time you get to leave work early
- IOU: One time you get to come to work late
- IOU: One request for a new pot of coffee be made (when the pot is empty)
- IOU: One admission paperwork completion
- IOU: A free breakfast
Don’t get me wrong, I’m always appreciative of the recognition, but I think if we’re going to celebrate all things nursing, then the gifts should be worth the year-long wait!!
Any other suggestions? What would be a great gift for you this Nurses Week?
Sexual relationships in long-term care facilities are not uncommon. But the long-term care industry is still grappling with the issue.
CAN A PERSON WITH DEMENTIA CONSENT TO SEX?
There's no greater evidence of that than a criminal case in Iowa. On Wednesday, a jury in Iowa found a 78-year-old man not guilty of raping his wife, who had Alzheimer's disease. Henry Rayhons' wife lived in a nursing home. The staff there told Rayhons that because of her dementia, his wife was no longer capable of consenting to sex. He had been charged with sexual assault for allegedly having sex with her after that.
But at the Hebrew Home in Riverdale, N.Y., the fact that some people with dementia still have sex lives isn't news. That facility has had a written policy to help staff manage such relationships for 20 years.
"It was controversial in 1995 and it's controversial today," says Daniel Reingold, the CEO of RiverSpring Health, the nonprofit that runs the Hebrew Home.
"We knew that there was intimacy occurring, and we considered it to be a civil right and a legal right," says Reingold. "We also felt that intimacy was a good thing, that touch is one of the last pleasures we abandon and lose as we age."
Reingold says the policy protects residents from unwanted sexual contact. And he argues that people with dementia are indeed capable of giving consent.
"People who have Alzheimer's disease or dementia are asked on a daily basis to make decisions about their desires," says Reingold, "from what they eat to activities they may want to engage in," including intimacy with another person.
But even with a written policy, it's not that easy for nursing homes to figure out when consent to sex is really valid, says Evelyn Tenenbaum, a professor of law at Albany Law School and bioethics professor at Albany Medical College.
"For example, suppose you have a couple and the woman believes that the man she's seeing is her husband," says Tenenbaum. "Then she consents to a sexual relationship. Is that really consent if she doesn't understand who he is and that she's not married to him?"
Sometimes in such cases, nursing homes will defer to the wishes of the resident's family, says Tenenbaum.
"On the other hand, nursing homes are required to take care of the psychosocial needs of their residents," says Tenenbaum. "Whether psychosocial needs would include sexual relationships is a question."
And it's a question with no commonly accepted answer. The American Health Care Association, a trade group representing the majority of nursing homes, only suggests that its member facilities develop their own policies. Patricia Bach, a geriatric psychologist, says when she started looking into the topic she didn't find much.
"There was very, very little empirical evidence, little data, few research studies and it really was a lower priority issue for long-term care providers," she says.
So with a colleague, Bach surveyed members of the American Medical Directors Association, which represents physicians who work in long-term care facilities.
Bach found that "only 25 to 30 percent actually had formal training in the area of intimacy and sexuality, as it would pertain to older adults. Thirty percent had no training at all." The survey also found that only about 30 percent of nursing homes where the respondents worked had formal policies.
That's something that needs to change, and fast, says Reingold.
"We are dealing with the arrival of my fellow baby boomers," he says. They've "grown up in an environment where sexuality was a much more open conversation and activity."
And there's no reason to think that will change, Reingold says, even when those boomers are in long-term care.