tag:ltcreform.posthaven.com,2013:/posts Health and Disability 2018-06-24T11:28:16Z Norm DeLisle tag:ltcreform.posthaven.com,2013:Post/1296640 2018-06-24T11:28:16Z 2018-06-24T11:28:16Z Ultra-Processed Foods Up IBS Risk

http://bit.ly/2MkZitU

Consumption also linked to greater risk of functional dyspepsia when IBS is present.

Adults with diets high in ultra-processed foods and beverages were at higher risk of developing irritable bowel syndrome (IBS) and concomitant functional dyspepsia (FDy), French researchers reported in the American Journal of Gastroenterology.

That suggests the need to incorporate the impact of highly processed convenience foods into nutritional guidelines, said Laure Schnabel, MPH, of Paris-Sorbonne University, and colleagues.

The team studied the consumption of ultra-processed foods -- the popular, shelf-durable packaged and convenience foods and drinks with industrial formulations and plentiful additives that are increasingly replacing freshly prepared meals, even in the haute cuisineculture of France.

Foods consisted of more than 3,000 widely consumed dietitian-analyzed items, ranging from fresh and unprocessed foods to minimally processed (canned vegetables) and ultra-processed products (fish sticks, chicken nuggets, cookies, and sweetened drinks).

For the investigation, which the researchers said they believe to be the first such study, the team assessed the association between these products and four functional gastrointestinal disorders: IBS, FDy, functional constipation (FC), and functional diarrhea (FDh), disorders estimated to affect up to 25% of the population in industrialized countries.

The study sample was 76.4% women, and the mean age was 50.4. Before taking a self-administered questionnaire centered on Rome III diagnostic criteria, participants completed at least three 24-hour food-intake records with details on breakfast, lunch, and dinner, plus up to three additional eating episodes."The low-fiber content of ultra-processed foods could be involved in the induction and/or exacerbation of digestive symptoms," the French investigators wrote. A recent systematic review and meta-analysis by Moayyedi et al found that soluble fibers supplements are effective in treating symptoms in IBS patients. Insoluble fiber -- found in fruits, vegetables, and legumes and fermented in the colon -- produce short-chain fatty acids that promote normal intestinal function.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1296365 2018-06-23T09:45:05Z 2018-06-23T09:45:05Z Why Is Everyone Getting Shingles?

http://bit.ly/2tnXnxr

The virus that causes shingles is cunning. It lies dormant inside the human body — often hiding in the nerve cells of the spinal column or the brain. Then, after decades of inactivity, it can remerge as a painful, blister-pocked skin rash.

“The way the virus is quiescent for decades and then reactivates — it’s unusual, but it makes sense from the perspective of the virus’ survival,” says Rafael Harpaz, MD, a medical epidemiologist with the CDC’s Division of Viral Diseases. Back when humans lived in small hunter-gatherer communities, Harpaz explains, viruses that depended on human hosts would have died out quickly if they infected everyone en masse. By lying in wait, shingles allows new generations of carriers to be born.

Harpaz has spent years studying the bug. A 2016 study of his in the journal Clinical Infectious Diseases helped shine a spotlight on a curious phenomenon: For at least the past 60 years, rates of shingles have been climbing. Compared to the period from 1945 to 1949, when 0.76 people per 1,000 developed shingles, rates climbed to 3.15 per 1,000 by the period from 2000 to 2007, his study found.

“[The rise] seems to be occurring across all age groups, and not just in the U.S.,” says Kosuke Kawai, ScD, an assistant professor of otolaryngology at Boston Children’s Hospital and one of Harpaz’s co-authors on the CID study. “There are studies in European countries, and also in Taiwan and Australia, that seem to show this same increase over time.”

While rates of shingles have been escalating for decades, Harpaz says the increase seems to be “plateauing” among older adults — a group that usually suffers from a higher incidence of shingles than younger people. (A new vaccine was introduced in 2006, and some experts suspect that may explain it.) But rates of shingles among those age 30 to 50 don’t seem to be leveling off.

From the late 1940s to the early 2000s, the prevalence of shingles among Americans younger than 50 more than quadrupled, Harpaz’s data shows. Some research suggests the incidence of shingles among younger adults may actually be gaining steam. At least anecdotally, shingles seems to be increasingly common among people in their twenties and thirties — a group that, historically, suffered from vanishingly low rates of the disease.

What’s fueling all this? Harpaz is stumped. “I have given this as much thought as anyone, and it remains a mystery to me,” he says.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1296364 2018-06-23T09:41:35Z 2018-06-23T09:41:35Z Parkinson's drugs may lead to compulsive behavior

Increases in compulsive behavior were clear in the use of L-dope in people with Parkinson's in the 60's, but the level of the problem is evident in this research....

http://bit.ly/2MfUC8s

The production of dopamine can be excessively stimulated by taking drugs such as alcohol, cocaine, or heroin.

So, the neurotransmitter is at the heart of addictions and impulse control disorders ranging from substance abuse to sex addiction and gambling.

Such impulse control issues have been found to be common in people with Parkinson's disease. Pathological gambling and compulsive shopping, as well as compulsive eating and sexual behavior, have all been documented among patients with Parkinson's.

The drugs often prescribed to people with Parkinson's are the main risk factor for such compulsive behavior. Because dopamine is deficient in Parkinson's, the go-to treatment is dopamine agonists — which are drugs that activate the brain's dopamine receptors — or the well known levodopa, which turns itself into dopamine.

The researchers investigated 411 people who had received a Parkinson's disease diagnosis 5 years or under before the study, and who were clinically followed for at least 3 years.

Dr. Corvol and his colleagues interviewed the participants about any symptoms of impulse control disorders, such as compulsive shopping, eating, gambling, or sexual behaviors.

Of the 411 participants, 356 (or almost 87 percent) had taken dopamine agonists at least once since their Parkinson's diagnosis. At baseline, 81 participants (almost 20 percent) reported an impulse control disorder.

Specifically, 11 percent reported binge eating, 9 percent reported compulsive sexual behavior, 5 percent said that they shopped compulsively, and 4 percent admitted to having a gambling problem.

Of the 306 participants who did not report having any impulse control problems at baseline, 94 developed such a problem during the study. According to the scientists, this amounts to a "5-year cumulative incidence" of impulse control disorders of 46 percent.

By comparison, those who had never taken the drugs had a 5-year incidence of 12 percent. What is more, 30 participants with compulsive behaviors stopped taking the drugs during the study, which put an end to their symptoms.

Finally, higher doses of dopamine agonists and the duration of the treatment correlated directly with the risk of developing impulse control disorders.


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1295688 2018-06-20T10:29:50Z 2018-06-20T10:29:50Z The Uber(ization) of In-Home Health Care

http://bit.ly/2JUwfQY

Caremap is a newly launched app for in-home care that, like Uber, connects users directly with service providers. And the lack of a middleman is one of the model’s most important distinctions, says founder and CEO Nectarios Charitakas.

“The whole time I was helping my parents, every time I told them, ‘Let’s get you care. It’s going to cost $30 or $35 an hour,’ they went ballistic. So I realized something had to be done. We had to bring a better price equilibrium. We had to help make it easier for families to find care,” says the enterprise IT veteran.

Unlike a traditional agency model, caregivers post their rate and users pay them directly via the app. Charitakas doesn’t take a cut. There is no administration fee. He’ll make money from users who choose to subscribe to the premium version of the app — the inspiration for its added features came from his own experience.

“So one of the problems I had was every time a caregiver took my mom or dad to an appointment, I never knew when the next follow-up was. So if your [Caremap] caregiver takes mom to a doctor’s appointment, they can’t close their shift until they go into the calendar to put in a follow-up.”

On both the free and premium versions, users can search a Market Place and connect with care providers — from non-accredited companion keepers to registered nurses — in their area. Appointments are scheduled via the app, and users can rate their caregiver(s). If you need care, you can also upload job postings with requirements – even language preference.

If the person in need of care isn’t tech-savvy, they can grant access to their profile and its administration. Charitakas believes being able to coordinate care remotely for a loved one can help ease the strain on family members.

Another pain point he decided to tackle was lack of information.

“My experience is that everything was a black hole. You had no idea if your caregiver was Mary Jane. You had no idea if she showed up, what time she showed up, what did she do and how is Mom. I found that very frustrating.”

Not only do caregivers have to “punch in” upon arriving and “out” at the end of his or her shift, the app uses geolocation to notify the user — and anyone to whom they’ve granted access — as to their impending arrival.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1295686 2018-06-20T10:26:49Z 2018-06-20T10:26:49Z Disrupted immune system? Avoid getting a tattoo

http://bit.ly/2JRGmWM

The new issue of the journal BMJ Case Reports features the case study of a woman who sought medical assistance due to severe and persistent pain in her left hip, knee, and thigh after having gotten her left thigh tattooed some months earlier.

In 2009, she had a double lung transplant that needed long-term immunosuppressant therapy, to avoid a transplant rejection response.

This, of course, meant that her entire immune system was disrupted, and it would not react to foreign agents inside the body in the same way that it normally would.

9 days after getting this tattoo, she started having severe pain in her left knee and thigh, the management of which required strong painkillers.

In time, the symptoms became less severe. But after 10 months, they had not wholly disappeared.

"Her pain was still troublesome, constant in nature, and causing regular sleep disturbance," write the authors of the case analysis.


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1294928 2018-06-17T10:21:56Z 2018-06-17T10:21:56Z New Epilepsy Guidelines Shed Light on Explosion of New Drugs

http://bit.ly/2JMXkFy

For new-onset epilepsy, there's not yet strong enough evidence for the American Academy of Neurology (AAN) and the American Epilepsy Society (AES) to recommend third-generation antiepileptic drugs (AEDs) in their new treatment guidelines.

But for treatment-resistant epilepsy, several recently approved AEDs may be winners.

"The update was prompted by the explosion of new antiepileptic drugs that have been approved since the time of the first guideline and the overwhelming amount of information available on each one," Jacqueline French, MD, of the New York University Comprehensive Epilepsy Center, told MedPage Today.

Issued jointly by the two organizations and published online in Neurology, the updated guidance for new-onset and treatment-resistant epilepsy replace ones in effect since 2004. The FDA has approved six third-generation AEDs that were included in this review since that time -- eslicarbazepine (Aptiom), ezogabine (Potiga, which has been discontinued), lacosamide (Vimpat), perampanel (Fycompa), pregabalin (Lyrica), and rufinamide (Banzel) -- and two older AEDs for certain types of epileptic disorders, clobazam (Onfi) and vigabatrin (Sabril).


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1294274 2018-06-15T10:20:34Z 2018-06-15T10:20:34Z Mr. Connolly Has ALS

http://bit.ly/2JBUzqN

Gene Connolly, principal of Concord High School in New Hampshire, was known for his non-stop energy, a love for rock & roll, and the innate ability to connect with the school’s 1,600 students. However, in 2014, he was diagnosed with Amyotrophic Lateral Sclerosis (ALS), also knows as Lou Gehrig’s Disease. Since the onset of his illness, Connolly showed tremendous persistence, humor, and leadership, crediting the school and community as a source of unfailing support and understanding.

Mr. Connolly Has ALS chronicles Connolly’s final year as principal of the school, when his physical abilities - to speak and walk - are significantly limited by the debilitating disease. The outpouring of love and support from the students, evident as they interview him one-on-one with both personal and tough questions, is remarkable and inspiring.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1293926 2018-06-14T11:32:58Z 2018-06-14T11:32:58Z Scientists Finally Think They Know What Causes Polycystic Ovary Syndrome – And How To Cure It

http://bit.ly/2y9DKOn 

Polycystic ovary syndrome (PCOS) is a condition that affects roughly one in five women – and now, scientists think they know why. (Just in time for National Women's Health Week.)

A study published in Nature Medicine found a link between hormonal imbalance in the womb and PCOS, specifically prenatal exposure to a growth factor called anti-Müllerian hormone (AMH). 

The team, led by Paolo Giacobini at the French National Institute of Health and Medical Research, realized levels of AMH were 30 percent higher in pregnant women with PCOS than those without. Because there is a hereditary component to the condition, they decided to test whether or not women with this hormonal imbalance give birth to daughters with PCOS. 

“It’s a radical new way of thinking about polycystic ovary syndrome and opens up a whole range of opportunities for further investigation,” explained Robert Norman from the University of Adelaide, Australia, reports New Scientist.

For the study, the researchers injected pregnant mice with AMH so that they had a higher than normal concentration of the hormone. Indeed, they gave birth to daughters who later developed PCOS-like tendencies. These included problems with fertility, delayed puberty, and erratic ovulation.

According to the researchers, the added AMH appeared to prompt the overstimulation of a particular set of brain cells called GnRH neurons, which are responsible for managing the body's testosterone levels. Hence, the offspring displayed higher levels of testosterone. The result: a "masculinization of the exposed female fetus" and a "PCOS-like reproductive and neuroendocrine phenotype" by the time they reached maturity.

But, excitingly, the team weren't just able to determine the cause of PCOS, they were able to reverse it (in mice, anyway). To do so, the researchers dosed the polycystic mice with an IVF drug called cetrorelix, which made the symptoms to go away.

This could be great news for the millions of women with the condition, often characterized by excessive hair growth, hair loss, acne, and obesity, though symptoms can vary from patient to patient. It is also the most common cause of infertility.

Next up, the team is planning to trial the drug in humans. Tests are planned to take place later in the year.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1293591 2018-06-13T09:30:54Z 2018-06-13T09:30:54Z Food Allergy Most Common Allergic Condition in Autism

http://bit.ly/2JNXj3z

Early food allergy and other allergic conditions showed a positive association with autism spectrum disorder (ASD) in a large, nationally representative sample of U.S. children, and the association persisted after researchers adjusted for demographic and socioeconomic variables and other types of allergic conditions.

Food allergies were the most common allergic condition found in children with autism, and the association was consistent and significant in all age, sex, and racial/ethnic subgroups in the population-based, cross-sectional analysis of data from the National Health Interview Survey collected between 1997 and 2016.

In an invited commentary published with the study, Christopher J. McDougle, MD, of Massachusetts General Hospital and Harvard Medical School in Boston, explored the researchers' hypothesis that the association may be related to gut-brain-behavior axis abnormalities thought to exist in some children with ASD: "Such an association has been reported in both patients with ASD and animal models of ASD, particularly those with the maternal immune activation model of ASD.

"From a clinical perspective, patients with ASD who are minimally verbal to nonverbal may be unable to describe the pain and discomfort they experience secondary to food allergy and subsequent inflammation in the gastrointestinal tract. Instead, their physical distress may manifest as irritability, aggression, and/or self injury."

The prevalence of ASD among children in the U.S. has increased steadily in recent decades, according to findings from nationally representative surveys, Bao and colleagues noted, explaining that immunologic dysfunction is a potential link between environmental risk factors and ASD.

Symptoms of immune function abnormalities, such as frequent infections and increased prevalence of autoimmune conditions have been frequently reported among children with ASD and maternal infection, inflammatory cytokines, and autoimmune diseases during pregnancy were also associated with ASD in children in some studies.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1293265 2018-06-12T10:14:59Z 2018-06-12T10:14:59Z Kent County Council's Shared Lives scheme supports unpaid carers in the county

This is England's Kent County, not Michigan's. A sort of Airbnb.....

http://bit.ly/2HGoMiz

We all need a break sometimes.

And that is especially important for those who are unpaid carers to enable them to continue looking after and supporting a friend or family member.

Kent Shared Lives, run by Kent County Council, can provide an alternative personalised break for eligible people with a range of different needs.

It is designed to be a real home from home service where approved hosts can take care of people with learning disabilities or difficulties, older people, those with dementia, mental health problems, sensory impairment, Autism or Asperger's.

Someone sharing a home with an approved host is given a safe and supportive environment where they can bring their own things and be supported in their hobbies, activities or interests.

From the homes of KCC approved hosts the Kent Shared Lives scheme can offer:

Short Breaks: Where a loved one would stay with a host for a couple of days or weeks at a time or longer if required.

Day Support: Which is based at the host’s home and can be on any given day of the week or time of the day and one session is up to five hours.

Long Term Care: Offered by Shared Lives and often an option for the future when someone's carer is unable to provide support. In these cases individuals would move in with a host and live as part of the family.

Kent County Council has a wide range of Shared Lives hosts around the county ranging from single people to couples and families who have availability to welcome someone into their lives.

Shared Lives is regulated by the Care Quality Commission and staff will always make sure everyone is happy with the chosen arrangement before it begins and regular checks are made to ensure everything is working well.

A referral from a care/case manager or social worker will be required to be considered for the scheme. To find out more please contact the team through facebook @kentsharedlives

via the website www.kent.gov.uk/sharedlives


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1291942 2018-06-08T11:07:09Z 2018-06-08T11:07:09Z A Typical Communication Pattern of People with Alzheimer’s

http://bit.ly/2kXJq4A

Dementia, in any form, is a heartbreaking disease that can take away one’s thinking and judgement abilities before they pass. To save face, people with dementia often pretend to know answers to questions, even if they really don’t. This often hides the severity of the disease and exasperates the fears and frustrations of the people who care for them. 

The act of pretending to know answers to keep up appearances is referred to as “saving appearance responses” (SARs), and a research group from Kumamoto University in Japan has performed the first statistical analysis of SARs in patients with various forms of dementia. Their findings revealed that those face-saving responses are particularly common in people with Alzheimer’s disease (AD), leading the researchers to recommend that doctors and caregivers should develop a more respectful attitude toward dementia patients who exhibit SARs because SARs imply conflicted feelings about questions that patients cannot answer correctly.

“SARs are a patient’s effort to show that they have no cognitive problems, but it seems that there are various psychological conflicts involved,” said Kumamoto University’s Dr. Masateru Matsushita of the Center for Medical Education and Research, leader of the study. “The reason more SARs are seen in AD may be because even though the memory function of the brain is in decline, thinking and judgment abilities are barely compromised. Attention to SARs might be helpful for more accurate dementia diagnosis. We expect that a better understanding of the characteristics of SARs, particularly in AD, will lead to earlier detection and better medical care for people suffering from dementia.”


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1291593 2018-06-07T10:10:03Z 2018-06-07T10:10:03Z Declines in Hospital-Acquired Conditions Save 8,000 Lives and $2.9 Billion in Costs

http://bit.ly/2kSwQDK

Data released today by the Agency for Healthcare Research and Quality (AHRQ) show continued progress in improving patient safety, a signal that initiatives led by the Centers for Medicare & Medicaid Services (CMS) are helping to make care safer. National efforts to reduce hospital-acquired conditions, such as adverse drug events and injuries from falls, helped prevent an estimated 8,000 deaths and save $2.9 billion between 2014 and 2016, according to the report.

The AHRQ National Scorecard on Hospital-Acquired Conditionsestimates that 350,000 hospital-acquired conditions were avoided and the rate was reduced by 8 percent from 2014 to 2016. Federal experts note that the gains in safety among hospital patients echoed earlier successes, including 2.1 million hospital-acquired conditions avoided between 2010 and 2014.

CMS has set a goal of reducing hospital-acquired conditions by 20 percent from 2014 through 2019. Through the work of the Hospital Improvement Innovation Networks (HIINs), CMS drives this aim through intensive, focused quality improvement assistance to more than 4,000 of the nation’s 5,000 hospitals by spreading best practices in harm reduction. The HIINs, together with federal agencies, private partners, and patient advocacy organizations, work collaboratively to make hospital care safer. Once the 20 percent reduction goal is met, AHRQ projects that during 2015 through 2019 there would be 1.8 million fewer patients with hospital-acquired conditions, resulting in 53,000 fewer deaths and saving $19.1 billion in hospital costs from 2015 through 2019.

Examples of hospital-acquired conditions include adverse drug events, catheter-associated urinary tract infections, central-line associated bloodstream infections, pressure injuries, and surgical site infections, among others.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1291283 2018-06-06T10:05:29Z 2018-06-06T10:05:29Z Woman Cured of Advanced Breast Cancer With New Treatment

https://thebea.st/2kQCd6v

A woman’s advanced stage breast cancer that metastasized throughout her body was completely eradicated with her own immune cells, marking the first time immunotherapy has successfully treated late-stage breast cancer. 

According to The Guardian, Florida engineer Judy Perkins, 49, was selected to undergo the radical therapy after rounds of chemo failed to cure her breast cancer. She’d been given just three years to live. The immunotherapy used Perkins’ “own immune cells to find and destroy cancer cells that have formed in the body,” and doctors at the U.S. National Cancer Institute say she’s now been cancer-free for two years. 

“It feels miraculous, and I am beyond amazed that I have now been free of cancer for two years,” Perkins said. Doctors call her recovery a sign that science is at the “cusp of a major revolution” in figuring out how to treat cancer through all of its mutations. They caution that the treatment must still go through clinical trials and may not work for all cases.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1290964 2018-06-05T11:06:57Z 2018-06-05T11:06:57Z Is there a link between GERD and fatigue?

http://bit.ly/2sIecSC

Fatigue is different from feeling tired. A tired person who has not slept well may struggle the next day and want to do less than they normally would.

In contrast, fatigue can have a significant impact on day-to-day life.

A person experiencing fatigue will feel that they do not have the energy to complete everyday tasks, and this feeling will continue over an extended period.

While a person can usually identify why they feel tired, fatigue is often a symptom of an underlying health condition that needs to be investigated. A doctor will need to make a diagnosis before the person can be treated.

GERD is one condition that can interfere with sleep patterns and cause fatigue. It occurs when stomach acid flows upward into the food pipe, which is called the esophagus, rather than staying in the stomach and aiding digestion.

There are different reasons why a person with GERD may experience fatigue.

When a person is walking or standing upright, gravity helps to keep stomach contents, including acid, where they belong.

However, when a person lies down, the position prevents stomach contents from moving through the body efficiently and allows stomach acid to rise into the food pipe.

When a person is lying down and trying to sleep, symptoms such as heartburn and coughing may worsen to become painful and disruptive. Heightened symptoms can prevent a person from sleeping properly and may eventually lead to fatigue.

Also, fibromyalgia sometimes occurs alongside GERD, and one symptom is fatigue. Fibromyalgia is a painful condition that can affect every area of the body.

Feeling permanently exhausted and lacking the energy to complete simple tasks is a sign that something is wrong.

Fatigue can be a symptom of various underlying conditions, and it is important to see a doctor, who can rule out unrelated issues.

Anyone experiencing fatigue should make a note of other symptoms.

This will help the doctor make a more quick and accurate diagnosis.

Other conditions that can cause fatigue include:

If GERD symptoms, such as heartburn and coughing, are interrupting a person's sleep, they should seek advice from a medical professional. Treatments a can ease symptoms and help a person to get a better night's rest.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1290617 2018-06-04T10:13:59Z 2018-06-04T10:13:59Z Colonoscopies lead to many more infections than previously thought

http://bit.ly/2xPbBwf

"Though patients are routinely told that common endoscopic procedures are safe, we found that post-endoscopic infections are more common than we thought, and that they vary widely from one ASC facility to another," says lead researcher Susan Hutfless of Johns Hopkins University.

Colonoscopy is one of six options suggested by the American Cancer Society for colon cancer screening. The traditional recommendation is that patients be regularly screened starting at 50, but the ACS recently reduced its recommended age to 45.

Upper-GI endoscopies, known as EGDs, can be used to diagnose a number of problems in the upper digestive tract, including heartburn, swallowing issues, and abdominal pain.

Each year in the United States, there are more than 15 million colonoscopies and 7 million EGDs. Both procedures are performed with an endoscope, a reusable optical instrument that gives doctors a view of a patient's gastrointestinal tract. Besides screening and diagnosis, they can be used for procedures such as removing polyps without invasive surgery.

Researchers examined data from six states—California, Florida, Georgia, Nebraska, New York, and Vermont—to track infection-related emergency room visits and unplanned inpatient admissions within seven and 30 days after a colonoscopy or EGD.

Post-endoscopic infection rates were previously believed to be in the neighborhood of one in a million, Hutfless says. The new study found a rate of infection seven or fewer days after a procedure was slightly higher than one in 1,000 for screening colonoscopies and about 1.6 per 1,000 for non-screening colonoscopies. Rates for EGDs within that time were more than three per 1,000.

Patients who had been hospitalized before undergoing one of the procedures were at even greater risk of infection. Since many ASCs lack an electronic medical record system connected to hospital emergency departments, those ASCs are unlikely to learn of their patients' infections, Hutfless says.

"If they don't know their patients are developing these serious infections, they're not motivated to improve their infection control."

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1290267 2018-06-03T10:23:16Z 2018-06-03T10:23:16Z Ten tips to help you communicate with a person with dementia and sight loss

http://bit.ly/2JjRkDx

There are six sight loss guides in the top tips series. This is the fifth guide of six.

The advice given here will help you feel confident about talking to a person with dementia and sight loss:

  1. Gain an understanding of the effects of the eye condition(s) and position yourself to minimise their impact
  2. Ensure the 3 C’s - correct, clean, and current glasses are worn
  3. Minimise “visual noise” by wearing block colours and minimal accessories
  4. Gain the person’s attention by saying their name first and/or by a gentle touch on the arm
  5. Introduce yourself and what you do
  6. Tell the person when you are moving away from them or leaving the room
  7. Speak clearly using simple, short sentences, giving only one idea, question or instruction at a time
  8. Follow the OWL principle - Observe, Wait and Listen for responses
  9. Ask if guidance or support is required and provide in a consistent manner
  10. Provide information in an alternative/accessible way such as audio, large print or braille.

Download the Ten tips to help you communicate with a person with dementia and sight loss  as an accessible PDF.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1289772 2018-06-01T11:42:29Z 2018-06-01T11:42:29Z Drug-Free Remission a Possibility in Early SpA

http://bit.ly/2Jl3onT

More than half of patients had sustained remission after induction with golimumab.

Patients with very early peripheral spondyloarthritis (SpA) who underwent induction treatment with golimumab (Simponi) had high rates of sustained clinical remission, and more than half were able to achieve drug-free remission, a pilot study found.

In a cohort of 60 patients whose mean symptom duration was approximately 5 weeks, 82% achieved sustained clinical remission, with most reaching this goal by week 24, according to Filip Van den Bosch, MD, PhD, and colleagues from Ghent University in Belgium.

And with at least 18 months of follow-up after stopping the golimumab, 53% remained in drug-free remission, they reported in Arthritis & Rheumatology.

Peripheral SpA is a subtype of spondyloarthritis that includes psoriatic arthritis and non-psoriatic peripheral SpA and is characterized by arthritis, dactylitis, and enthesitis. Therapeutic options in the past were limited, but biologic therapies have dramatically improved outcomes. The tumor necrosis factor (TNF) inhibitors have shown efficacy across the entire spectrum of SpA, including ankylosing spondylitis and psoriatic arthritis.

In addition, in previous studies of axial and nonradiographic SpA, better efficacy has been seen when treatment is introduced early rather than when the disease is established, and ongoing trials are exploring the possibility of treatment withdrawal in axial SpA once remission is achieved. Evidence has been growing in support of an early "window of opportunity" for optimal treatment outcomes in various other inflammatory diseases such as rheumatoid arthritis.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1289433 2018-05-31T10:21:28Z 2018-05-31T10:21:28Z Leaky gut: What is it, and what does it mean for you?

http://bit.ly/2LaqTNO

The expression “leaky gut” is getting a lot of attention in medical blogs and social media lately, but don’t be surprised if your doctor does not recognize this term. Leaky gut, also called increased intestinal permeability, is somewhat new and most of the research occurs in basic sciences. However, there is growing interest to develop medications that may be used in patients to combat the effects of this problem.

What exactly is leaky gut?

Inside our bellies, we have an extensive intestinal lining covering more than 4,000 square feet of surface area. When working properly, it forms a tight barrier that controls what gets absorbed into the bloodstream. An unhealthy gut lining may have large cracks or holes, allowing partially digested food, toxins, and bugs to penetrate the tissues beneath it. This may trigger inflammation and changes in the gut flora (normal bacteria) that could lead to problems within the digestive tract and beyond. The research world is booming today with studies showing that modifications in the intestinal bacteria and inflammation may play a role in the development of several common chronic diseases.

Who gets a leaky gut (and why)?

We all have some degree of leaky gut, as this barrier is not completely impenetrable (and isn’t supposed to be!). Some of us may have a genetic predisposition and may be more sensitive to changes in the digestive system, but our DNA is not the only one to blame. Modern life may actually be the main driver of gut inflammation. There is emerging evidence that the standard American diet, which is low in fiber and high in sugar and saturated fats, may initiate this process. Heavy alcohol use and stress also seem to disrupt this balance.

We already know that increased intestinal permeability plays a role in certain gastrointestinal conditions such as celiac disease, Crohn’s disease, and irritable bowel syndrome. The biggest question is whether or not a leaky gut may cause problems elsewhere in the body. Some studies show that leaky gut may be associated with other autoimmune diseases (lupus, type 1 diabetes, multiple sclerosis), chronic fatigue syndrome, fibromyalgia, arthritis, allergies, asthma, acne, obesity, and even mental illness. However, we do not yet have clinical studies in humans showing such a cause and effect.

A path toward a healthier gut

A common initial step some practitioners take is to remove foods that can be inflammatory and could promote changes in the gut flora. Among the most common are alcohol, processed foods, certain medications, and any foods that may cause allergies or sensitivities. In my practice, I often see patients improve significantly when they start eating a healthier diet.


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1288316 2018-05-28T10:07:28Z 2018-05-28T10:07:29Z America’s graying population in 3 maps

http://bit.ly/2GVGHkI

The U.S. population has changed substantially in the last half century, growing by nearly 63 percent.

Perhaps the two most prominent demographic changes over the past 50 years relate to age. In 1968, the baby boom had just ended, and the oldest members of its cohort were only 22 years old.

As baby boomers age, the nation has substantially aged as well. In 1970, the median age in the U.S. was 28.1. In 2016, it was 37.9.

Demographers and geographers like myself have watched as this aging cohort transformed the U.S., from young children in the 1950s and 1960s to senior citizens today. This graying of America has left a distinctive geographical fingerprint.

Where older Americans live

Unsurprisingly, popular retirement states like Florida and Arizona have high concentrations of older Americans.

What may be more of a surprise is the broad swaths of elderly running through the Midwest and the Appalachians. These regions have aged significantly, as many younger residents headed toward the coasts.

Younger people have also moved out of New England, primarily in search of jobs. Maine, New Hampshire, Vermont and Connecticut are among the seven states with a median age of over 40 in 2010; Pennsylvania, West Virginia and Florida are the others.

Not only is the U.S. aging, but the number of deaths is rising. This trend will accelerate over the next few decades.

Meanwhile, the number of births has declined since 2007. In fact, in 2013, over 30 percent of all U.S. counties experienced a phenomenon known as “natural decrease,” due the greater number of deaths than births. Natural decrease is now most prominent in Maine, the Appalachian region, the Great Plains and the Midwest.

Demographers expect this phenomenon to expand geographically over the coming years, as the general population continues to age.

The country has also become more urban. The percentage of the population living in urban areas increased by about 7 percentage points between 1970 and 2010. Urbanization increased in all states except Oklahoma and Maine.

Despite this trend, many cities are now shrinking – particularly cities in the Northeast and Midwest. More people, particularly young adults, are leaving these places for economic opportunity than are coming in. The percentage of the population living in large cities has declined since 2013, while the percentage living in smaller cities increased from 17.9 to 20.1 percent.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1288000 2018-05-27T10:52:31Z 2018-05-27T10:52:31Z Could Lawn Weed Prevent COPD Exacerbations?

http://bit.ly/2L1tZnk

An oral extract of the speedwell (also known as veronica) plant appeared to reduce some symptoms of chronic obstructive pulmonary disease (COPD), researchers reported here.

The peak expiratory flow increased in patients on YPL-001 by about 10%, while the increase in the placebo patients was less than 3%, according to Nathaniel Marchetti, DO, of the Lewis Katz School of Medicine at Temple University in Philadelphia, and colleagues.

"YPL-001 is an oral formulation of an extract from the aerial part of the plant speedwell used in traditional Asian medicine to treat respiratory inflammatory diseases including ... COPD," they explained in a presentation at the American Thoracic Society (ATS) annual meeting.

The phase IIa study was initiated to determine the safety and tolerability of YPL-001, so the trend toward efficacy was encouraging, Marchetti said.

"We found that the treatment with the drug was very well tolerated," he noted. "There were very few side effects other than those commonly seen among COPD patients including exacerbations."

"This is a medication, a herbal product, that has been used for millennia in Asia to treat inflammatory respiratory diseases," he added. "What Yungjin Pharm of Korea is trying to do is to take this herbal, and make it more standardized, so that everyone gets the same dose, and also to figure how not only whether it works, but how it works, so we can use it to treat people in a more systematic way."

Speedwell/veronica is commonly found in the U.S. as well. Plants are sold in garden shops and are also a frequent lawn weed problem.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1287989 2018-05-27T10:29:15Z 2018-05-27T10:29:15Z Gut Bacteria Play Key Role in Anti Seizure Effects of Ketogenic Diet

http://bit.ly/2J9uZs0

UCLA scientists have identified specific gut bacteria that play an essential role in the anti-seizure effects of the high-fat, low-carbohydrate ketogenic diet. The study, published today in the journal Cell, is the first to establish a causal link between seizure susceptibility and the gut microbiota — the 100 trillion or so bacteria and other microbes that reside in the human body’s intestines.

The ketogenic diet has numerous health benefits, including fewer seizures for children with epilepsy who do not respond to anti-epileptic medications, said Elaine Hsiao, UCLA assistant professor of integrative biology and physiology, and senior author of the study. However, there has been no clear explanation for exactly how the diet aids children with epilepsy.

Researchers in Hsiao’s laboratory hypothesized that the gut microbiota is altered through the ketogenic diet and is important for the diet’s anti-seizure effects. Hsiao’s research team conducted a comprehensive investigation into whether the microbiota influences the ability of the diet to protect against seizures and if so, how the microbiota achieves these effects.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1287674 2018-05-26T10:37:24Z 2018-05-26T10:37:24Z Trials Support Emicizumab as Standard Tx in Hemophilia A

Amazing....

http://bit.ly/2GSdwiL

$448,000 annual price would actually reduce per-patient costs.

Prophylactic treatment with emicizumab (Hemlibra) could soon replace the current standard treatment for hemophilia A patients without factor VIII inhibitors, and at a largely reduced treatment schedule, results of the manufacturer-sponsored HAVEN 3 and HAVEN 4 trials suggested.

The trials showed that emicizumab prevented or significantly reduced bleeds in these patients. Compared with no prophylaxis, emicizumab every week or 2 weeks yielded 96% and 97% reductions in bleeds requiring treatment (P<0.0001 for both), reported Michael Callaghan, MD, of Children's Hospital of Michigan in Detroit, and colleagues.

In addition, bleeds were reduced by 68% among patients who previously received standard of care factor VIII prophylaxis (P<0.0001).

"In the long run, as long as there aren't any unexpected safety events ... I think this will be the standard of care," Callaghan told MedPage Today.

Results of both trials were presented at the World Federation of Hemophilia's World Congress in Glasgow.

During the study period, 55.6% of patients on the once-weekly emicizumab schedule (95% CI 38.1-72.1) and 60% of those on the every 2-week schedule (95% CI 42.1-76.1) experienced no bleeds. None of the patients randomized to no prophylaxis were free from bleeds.

Callaghan said he did not see many hurdles in terms of emicizumab becoming the preferred first-line therapy for hemophilia A. While the price of the drug is high, annual cost-effectiveness estimates place it lower than current factor VIII prophylaxis.


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1286968 2018-05-24T10:23:57Z 2018-05-24T10:23:57Z Hotel Pools and Hot Tubs Are Major Sources of Waterborne Illness Outbreaks, CDC Says

https://ti.me/2GKD4hK

You may want to think twice before taking a dip on your next vacation, according to the results of a new report from the Centers for Disease Control and Prevention (CDC).

Between 2000 and 2014, the CDC recorded 493 disease outbreaks related to treated recreational water, resulting in more than 27,000 illnesses and eight deaths. And in almost a third of those outbreaks, the infections could be traced back to hotel pools, hot tubs and spas, the CDC says. In hotels, pools were a major culprit, but 65 cases stemmed from hot tubs or spas.

Of the outbreaks with a confirmed cause, the vast majority — 94% — were due to pathogens, while the remaining outbreaks were caused by chemicals. Cryptosporidium (also called Crypto) — which is a parasite that causes diarrhea and other gastrointestinal issues — caused 212 outbreaks and more than 21,700 illnesses over the 14 years. It’s typically spread when a person swims while they have diarrhea, putting others at risk of swallowing contaminated water. Legionella, which causes the serious pneumonia-like illness Legionnaires’ disease, as well as the less-severe Pontiac fever, was responsible for 57 outbreaks and 624 illnesses. (At least six of the eight deaths were caused by Legionella, the CDC says.) Pseudomonas, which results in swimmer’s ear or a skin condition known as “hot tub rash,” caused 47 outbreaks and 920 infections.

Outbreaks spiked during June, July and August, but they were observed all year long throughout the study period.

The prevalence of waterborne disease outbreaks highlights how difficult they can be to prevent, the report says. Crypto, for example, can survive even in properly maintained and chlorinated pools, and Pseudomonas and Legionella thrive in slimy areas in hot tubs, pools and water playgrounds. While hotels, water parks and public pools can minimize these risks through adequate maintenance, much of the burden of prevention falls on swimmers, especially when it comes to keeping Crypto out of the water.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1286608 2018-05-23T10:14:45Z 2018-05-23T10:14:45Z Deaths from fungal infections exceeding malaria, say researchers in new drug resistance warning

https://ind.pn/2ID37x0

Common fungal infections are “becoming incurable” with global mortality exceeding that for malaria or breast cancer because of drug-resistant strains which “terrify” doctors and threaten the food chain, a new report has warned.

Writing in a special “resistance” edition of the journal Science, researchers from Imperial College London and Exeter University have shown how crops, animals and people are all threatened by nearly omnipresent fungi.

“Fungal infections on human health are currently spiralling, and the global mortality for fungal diseases now exceeds that for malaria or breast cancer,” the report notes.

While the problem of bacteria becoming resistant to commonly used antibiotics has been widely reported on, and likened to the “apocalypse” by medical leaders, the risks of disease-causing fungi have received far less recognition.

Fungicides share a problem with antibiotics in that the organisms they aim to kill are becoming resistant to treatments faster than they can be developed, and there are growing numbers of people vulnerable to infection.

“We’ve got increasing numbers of immunosuppressed patients, that’s what fungi love to parasitise,” Matthew Fisher, professor of fungal disease epidemiology at Imperial, told The Independent.

“Half a million people a year probably die from fungal meningitis in Africa, which wouldn’t affect them if they didn’t have Aids.

“Similarly in the UK we have transplant patients as well, as soon as you whack them on immunosuppressants they start coming down with fungal infections.”

“Transplant doctors are absolutely terrified of these fungal infections,” he added, and the same issues arise in cancer patients, or people whose immune systems are destroyed by disease or age – leaving them unable to fight off infection on their own.

Our immune systems have evolved alongside fungi for millennia to keep us protected against the ever-present pathogens.

Unlike bacteria on surfaces and water droplets, fungi are much better at getting airborne and there are at least five types of potentially disease-causing spores in every breath.

“Compost heaps are absolutely lethal if you don’t have fully functioning innate immunity,” said Mr Fisher.

“If you dig into a heap and get a puff of powder, that will be aspergillus fumigatus.

“If your lung macrophages [white blood cells], don’t mop those spores up, they’re absolutely happy growing at 37 degrees and they’ll just rot you down as quick as a flash – that’s a heavy-duty pathogen.”

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1286607 2018-05-23T10:12:46Z 2018-05-23T10:12:47Z Effect of omega-3 (n-3) fatty acid supplementation in patients with sickle cell anemia

http://bit.ly/2GIIhqb

BACKGROUND:

Blood cell aggregation and adherence to vascular endothelium and inflammation play a central role in vaso-occlusive crisis in sickle cell disease. The antiaggregatory, antiadhesive, antiinflammatory, and vasodilatory omega-3 (n-3) fatty acids (DHA and EPA) are significantly reduced in patients with the disease.

OBJECTIVE:

The aim was to investigate the therapeutic potential of omega-3 fatty acids for patients with homozygous sickle cell disease in a randomized, placebo-controlled, double-blind trial.

RESULTS:

Omega-3 treatment reduced the median rate of clinical vaso-occlusive events (0 compared with 1.0 per year, P < 0.0001), severe anemia (3.2% compared with 16.4%; P < 0.05), blood transfusion (4.5% compared with 16.4%; P < 0.05), white blood cell count (14.4 ± 3.3 compared with 15.6 ± 4.0 ×10(3)/μL; P < 0.05), and the OR of the inability to attend school at least once during the study period because of illness related to the disease to 0.4 (95% CI: 0.2, 0.9; P < 0.05).

CONCLUSION:

The findings of this trial, which need to be verified in a large multicenter study, suggest that omega-3 fatty acids can be an effective, safe, and affordable therapy for sickle cell anemia.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1286605 2018-05-23T10:11:04Z 2018-05-23T10:11:04Z FDA approves novel preventive treatment for migraine

http://bit.ly/2khLsw9

The U.S. Food and Drug Administration today approved Aimovig (erenumab-aooe) for the preventive treatment of migraine in adults. The treatment is given by once-monthly self-injections. Aimovig is the first FDA-approved preventive migraine treatment in a new class of drugs that work by blocking the activity of calcitonin gene-related peptide, a molecule that is involved in migraine attacks.

“Aimovig provides patients with a novel option for reducing the number of days with migraine,” said Eric Bastings, M.D., deputy director of the Division of Neurology Products in the FDA’s Center for Drug Evaluation and Research. “We need new treatments for this painful and often debilitating condition.” 

The effectiveness of Aimovig for the preventive treatment of migraine was evaluated in three clinical trials. The first study included 955 participants with a history of episodic migraine and compared Aimovig to placebo. Over the course of six months, Aimovig-treated patients experienced, on average, one to two fewer monthly migraine days than those on placebo. The second study included 577 patients with a history of episodic migraine and compared Aimovig to placebo. Over the course of three months, Aimovig-treated patients experienced, on average, one fewer migraine day per month than those on placebo. The third study evaluated 667 patients with a history of chronic migraine and compared Aimovig to placebo. In that study, over the course of three months, patients treated with Aimovig experienced, on average, 2 ½ fewer monthly migraine days than those receiving placebo. 

The most common side effects that patients in the clinical trials reported were injection site reactions and constipation. 

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1285870 2018-05-21T09:53:39Z 2018-05-21T09:53:39Z Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals

These are the kinds of problems that develop when you try to design a system for a task that really requires human input...

http://bit.ly/2Li8QWW

To study the association of workarounds with medication administration errors using barcode-assisted medication administration (BCMA), and to determine the frequency and types of workarounds and medication administration errors.

We included 5793 medication administrations for 1230 inpatients. Workarounds were associated with medication administration errors (adjusted odds ratio 3.06 [95% CI: 2.49-3.78]). Most commonly, procedural workarounds were observed, such as not scanning at all (36%), not scanning patients because they did not wear a wristband (28%), incorrect medication scanning, multiple medication scanning, and ignoring alert signals (11%). Common types of medication administration errors were omissions (78%), administration of non-ordered drugs (8.0%), and wrong doses given (6.0%).

In hospitals using barcode-assisted medication administration, workarounds occurred in 66% of medication administrations and were associated with large numbers of medication administration errors.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1285515 2018-05-20T10:55:47Z 2018-05-20T10:55:47Z History of Morgellons disease: from delusion to definition

Because of medicine's ready leap to victim blaming whenever medicine doesn't have an explanation for a person's complaint, I thought Morgellons was likely a physical disorder. I'm glad I lived long enough to see the truth of that belief....

http://bit.ly/2KG3djQ

Morgellons disease (MD) is a skin condition characterized by the presence of multicolored filaments that lie under, are embedded in, or project from skin. Although the condition may have a longer history, disease matching the above description was first reported in the US in 2002. 

Since that time, the condition that we know as MD has become a polemic topic. Because individuals afflicted with the disease may have crawling or stinging sensations and sometimes believe they have an insect or parasite infestation, most medical practitioners consider MD a purely delusional disorder. 

Clinical studies supporting the hypothesis that MD is exclusively delusional in origin have considerable methodological flaws and often neglect the fact that mental disorders can result from underlying somatic illness. 

In contrast, rigorous experimental investigations show that this skin affliction results from a physiological response to the presence of an infectious agent. Recent studies from that point of view show an association between MD and spirochetal infection in humans, cattle, and dogs. These investigations have determined that the cutaneous filaments are not implanted textile fibers, but are composed of the cellular proteins keratin and collagen and result from overproduction of these filaments in response to spirochetal infection. 

Further studies of the genetics, pathogenesis, and treatment of MD are warranted.


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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1284379 2018-05-17T10:04:41Z 2018-05-17T10:04:41Z Longer Home Health Visits Tied to Lower Hospital Rates

http://bit.ly/2IPATyg

Home health care visits that are longer by just one minute may be tied to lower hospital readmission rates. That’s the key finding from a recent study from the National Bureau of Economic Research (NBER).

“We obviously see an effect,” Guy David, associate professor at the University of Pennsylvania’s Wharton School and author of the research, told Home Health Care News. “Shorter visits tend to increase the likelihood of readmissions.”

However, that doesn’t mean home health care providers should immediately start mandating longer visits.

Length of visit

The study looked at data from an unnamed private, for-profit, multi-state home health care company with 96 offices in 16 states. The data spanned three years and eight months: January 2012 to August 2015.

“An extra minute relative to the average length of a patient’s home health visits reduces their readmission likelihood by approximately 8%,” the study found.

The results were opposite than what researchers expected to find, according to David, who anticipated that longer visits would indicate higher patient acuity and a greater likelihood of heading back to the hospital.

“One [thought] is that longer visits [are] associated with more readmissions—with sicker patients who require more attention and are [therefore] likely to be readmitted,” he said. “It’s interesting that we are seeing the opposite. The causal relationship runs in the other direction.”

The relationship between length of visit and readmission rates is a little more nuanced, though.

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Norm DeLisle
tag:ltcreform.posthaven.com,2013:Post/1284013 2018-05-16T10:06:42Z 2018-05-16T10:06:42Z CMS Debuts Strategy to Improve Rural Healthcare

http://bit.ly/2IIAAFD

According to the agency's fact sheet, CMS is focused on accomplishing five goals through the new strategy: advance telehealth services, apply a "rural lens" to agency policies, improve access to care, empower rural patients to make healthcare decisions, and leverage partnerships to achieve these objectives.

Below are specific actions CMS plans to take to advance its five goals:

  • Reduce barriers to implementing telehealth and telemedicine services. This addresses reimbursement, cross-state licensure issues as well as administrative and financial burdens surrounding set-up.

  • Institute a redesigned checklist with a rural lens to relevant policies, procedures and initiatives.

  • Promote evidence-based practices to improve access to rural service providers.

  • Provide technical assistance to ensure providers participate in CMS programs.

  • Address patient barriers like lack of transportation.

  • Work to develop and distribute materials to citizens through rural communications networks.

  • Bolster health technology and infrastructure to improve patient access to health information.

  • Partner with federal agencies like the Office of the National Coordinator for Health Information Technology to promote interoperability and increased use of EHRs among patients and providers.

  • Increase focus on maternal health, behavioral health, and substance abuse through partnership with Center for Disease Control.

  • Assist state Medicaid agencies to advance rural health strategies to citizens in need.


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Norm DeLisle