Unmet Needs for Help With Mobility Limitations Among Older Adults Aging in Place: The Role of Rurality

OBJECTIVES

This study identifies differences in unmet mobility needs among older adults living in rural versus urban areas.

METHODS

We used data from Round 9 of the National Health and Aging Trends Study (NHATS), limiting our analyses to respondents who had not moved since baseline (average housing tenure of 27 years; n = 3343). We conducted bivariate and multivariate analyses to detect rural/urban differences in unmet mobility needs, adjusting for socio-demographics, health status, and housing characteristics.

RESULTS

Rural residence was associated with higher odds of any unmet mobility needs for older adults aging in place (adjusted odds ratio: 1.64, 95% confidence interval: 1.10-2.44, p < .05). The relationship between rurality and unmet needs for help with mobility limitations remained significant in fully adjusted models.

DISCUSSION

Rural older adults aging in place have greater unmet needs for help with mobility limitations. This study highlights several important gaps in supporting rural older adults aging in place.

First safety outcomes for rigicon conticlassic® artificial urinary sphincter

The Rigicon ContiClassic® is a new sphincteric device designed to treat male stress urinary incontinence. This study evaluates the surgical outcomes and safety profile of the first 116 patients who received the implant between September 2021 and April 2022. Data were collected from patient information forms completed at the time of the implant and submitted by implanting surgeons, nursing staff in the Operating Room or company representatives present during the surgery. The study analyzed patient demographics, surgical details, and etiology of incontinence. The mean age of patients was 68.3 years +/- 9.65 yrs. Minimum age was 23 and maximum age was 83. The most common reason for implantation was urinary incontinence (58.6%) after radical prostatectomy. The results showed a revision rate of 6.90%, with three cases of fluid loss, four cases of iatrogenic mistaken sizing, and one case of patient dissatisfaction. There were no reported infections. Kaplan-Meier calculation showed survival rate of 93.2% at 12 months. This study shows the early safety outcomes for the Rigicon ContiClassic® sphincter device to be comparable to others presently on the market.

Demographic, social, and behavioral correlates of SARS-CoV-2 seropositivity in a representative, population-based study of Minnesota residents

BACKGROUND

Monitoring COVID-19 infection risk in the general population is a public health priority. Few studies have measured seropositivity using representative, probability samples. The present study measured seropositivity in a representative population of Minnesota residents prior to vaccines and assess the characteristics, behaviors, and beliefs of the population at the outset of the pandemic and their association with subsequent infection.

METHODS

Participants in the Minnesota COVID-19 Antibody Study (MCAS) were recruited from residents of Minnesota who participated in the COVID-19 Household Impact Survey (CIS), a population-based survey that collected data on physical health, mental health, and economic security information between April 20 and June 8 of 2020. This was followed by collection of antibody test results between December 29, 2020 and February 26, 2021. Demographic, behavioral, and attitudinal exposures were assessed for association with the outcome of interest, SARS-CoV-2 seroprevalence, using univariate and multivariate logistic regression.

RESULTS

Of the 907 potential participants from the CIS, 585 respondents then consented to participate in the antibody testing (64.4% consent rate). Of these, results from 537 test kits were included in the final analytic sample, and 51 participants (9.5%) were seropositive. The overall weighted seroprevalence was calculated to be 11.81% (95% CI, 7.30%-16.32%) at of the time of test collection. In adjusted multivariate logistic regression models, significant associations between seroprevalence and the following were observed; being from 23-64 and 65+ age groups were both associated with higher odds of COVID-19 seropositivity compared to the 18-22 age group (17.8 [1.2-260.1] and 24.7 [1.5-404.4] respectively). When compared to a less than $30k annual income reference group, all higher income groups had significantly lower odds of seropositivity. Reporting practicing a number of 10 (median reported value in sample) or more of 19 potential COVID-19 mitigation factors (e.g. handwashing and mask wearing) was associated with lower odds of seropositivity (0.4 [0.1-0.99]) Finally, the presence of at least one household member in the age range of 6 to 17 years old was associated with higher odds of seropositivity (8.3 [1.2-57.0]).

CONCLUSIONS

The adjusted odds ratio of SARS-CoV-2 seroprevalence was significantly positively associated with increasing age and having household member(s) in the 6-17 year age group, while increasing income levels and a mitigation score at or above the median were shown to be significantly protective factors.

Associations Between Use of Paid Help and Care Experiences Among Medicare-Medicaid Enrolled Older Adults With and Without Dementia

OBJECTIVES

Community-living older Medicare and Medicaid enrollees ("dual-enrollees") have high care needs and commonly receive paid and unpaid long-term services and supports (LTSS) to help with routine activities. Little is known about whether receiving paid help or individuals' state and neighborhood environmental context ("LTSS environment") relates to dual-enrollees' care experiences.

METHODS

We examine a sample of n = 979 community-dwelling dual-enrollees with disabilities from 2011 to 2015 National Health and Aging Trends Study, linked to measures of neighborhood disadvantage and state Medicaid home and community-based services (HCBS) generosity. Logistic regression models stratified by dementia status assess associations between paid help and: (a) adverse consequences due to unmet care needs, and (b) participation restrictions in valued activities, among dual-enrollees with and without dementia, adjusting for individual and LTSS environmental characteristics.

RESULTS

Use of paid help was greater for those with (versus without) dementia (46.9% vs. 37.8%). Neighborhood disadvantage was associated with greater use of paid help among dual-enrollees living with dementia. High state Medicaid HCBS generosity was associated with the use of paid help, regardless of dementia status. Dual-enrollees with dementia receiving paid help had higher odds of experiencing adverse consequences due to unmet need (adjusted odds ratio = 2.05; 95% confidence interval 1.16-3.61; p = .02)-no significant associations were observed for participation restrictions. Use of paid help and LTSS environment were not significantly associated with care experiences for dual-enrollees without dementia.

DISCUSSION

Findings highlight the complexities of caring for dual-enrollees, particularly those with dementia, and emphasize the need to strengthen the delivery of paid care with considerations for the LTSS environment.

ACTUAL AND DESIRED SERVICE USE OF COMMUNITY-DWELLING CONSUMERS OF HOME- AND COMMUNITY-BASED SERVICES

Federal and state long-term care policies are focused on helping people age in their community rather than in nursing homes or other institutional settings. Through home- and community-based (HCBS) waiver programs, states have the flexibility to target specific populations, providing supportive services meant to promote residence in the community. Although consumer needs and goals are a key component of HCBS delivery and effectiveness, little is known about how actual service use differs from the services individuals desire to meet their needs. Using the National Core Indicators-Aging and Disability (NCI-AD™) survey responses from 2018-2019 (N=14,202), an effort by state agencies to measure and track performance outcomes using standardized measures, we examined differences in actual versus desired use of HCBS among people living in the community. Services were categorized as delivered in home-based setting, day services, transportation, support/modification services, health and therapeutic services, and respite. Among NCI-AD respondents in the community (n=9,860), 11% used one service area, 49% used two service areas, and 36% used three or more service areas. The most common service area was home-based services (57%). About a third of community-dwelling respondents desired at least one additional service area. Factors significantly associated with wanting more services included being in combined Medicaid-Medicare, managed LTSS, a woman, an adult aged &gt;65, living alone, and having a physical disability. While the majority of community-dwelling HCBS recipients do not list unmet service needs, there is heterogeneity by program category and other key demographic and social characteristics.

ASSESSING DEMENTIA CLASSIFICATION IN THE NATIONAL CORE INDICATORS AGING AND DISABILITY SURVEY

Improving the quality of long-term care services for older adults is a national priority. The National Core Indicators Aging and Disability (NCI-AD) collects data from multiple states to evaluate long-term care recipients’ service satisfaction and needs. Many analysts are interested in exploring the service environments of people living with dementia. However, dementia measurement and reporting varies in NCI-AD between states. Dementia status may be obtained from administrative records or self-reported during the survey. We explored the measurement of dementia in NCI-AD and the implications of relying on administrative or self-reported dementia status. We analyzed NCI-AD data from 2015-2018 representing 24,569 respondents age 65+, of which 5,502 (22.4%) were identified as having dementia. 42.9% of respondents had dementia status determined administratively and 57.1% had it determined during the survey. To assess dementia accuracy by data source, we fit separate LASSO models for both the administrative and survey subpopulations predicting dementia status using demographic and functional predictors. We then used each model to predict dementia status in the subpopulation with discordant dementia data source. Using the administrative model to predict survey reported status resulted in a higher sensitivity than using the survey model to predict administrative status (44.6% vs 32.2%). The diminished predictive accuracy of the survey model suggests administrative records may capture cases of dementia diagnosis that would be missed by self-report. These findings highlight analytical caveats for researchers interested study long-term care quality for people with dementia using NCI-AD, and emphasize the importance of moving towards more standardized dementia reporting.

Role of NaV 1.7 in action potential conduction along human bronchial vagal afferent C-fibres

BACKGROUND AND PURPOSE

The purpose of this study was to determine the role of NaV 1.7 in action potential conduction in C-fibres in the bronchial branches of the human vagus nerve.

EXPERIMENTAL APPROACH

Bronchial branches of the vagus nerve were dissected from human donor tissue. The C-wave of the electrically evoked compound action potential was quantified in the absence and presence of increasing concentrations of the selective NaV 1.7 blocking drugs, PF-05089771 and ST-2262, as well as the NaV 1.1, 1.2, and 1.3 blocking drug ICA121-431. The efficacy and potency of these inhibitors were compared to the standard NaV 1 blocker, tetrodotoxin. We then compared the relative potencies of the NaV 1 blockers in inhibiting the C-wave of the compound action potential, with their ability to inhibit parasympathetic cholinergic contraction of human isolated bronchi, a response previously shown to be strictly dependent on NaV 1.7 channels.

KEY RESULTS

The selective NaV 1.7 blockers inhibited the C-wave of the compound action potential with potencies similar to that observed in the NaV 1.7 bronchial contractions assay. Using rt-PCR, we noted that NaV 1.7 mRNA was strongly expressed and transported down the vagus nerve bundles.

CONCLUSIONS AND IMPLICATIONS

NaV 1.7 blockers can prevent action potential conduction in the majority of vagal C-fibres arising from human bronchi. Blockers of NaV 1.7 channels may therefore have value in inhibiting the responses to excessive airway C-fibre activation in inflammatory airway disease, responses that include coughing as well as reflex bronchoconstriction and secretions.

Scoping Review: Home and Community-Based Service Waiver Programs and Person-Reported Outcomes

State Medicaid programs are rebalancing their long-term care spending from nursing home to home and community-based services (HCBS). Emphasis on person-centered and person-directed care warrants investigation into models of HCBS delivery that promote quality of life. We performed a scoping review of the literature to catalogue the breadth of the studies describing HCBS waiver programs targeting adults (18+). We identified 757 articles, and after duplicate removal and reconciliation, we excluded articles on children or adolescents, non-peer reviewed reports, international studies, and articles that did not describe HCBS waiver programs. After abstract and title review, 292 articles met our inclusion criteria. Most included articles (22.3%) were single state descriptive evaluations or evaluations of service use patterns among participants. 17.8% of included articles examined multi-state or national variation in program trends, while 17.1% made national program conclusions without a major focus on interstate comparison. Less common were studies examining integrated care or dual-eligibles (7.5%), PACE (3.4%), medication management (3.1%), quality and satisfaction of both consumer and caretaker perspectives (3.8%) and consumer-only perspectives (5.1%). The remaining articles focused on HIV (4.1%), TBI (1.4%) or ID/DD (14.4%) waiver programs. The 8.9% of articles addressing quality and satisfaction consisted mostly of interviews, either with state Medicaid administrators or with care recipients and/or caregivers. Consumer reported satisfaction and unmet care needs were the primary outcomes examined. Given the heightened focus on long-term care as a result of the ongoing coronavirus pandemic, this review justifies further exploration into the delivery and outcomes of state-directed HCBS waiver programs.

Home and Neighborhood Context of Falls Among Black and White Older Americans

Objectives: To examine social and physical environmental fall-risk factors in a nationally representative sample of community-living older adults overall and by racial group. Methods: We used data from the 2015 and 2016 rounds of the National Health and Aging Trends Study (n = 5581) linked to census tract measures from the American Community Survey. Recurrent falls are defined as 2+ self-reported falls over 12 months. Results: Older adults with recurrent falls were more likely to have lower education, lower income, financial hardship, live in homes with disorder and disrepair and in neighborhoods without sidewalks, with high social deprivation, and in nonmetropolitan counties. Home disrepair, lack of sidewalks, and residence in a nonmetropolitan county were important fall-risk factors among White older adults only. Financial hardship was an important risk factor among Black older adults. Discussion: Environmental factors are associated with recurrent falls among older Americans and should be incorporated into fall-risk profiles and prevention efforts.

Home and Neighborhood Context and Fall Risk Among Older Americans

Falls result from complex interactions between individuals and their environment and are the leading cause of injuries among older adults. A nascent literature demonstrates an association between neighborhood characteristics and falls. However, available evidence is from small, nonrepresentative samples and generally focuses on individual, home, or neighborhood risk-factors rather than the contribution of all three. We link information from N=6,489 community-dwelling participants in the 2015 National Health and Aging Trends Study with the Social Deprivation Index (SDI), which yields a census-tract-level score of socioeconomic disadvantage, to assess associations between home and neighborhood context and falls in the previous year. Household financial strain was associated with a 31% increased risk of falling, and indoor trip hazards with a 14% increased risk, after adjusting for individual factors and neighborhood SDI (all p &lt;0.05). Findings reflect the interplay between home and neighborhood context and fall-risk, and can inform community-based fall-prevention interventions.

Neighborhood Social Deprivation and Caregiving Intensity for Community-Dwelling Older Adults With Disabilities

There is growing interest in the role of “place” in the provision of long-term services and supports (LTSS) for older adults with disabilities, who receive ~16 billion hours of care per year from family and unpaid caregivers, but information is lacking. Using data from the 2015 National Health and Aging Trends Study (NHATS) linked to census-tract-level information from the American Community Survey, we described the association between caregiving intensity (hours of care received per week) and neighborhood social deprivation among N=2125 community-dwelling older adults with disabilities. Individuals receiving 40 hours or more of help per week had greater levels of functional impairment and dementia, and more often lived in neighborhoods at the highest quartile of social deprivation compared to those receiving fewer than 20 hours of care (26.8% vs. 21.7%, respectively). Findings have policy implications for targeting LTSS strategies toward addressing inequities in social determinants of health for vulnerable populations.

Do Caregiving Factors Affect Hospitalization Risk Among Disabled Older Adults?

BACKGROUND/OBJECTIVES

Hospitalization is common among older adults with disability, many of whom receive help from a caregiver and have dementia. Our objective was to evaluate the association between caregiver factors and risk of hospitalization and whether associations differ by dementia status.

DESIGN

Longitudinal observational study.

SETTING

The 1999 and 2004 National Long-Term Care Survey and the 2011 and 2015 National Health and Aging Trends Study, linked caregiver surveys, and Medicare claims.

PARTICIPANTS

A total of 2,589 community-living Medicare fee-for-service beneficiaries, aged 65 years or older (mean age = 79 years; 63% women; 31% with dementia), with self-care or mobility disability and their primary family or unpaid caregiver.

MEASUREMENTS

Self-reported characteristics of older adults and their caregivers were assessed from older adult and caregiver survey interviews. Older adult hospitalization over the subsequent 12 months was identified in Medicare claims. Multivariable Cox proportional hazards models adjusted for older adult characteristics and were stratified by dementia status.

RESULTS

In this nationally representative cohort, 38% of older adults with disabilities were hospitalized over 12 months following interview. Increased hospitalization risk was associated with having a primary caregiver who helped with healthcare tasks (adjusted hazard ratio (aHR) = 1.22; 95% confidence interval (CI) = 1.05-1.40), reported physical strain (aHR = 1.21; 95% CI = 1.04-1.42), and provided more than 40 hours of care weekly (aHR = 1.26; 95% CI = 1.04-1.54 vs ≤20 hours). Having a caregiver who had helped for 4 years or longer (vs <1 year) was associated with 38% lower risk of hospitalization (aHR = 0.62; 95% CI = 0.49-0.79). Older adults with and without dementia had similar rates of hospitalization (39.5% vs 37.3%; P = .4), and caregiving factors were similarly associated with hospitalization regardless of older adults' dementia status.

CONCLUSION

Select caregiving characteristics are associated with hospitalization risk among older adults with disability. Hospitalization risk reduction strategies may benefit from understanding and addressing caregiving circumstances.

Nuances of subcoronal inflatable penile prosthesis for physicians accustomed to penoscrotal approach

In a special miniseries highlighting the different surgical techniques to the inflatable penile prosthesis (IPP), Wilson's Workshop seeks to bring forth skill considerations for the modern implanter. Each work is authored by a highly regarded surgeon who has truly honed the art of their respective approach. Today, most implanters are comfortable with either the penoscrotal or suprapubic incision. The following work directs the spotlight onto a much newer and less known technique, IPP implant via the subcoronal incision. SHP leads the Urology Center of Excellence in Seoul, South Korea, and has implanted more than 700 IPPs using the subcoronal approach since 2015. Here, he will share the clinical pearls of this novel incision gathered through trial and error over many repetitions. We are hopeful that this work will peak the interest of inquisitive minds and help disseminate improved implant techniques.

The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions

INTRODUCTION

The Mulcahy salvage fundamentally altered the management of penile prosthesis infections (PPI). Central to this procedure is a sequence of antiseptic irrigations that aims to remove and eradicate pathogenic microflora from the infected field, thus preparing for immediate reimplantation. The antiseptic solutions and their respective concentrations, however, have never been evaluated for efficacy.

AIM

This review critically examines 3 commonly used antiseptic irrigation solutions (povidone-iodine [PVI], hydrogen peroxide [H₂O₂], and chlorhexidine gluconate [CHG]) in terms of their antimicrobial activity, cytotoxicity, and clinical use.

METHODS

A PubMed literature review was performed on articles published between 2003 and 2018. Both preclinical as well as clinical studies from various surgical disciplines were included in this review.

MAIN OUTCOME MEASURE

The original salvage protocol selected for irrigation solutions at concentrations that are likely detrimental to native tissue.

RESULTS

All 3 agents demonstrate in vitro cytotoxic effects at subclinical concentrations, but H₂O₂ is associated with the most significant deleterious properties. It does not seem to broaden antimicrobial coverage beyond what is covered by PVI. Dilute PVI (0.35-3.5% with exposure time of at least 3 minutes) possesses the most robust clinical evidence as an intraoperative adjunct, reducing the incidence of postoperative infectious complications. chlorhexidine gluconate is a promising new agent but lacks clinical data.

CLINICAL IMPLICATION

Improvements in the salvage protocol are warranted based on current evidence. Careful selection of lavage solution and usage of the lowest necessary concentration will help achieve desired antimicrobial activity while avoiding native tissue cytotoxicity. Strength and limitation: The study is limited by its retrospective nature, and the heterogeneity of literature reviewed precluded a formal meta-analysis. Furthermore, future studies will need to address the roles of normal saline and antibiotic irrigations as intraoperative adjuncts for infection prevention.

CONCLUSION

Diluted PVI (0.35-3.5% for 3 minutes) may be beneficial in the prevention of PPI. Evidence supports its use both in the setting of primary implantation as well as salvage of infected hardware. An improved, evidence-based protocol may increase positive outcomes of urologic prosthetic surgery. Pan S, Rodriguez D, Thirumavalavan N, et al. The Use of Antiseptic Solutions in the Prevention and Management of Penile Prosthesis Infections: A Review of the Cytotoxic and Microbiological Effects of Common Irrigation Solutions. J Sex Med 2019;16:781-790.

Implementation of artificial intelligence and non-contact infrared thermography for prediction and personalized automatic identification of different stages of cellulite

Background

Cellulite is a common physiological condition of dermis, epidermis, and subcutaneous tissues experienced by 85 to 98% of the post-pubertal females in developed countries. Infrared (IR) thermography combined with artificial intelligence (AI)-based automated image processing can detect both early and advanced cellulite stages and open up the possibility of reliable diagnosis. Although the cellulite lesions may have various levels of severity, the quality of life of every woman, both in the physical and emotional sphere, is always an individual concern and therefore requires patient-oriented approach.

Objectives

The purpose of this work was to elaborate an objective, fast, and cost-effective method for automatic identification of different stages of cellulite based on IR imaging that may be used for prescreening and personalization of the therapy.

Materials and methods

In this study, we use custom-developed image preprocessing algorithms to automatically select cellulite regions and combine a total of 9 feature extraction methods with 9 different classification algorithms to determine the efficacy of cellulite stage recognition based on thermographic images taken from 212 female volunteers aged between 19 and 22.

Results

A combination of histogram of oriented gradients (HOG) and artificial neural network (ANN) enables determination of all stages of cellulite with an average accuracy higher than 80%. For primary stages of cellulite, the average accuracy achieved was more than 90%.

Conclusions

The implementation of computer-aided, automatic identification of cellulite severity using infrared imaging is feasible for reliable diagnosis. Such a combination can be used for early diagnosis, as well as monitoring of cellulite progress or therapeutic outcomes in an objective way. IR thermography coupled to AI sets the vision towards their use as an effective tool for complex assessment of cellulite pathogenesis and stratification, which are critical in the implementation of IR thermographic imaging in predictive, preventive, and personalized medicine (PPPM).

Electronic supplementary material

The online version of this article (10.1007/s13167-020-00199-x) contains supplementary material, which is available to authorized users.

FAMILY CAREGIVER FACTORS AND SUBSEQUENT EMERGENCY DEPARTMENT UTILIZATION AMONG OLDER ADULTS WITH DISABILITY

Community-living older adults with disability are frequent Emergency Department (ED) users and most rely on family caregiver support. However, no prior research has examined associations between caregiver characteristics and subsequent ED utilization among older adults. We draw on a sample of 2,521 community-living older adults with mobility/self-care disability and their primary family caregivers to identify caregiver characteristics associated with all-cause or potentially preventable ED use. We use Cox proportional hazards regression to separately model the likelihood of all-cause and potentially preventable ED use as a function of caregiver characteristics. Models account for competing risk of mortality and adjust for measures of older adults’ socio-demographic characteristics, health status, and survey wave. About half (52.5%) of older adults incurred 1+ ED visit and 26.8% incurred 1+ potentially preventable ED visit within 12 months of interview. Adjusting for survey wave and older adult sociodemographic characteristics and health status, older adults were at greater risk of all-cause ED use if their primary caregiver provided greater than 40 hours of care per week (HR: 1.22, 95% CI: 1.04-1.43; p=0.02), helped with health care tasks (HR: 1.26; 95% CI: 1.08-1.46; p<0.01), or experienced physical strain (HR: 1.18; 95% CI: 1.03-1.36; p=0.02). Older adults were at greater risk of potentially preventable ED use if their primary caregiver helped with health care tasks (HR: 1.25; 95% CI: 1.02-1.54; p=0.03). Findings highlight the relevance of caregiver factors to older adults’ ED use and suggest the need for assessment and support of family caregivers in the care delivery setting.

FAMILY CAREGIVER FACTORS AND HOSPITALIZATION IN DISABLED OLDER ADULTS WITH AND WITHOUT DEMENTIA

Older adults with disabilities commonly rely on family caregivers’ help, yet effects of caregiver factors on patient outcomes are poorly understood. Within this population, dementia is common. Our objective was to evaluate the association between caregiver factors and risk of hospitalization in disabled older adults with and without dementia. We examined 2,589 community-living older adults with mobility/self-care disability and their primary family caregiver in four waves of the National Long-Term Care Survey and National Health and Aging Trends Study. We used Cox proportional hazards models to examine risk of one-year, Medicare claims-derived, all-cause hospitalization as a function of caregiver factors, adjusting for older adult characteristics (sociodemographics, comorbidities, healthcare utilization) and survey year, considering dementia a characteristic of interest. Among disabled older adults, 38% were hospitalized over one year, and 31% had probable dementia. Hospitalization rates were similar for older adults with and without dementia (39.5% and 37.3% respectively); dementia was not associated with hospitalization risk (HR 1.09, 95% CI 0.95-1.26). Older adults demonstrated greater risk of hospitalization if their caregiver was male (HR 1.31, 95% CI 1.10-1.56), new to caregiving (HR 1.61, 95% CI 1.27-2.04 for &lt; 1 year versus ≥ 4 years), or helped with healthcare tasks (HR 1.21, 95% CI 1.04-1.41). The association between most caregiving factors and hospitalization risk did not differ by dementia status. Results suggest that strategies to reduce hospitalization in older adults with disabilities could target select caregivers using similar strategies in populations with and without dementia.

Financial Stress and Risk for Entry into Medicaid Among Older Adults

Background and Objectives

Spending in the Medicaid program is a significant concern to both state and federal policy makers. Medicaid spending is driven by program enrollment and services use. Older adults with high health care needs incur a disproportionate proportion of program spending. This analysis identifies factors that place older Medicare beneficiaries at increased risk for entering into Medicaid.

Research Design and Methods

We use multinomial logistic regression and the 2011–2017 National Health and Aging Trends Study (NHATS) to examine the risks among older Medicare beneficiaries for entering into Medicaid over a 6-year follow-up period. We examine both time-invariant and time-varying factors to measure the impact of social and health and functioning changes at older ages.

Results

The risk of entry into Medicaid was higher for older adults who relocated to a nursing home (relative risk ratio [RRR]: 7.75; 95% confidence interval [CI]: 5.33–11.26) or other residential care setting (RRR: 1.36; 95% CI: 0.96–1.92) compared to those who remained in traditional community settings. Older adults who reported skipping a meal in the last month because there was not enough money to buy food were 2.4 times (95% CI: 1.10–5.21) more likely to enter Medicaid than those who did not. Similarly, older adults who reported not having enough money to pay household utility bills in the last year were 1.89 times (95% CI: 1.08–3.30) more likely to enter Medicaid.

Discussion and Implications

Study findings suggest that trouble paying for basic needs increases the risk of entry into Medicaid. Further research is required to examine whether addressing these needs through improved access to social services that enable older adults to live safely in their home may delay or mitigate entry into Medicaid.

Medicare Spending and the Adequacy of Support With Daily Activities in Community-Living Older Adults With Disability: An Observational Study

BACKGROUND

Identifying factors that affect variation in health care spending among older adults with disability may reveal opportunities to better address their care needs while offsetting excess spending.

OBJECTIVE

To quantify differences in total Medicare spending among older adults with disability by whether they experience negative consequences due to inadequate support with household activities, mobility, or self-care.

DESIGN

Observational study of in-person interviews and linked Medicare claims.

SETTING

United States, 2015.

PARTICIPANTS

3716 community-living older adults who participated in the 2015 NHATS (National Health and Aging Trends Study) and survived for 12 months.

MEASUREMENTS

Total Medicare spending by spending quartile in multivariable regression models that adjusted for individual characteristics.

RESULTS

Negative consequences were experienced by 18.3% of participants with disability in household activities, 25.6% with mobility disability, and 20.0% with self-care disability. Median Medicare spending was higher for those who experienced negative consequences due to household ($4866 vs. $4095), mobility ($7266 vs. $4115), and self-care ($10 935 vs. $4436) disability versus those who did not. In regression-adjusted analyses, median spending did not differ appreciably for participants who experienced negative consequences in household activities ($338 [95% CI, -$768 to $1444]), but was higher for those with mobility ($2309 [CI, $208 to $4409]) and self-care ($3187 [CI, $432 to $5942]) disability. In the bottom-spending quartile, differences were observed for self-care only ($1460 [CI, $358 to $2561]). No differences were observed in the top quartile.

LIMITATION

This observational study could not establish causality.

CONCLUSION

Inadequate support for mobility and self-care is associated with higher Medicare spending, especially in the middle and lower ends of the spending distribution. Better support for the care needs of older adults with disability could offset some Medicare spending.

PRIMARY FUNDING SOURCE

The Commonwealth Fund.

Comparing Survey-Based Frailty Assessment to Medicare Claims in Predicting Health Outcomes and Utilization in Medicare Beneficiaries

Objectives: To assess two models for the prediction of health utilization and functions using standardized in-person assessments of frailty and administrative claims-based geriatric risk measures among Medicare fee-for-service beneficiaries aged 65 years and above. Methods: Outcomes of hospitalizations, death, and functional help were investigated for participants in the 2011 National Health and Aging Trends Study. For each outcome, multivariable logistic regression model was used to investigate claims-based geriatric risk and survey-based frailty. Results: Both claims-based and survey-based models showed moderate discrimination. The c-statistic of the standardized frailty models ranged from 0.67 (for any hospitalization) to 0.84 (for any IADL [instrumental activities of daily living] help). Models using administrative data ranged from 0.71 (for any hospitalization) to 0.81 (for any IADL help). Discussion: Models based on existing administrative data appear to be as discriminate as survey-based models. Health care providers and insurance plans can effectively apply existing data resources to help identify high-risk individuals for potential care management interventions.

Family Caregivers of Older Adults, 1999-2015: Trends in Characteristics, Circumstances, and Role-Related Appraisal

Purpose of Study

To assess trends in family caregiving between 1999 and 2015.

Design and Methods

We construct nationally representative profiles of community-dwelling older adults receiving help with self-care or indoor mobility and their "primary" family or unpaid caregiver using the 1999 and 2004 National Long Term Care Survey, 2011 and 2015 National Health and Aging Trends Study, and linked caregiver surveys. Trends are examined.

Results

Older adults receiving help were incrementally younger, more racially diverse, and better educated in 2015. Primary caregivers overwhelmingly continued to be spouses and adult children. Arrangements were increasingly 4 years or longer in duration (shifting from 44.8% in 1999 to 60.5% by 2015). On average, primary caregivers provided about or in excess of 30 hr per week at all four time points. Spouses provided fewer hours of care, were twice as likely to work, and half as likely to report substantial emotional, physical, and financial difficulty due to caregiving in 2015 than 1999. Adult children provided comparable hours of care to a more impaired population; a similar proportion reported substantial caregiving-related difficulty at each time. Use of respite care nearly doubled from 8.5% in 1999 to 15.7% in 2015. Dementia caregivers were less likely to report substantial physical and financial difficulty and more likely to use respite care in 2015 than 1999.

Implications

Family caregivers' circumstances generally improved during the 16-year period. Results diverge from prevailing concerns regarding the state of family caregiving and demonstrate the importance of longitudinally monitoring trends in late-life family caregiving.

Thermal effects of mobile phones on human auricle region

Mobile phones have become an indispensable utility to modern society, with international use increasing dramatically each year. The GSM signal operates at 900 MHz, 1800 MHz and 2250 MHz, may potentially cause harm to human tissue. Yet there is no in silico model to aid design these devices to protect from causing potential thermal effect. Here we present a model of sources of heating in a mobile phone device with experimental verification during the phone call. We have developed this mobile phone thermal model using first principles on COMSOL® Multiphysics modelling platform to simulate heating effect in human auricle region due to mobile phone use. In particular, our model considered both radiative and non-radiative heating from components such as the lithium ion battery, CPU circuitry and the antenna. The model showed the distribution and effect of the heating effect due to mobile phone use and considered impact of battery discharge rate, battery capacity, battery cathode material, biological tissue distance, antenna radio-wave frequency and intensity. Furthermore, the lithium ion battery heating was validated during experiments using temperature sensors with an excellent agreement between simulated and experimental data (<1% variation). Mobile phone heating during a typical call has also been simulated and compared with experimental infrared thermographic imaging. Importantly, we found that 1800 MHz frequency of data transmission showed the highest temperature increase in the fat/water phantom used in this simulation. We also successfully compared heating distribution in human auricle region during mobile phone use with clinical thermographic images with reasonable qualitative and quantitative agreements. In summary, our model provides a foundation to conceive thermal and other physical effects caused by mobile phone use and allow for the understanding of potential negative health effects thus supporting and promoting personalized and preventive medicine using thermography.

Are Older Americans Getting the Long-Term Services and Supports They Need?

ISSUE

Older adults' needs have evolved and are no longer met by the Medicare program. With the recent passage of the Bipartisan Budget Act of 2018 (BBA), Medicare Advantage (MA) plans can now provide beneficiaries with nonmedical benefits, such as long-term services and supports (LTSS), which Medicare does not cover.

GOAL

To examine the use of LTSS among Medicare beneficiaries age 65 and older living in the community and explore differences by age, income, and other variables.

METHODS

Descriptive analyses of the National Health and Aging Trends Study (NHATS), 2015.

FINDINGS AND CONCLUSIONS

Two-thirds of older adults living in the community use some degree of LTSS. Reliance on assistive devices and environmental modifications is high; however many adults, particularly dual-eligible beneficiaries, experience adverse consequences of not receiving care. Although the recent policy change allowing MA plans to offer LTSS benefits is an important step toward meeting the medical and nonmedical needs of Medicare beneficiaries, only the one-third of Medicare beneficiaries enrolled in MA plans stand to benefit. Accountable care organizations operating in traditional Medicare also should have the increased flexibility to provide nonmedical services.

Family Caregiver Factors Associated With Emergency Department Utilization Among Community-Living Older Adults With Disabilities

Background: Older adults with disability are frequent users of the emergency department (ED) and often rely on family caregiver support. We identify whether and which caregiver characteristics are associated with older adults' ED use. Methods: We use Cox proportional hazards regression to model the likelihood of all-cause ED use (defined as 1 or more visits within 12 months of survey) as a function of caregiver characteristics after adjusting for older adult sociodemographic and health characteristics. We draw from linked older adult and caregiver surveys and administrative claims, creating a sample of 2521 community-living older adults with mobility/self-care disability receiving care from a family or unpaid caregiver. Results: About half (52.5%) of older adults receiving mobility or self-care help incurred 1 or more ED visits within 12 months of interview. Adjusting for year of data collection, sociodemographic characteristics, and health status, these older adults were at greater risk of all-cause ED use if their primary caregiver provided greater than 40 hours of care per week (hazard ratio [HR] 1.22, 95% CI 1.04-1.43; P = .02), helped with health care tasks (HR 1.26; 95% CI 1.08-1.46; P < .01), or experienced physical strain (HR 1.18; 95% CI 1.03-1.36; P = .02). Conclusion: Caregiver strain, helping with health care tasks, and greater hours of help per week are associated with heightened risk of ED use among older adults receiving mobility or self-care help. Study findings suggest the potential benefit of caregiver assessment and support.

The Financial Hardship Faced by Older Americans Needing Long-Term Services and Supports

ISSUE

In addition to medical care, individuals with functional or cognitive impairment often require long-term services and supports (LTSS), which Medicare does not cover. Little is known about the additional out-of-pocket expenses that individuals and their families incur to meet these needs.

GOAL

To analyze medical and LTSS spending among older Medicare beneficiaries, particularly the costs of assistive devices and personal care and the ways those costs are met.

METHODS

Descriptive analyses of the National Health and Aging Trends Study (NHATS), 2015.

KEY FINDINGS AND CONCLUSIONS

Beneficiaries with high LTSS needs have higher Medicare and out-of-pocket spending than those without such needs and are more likely to report that medical care makes up part of their credit card debt. Those with high LTSS needs are also more likely to report trouble paying for food, rent, utilities, medical care, and prescription drugs. Many older Medicare beneficiaries using LTSS are vulnerable to incurring substantial costs. Without an affordable, sustainable financing solution, Medicare beneficiaries with LTSS needs will continue to be at greater risk of delaying necessary care, being placed in a nursing home prematurely, and having to "spend down" into the Medicaid program.

Long-Term Nursing Home Entry: A Prognostic Model for Older Adults with a Family or Unpaid Caregiver

OBJECTIVES

To comprehensively examine factors associated with long-term nursing home (NH) entry from 6 domains of older adult and family caregiver risk from nationally representative surveys and develop a prognostic model and a simple scoring system for use in risk stratification.

DESIGN

Retrospective observational study.

SETTING

National Long-Term Care Surveys 1999 and 2004 and National Health and Aging Trends Study 2011 and linked caregiver surveys.

PARTICIPANTS

Community-living older adults receiving help with self-care disability and their primary family or unpaid caregiver (N=2,676).

MEASUREMENTS

Prediction of long-term NH entry (>100 days or ending in death) by 24 months follow up, ascertained from Minimum Data Set assessments and dates of death from Medicare enrollment files. Risk factors were measured from survey responses.

RESULTS

In total, 16.1% of older adults entered a NH. Our final model and risk scoring system includes 7 independent risk factors: older adult age (1 point/5 years), living alone (5 points), dementia (3 points), 3 or more of 6 self-care activities (2 points), caregiver age (45-64: 1 point, 65-74: 2 points, ≥75: 4 points), caregiver help with money management (2 points), and caregiver report of moderate (2 points) or high (4 points) strain. Using this model, participants were assigned to risk quintiles. Long-term NH entry was 7.0% in the lowest quintile (0-6 points), 20.4% in the middle 3 quintiles (7-14 points), and 30.9% in the highest quintile (15-22 points). The model was well calibrated and demonstrated moderate discrimination (c-statistic=0.670 in the original data, c-statistic=0.647 in bootstrapped samples, c-statistic=0.652 using the point-scoring system).

CONCLUSION

We developed a prognostic model and simple scoring system that may be used to stratify risk of long-term NH entry of community-living older adults. Our model may be useful for population health and policy applications.

Use of Paid and Unpaid Personal Help by Medicare Beneficiaries Needing Long-Term Services and Supports

ISSUE

Older adults who reside in communities, as opposed to nursing homes or other residential institutions, are largely dependent on family and unpaid caregivers for assistance with daily activities, like preparing meals or laundry, and self-care tasks like bathing or dressing. For low-income older adults, assistance with such activities, also known as long-term services and supports (LTSS), can also come from Medicaid. These sources of support will be increasingly inadequate as the population ages.

GOALS

To examine the extent of paid and unpaid personal care assistance used by community-residing people who require LTSS; and to analyze how this differs by demographics and the economic status of Medicare beneficiaries.

METHODS

Descriptive analyses of the National Health and Aging Trends Study (NHATS), 2015.

FINDINGS AND CONCLUSIONS

Medicare beneficiaries needing LTSS rely predominantly on unpaid care. Hours of unpaid care are not substantially lower when paid care is also received. Findings suggest that public financing of LTSS would not replace but rather supplement the contribution of family and unpaid caregivers to support individuals living independently in the community.

Selective endothelin-1 receptor type A inhibition in subjects undergoing cardiac surgery with preexisting left ventricular dysfunction: Influence on early postoperative hemodynamics

OBJECTIVE

A robust release of endothelin-1 with subsequent endothelin-A subtype receptor activation occurs in patients after cardiac surgery requiring cardiopulmonary bypass. Increased endothelin-A subtype receptor activation has been identified in patients with poor left ventricular function (reduced ejection fraction). Accordingly, this study tested the hypothesis that a selective endothelin-A subtype receptor antagonist administered perioperatively would favorably affect post-cardiopulmonary bypass hemodynamic profiles in patients with a preexisting poor left ventricular ejection fraction.

METHODS

Patients (n = 29; 66 +/- 2 years) with a reduced left ventricular ejection fraction (37% +/- 2%) were prospectively randomized in a blinded fashion, at the time of elective coronary revascularization or valve replacement requiring cardiopulmonary bypass, to infusion of the highly selective and potent endothelin-A subtype receptor antagonist sitaxsentan at 1 or 2 mg/kg (intravenous bolus; n = 9, 10 respectively) or vehicle (saline; n = 10). Infusion of the endothelin-A subtype receptor antagonist/vehicle was performed immediately before separation from cardiopulmonary bypass and again at 12 hours after cardiopulmonary bypass. Endothelin and hemodynamic measurements were performed at baseline, at separation from cardiopulmonary bypass (time 0), and at 0.5, 6, 12, and 24 hours after cardiopulmonary bypass.

RESULTS

Baseline plasma endothelin (4.0 +/- 0.3 fmol/mL) was identical across all 3 groups, but when compared with preoperative values, baseline values obtained from age-matched subjects with a normal left ventricular ejection fraction (n = 37; left ventricular ejection fraction > 50%) were significantly increased (2.9 +/- 0.2 fmol/mL, P < .05). Baseline systemic (1358 +/- 83 dynes/sec/cm(-5)) and pulmonary (180 +/- 23 dynes/sec/cm(-5)) vascular resistance were equivalent in all 3 groups. As a function of time 0, systemic vascular resistance changed in an equivalent fashion in the post-cardiopulmonary bypass period, but a significant endothelin-A subtype receptor antagonist effect was observed for pulmonary vascular resistance (analysis of variance; P < .05). For example, at 24 hours post-cardiopulmonary bypass, pulmonary vascular resistance increased by 40 dynes/sec/cm(-5) in the vehicle group but directionally decreased by more than 40 dynes/sec/cm(-5) in the 2 mg/kg endothelin-A subtype receptor antagonist group (P < .05). Total adverse events were equivalently distributed across the endothelin-A subtype receptor antagonist/placebo groups.

CONCLUSION

These unique findings demonstrated that infusion of an endothelin-A subtype receptor antagonist in high-risk patients undergoing cardiac surgery was not associated with significant hemodynamic compromise. Moreover, the endothelin-A subtype receptor antagonist favorably affected pulmonary vascular resistance in the early postoperative period. Thus, the endothelin-A subtype receptor serves as a potential pharmacologic target for improving outcomes after cardiac surgery in patients with compromised left ventricular function.

Summary of the Recommendations on Sexual Dysfunctions in Men

INTRODUCTION

There are few published guidelines for the management of sexual dysfunctions in men and women, despite the prevalence and lack of attention to these problems. Disorders of sexual function in men include erectile dysfunction, orgasm/ejaculation disorders, priapism, and Peyronie's disease.

AIM

To provide evidence-based and expert-opinion consensus guidelines for the clinical management of men's sexual dysfunctions.

METHODS

An International Consultation in collaboration with major urological and sexual medicine societies assembled over 200 multidisciplinary experts from 60 countries into 17 consultation committees. Committee members established the scope and objectives for each chapter. Following intensive review of available data and publications, committees developed evidence-based guidelines in each area.

MAIN OUTCOME MEASURE

New algorithms and guidelines for assessment and treatment of men's sexual dysfunction were developed. The Oxford system of evidence-based review was systematically applied. Expert opinion was based on systematic grading of the medical literature, in addition to cultural and ethical considerations.

RESULTS

Recommendations and guidelines for men's sexual dysfunction are presented. These guidelines were developed as evidence-based, patient-centered, and multidisciplinary in focus. For the clinical assessment and diagnosis of ED, a basic evaluation was recommended for all patients, with optional and specialized testing reserved for special cases. A new treatment algorithm is proposed. This algorithm provides a clinically relevant guideline for managing ED in the large majority of men. New treatment guidelines and algorithms are provided for men's orgasm and ejaculation disorders, including premature ejaculation, retrograde and delayed ejaculation. Finally, expert opinion-based guidelines for the clinical management of priapism and Peyronie's disease are provided.

CONCLUSIONS

Additional research is needed to validate and extend these guidelines. Nonetheless, this summary encompasses the recommendations concerning men's sexual dysfunctions presented at the 2nd International Consultation on Sexual Medicine in Paris, France, June 28-July 1, 2003.

In vivo selection of wild-type hematopoietic stem cells in a murine model of Fanconi anemia

Fanconi anemia (FA) is an autosomal recessive disorder characterized by birth defects, increased incidence of malignancy, and progressive bone marrow failure. Bone marrow transplantation is therapeutic and, therefore, FA is a candidate disease for hematopoietic gene therapy. The frequent finding of somatic mosaicism in blood of FA patients has raised the question of whether wild-type bone marrow may have a selective growth advantage. To test this hypothesis, a cohort radio-ablated wild-type mice were transplanted with a 1:1 mixture of FA group C knockout (FACKO) and wild-type bone marrow. Analysis of peripheral blood at 1 month posttransplantation showed only a moderate advantage for wild-type cells, but upon serial transplantation, clear selection was observed. Next, a cohort of FACKO mice received a transplant of wild-type marrow cells without prior radio-ablation. No wild-type cells were detected in peripheral blood after transplantation, but a single injection of mitomycin C (MMC) resulted in an increase to greater than 25% of wild-type DNA. Serial transplantation showed that the selection occurred at the level of hematopoietic stem cells. No systemic side effects were observed. Our results show that in vivo selection for wild-type hematopoietic stem cells occurs in FA and that it is enhanced by MMC administration.

Upregulation of GH receptor and GH binding protein during pregnancy in the GH deficient rat

During pregnancy there are dramatic changes in the endocrine and metabolic status of the mother: growth hormone (GH) is an important regulator of growth and development. A proportion of GH is bound by specific GH binding proteins (GHBP) that closely resemble the GH receptor (GHR). In the rodent both GHBP and the GHR are considered to be GH dependent, and consequently during pregnancy the increase in serum GH is associated with an increase in GHBP. To examine whether an increase in maternal GH is obligatory for elevation of maternal GHBP or GHR during pregnancy, we used a unique GH-deficient (GHD) strain of rats, to avoid the methodological complications of hypophysectomy and assessed serum GH, GHBP and hepatic GHR binding during the course of pregnancy. In GH normal rats, serum GH concentrations increased twofold and GHBP levels increased threefold; there was no change in hepatic GHR binding. In GHD rats, serum GH concentrations were low and did not increase during pregnancy. Nonetheless, levels of both serum GHBP and hepatic GHR binding increased to that measured in normal rats. Thus, an increase in maternal GH concentration is not required for the gestational upregulation of maternal GHBP or hepatic GHR binding, suggesting that other hormones may be essential in modulating the GH axis during pregnancy.

Serum growth hormone binding protein and hepatic GH binding sites in the Lewis dwarf rat: effects of IGF-I and GH

A radioimmunoassay (RIA) for the rat growth hormone binding protein (GHBP) was developed using a synthetic peptide (corresponding to the hydrophilic carboxyl-terminal sequence of mouse GHBP) as standard and a monoclonal antibody (MAb 4.3) reactive with this peptide as the primary antibody. The values for GHBP concentration obtained for normal rats using this assay compare favourably with those obtained by gel filtration and ELISA methods. The concentration of GHBP in normal male rats at 11 weeks of age (680 +/- 30 ng/ml, SEM, n = 9) was significantly less than the concentration in normal females (943 +/- 47 ng/ml, SEM, n = 25). In 11-week-old dwarf male rats the concentration of GHBP was 423 +/- 35 ng/ml (n = 8); less than in dwarf females (542 +/- 32, P < 0.05, n = 9) and normal males (680 +/- 30, P < 0.001, n = 9). The GHBP concentration in dwarf rats was not age-dependent, whereas in normal females the concentration of GHBP increased with age. The availability of an RIA which is not susceptible to interference by endogenous GH, will facilitate further studies on hormonal and nutritional regulation of the rat GHBP. The assay was applied to studying the effects of IGF-I infusion (240 micrograms/day for 1 week) and GH injection (65 micrograms/100 g body weight, twice daily for 1 week and 4 weeks) on the serum concentration of GHBP in 11-week-old Lewis dwarf rats. Hepatic GH binding sites were also measured in desaturated membranes from the same animals.(ABSTRACT TRUNCATED AT 250 WORDS)

An outbreak of Serratia marcescens in 14 adult cardiac surgical patients associated with 12-lead electrocardiogram bulbs

Two clusters of Serratia marcescens in 14 adult cardiac surgical patients occurred over 10 months in an 876-bed teaching hospital. The 14 infections that were studied were as follows: one sternal and five leg incisions, five pneumonias, one bacteremia, one urinary tract infection, and one infected internal defibrillator site. The first cluster included four pneumonias, one urinary tract infection, and one bacteremia. Corrective actions were taken based on outbreak data through no source was identified. No further infections occurred during the following 2 months. The second cluster included one sternal and five leg incisions, an infected internal defibrillator incision site, and one pneumonia. Serratia marcescens was isolated from six electrocardiogram rubber welsh bulbs with sensitivities identical to patient isolates that indicated a common source outbreak in at least the second cluster of infections. Disposable electrocardiogram leads were introduced and the problem was resolved. We conclude that reusable electrocardiogram welsh bulbs are a vector for postoperative infections.

Spinal dysraphism: a comprehensive diagnostic approach

Twelve patients with the clinical findings of spinal dysraphism form the basis for this report. In eight patients, physical findings, plain x-rays, and unenhanced spinal computed tomography allowed for precise diagnosis and subsequent therapy, without contrast myelography. All patients in the study had intravenous pyelography, and this revealed evidence of renal deterioration in two. The other 10 patients had radiographically normal upper urinary tracts. Urodynamic assessment was performed in seven; three were normal and four were abnormal. The pattern of the abnormal studies (three "flaccid type" with an adequate urethral pressure profile and one with detrusor-sphincter dyssynergia) allowed for appropriate therapy to be employed for bladder emptying and continence. Both spinal computed tomography and urodynamic testing serve as noninvasive studies that can be employed in the follow-up and management of patients with spinal dysraphism.

Dominant piebald trait (white forelock and leukoderma) with neurological impairment

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