Dorothea Dix Hospital

Introduction: We sought to predict the course and rate of functional improvement and length of stay (LOS) in patients with ischemic and hemorrhagic strokes admitted to inpatient rehabilitation facilities(IRF). Aim: To study the course and associating factors affecting functional outcomes among a large cohort of stroke patients admitted to IRFs. Methods: The cohort consists of stroke patients admitted to 5 IRFs in Houston, between 4/17-8/19. Higher order polynomial (quartic, cubic, quadratic) regressions were fitted to predict the temporal relationship between FIM score improvement and LOS, and based on goodness of fit statistics, cubic polynomial fit was selected. Effects of interactions were tested and later dropped from the final model because of non-statistical significance. Models were adjusted for age, gender, stroke type (hemorrhagic vs ischemic), and stroke severity based on NIHSS. Results: The demographics of patients are presented in table 1. Among 679 patients, the univariate analyses reflected that age (F=24.2, p <0.001), admission NIHSS score (F=67, p<0.001), stroke type (F=25.2, p <0.001), and admission FIM (F=283, P<0.001) were significant factors predicting IRF LOS. History of previous stroke, diabetes, hypertension, and hyperlipidemia did not have any significant effects on LOS. In multiple regression model, age at onset (β=-0.18, p<0.001), hemorrhagic vs ischemic stroke (β=3.02, p <0.01) were significant predictors of total FIM change score when adjusting for stroke severity and gender. Total FIM change score was positively correlated with LOS at IRF with a steep improvement in the first 15 days of IRF stay which plateaued afterwards in patients with 1-30 days of IRF stay (Fig. 2). Conclusion: Patient’s age, ischemic vs hemorrhagic stroke were the most significant predictors when deriving the relationship between total FIM score and LOS while adjusting for stroke severity and patient’s gender, which plateaued after 2 weeks of IRF stay.

Health reform debate understandably focuses on large system design. We should not omit attention to the "last mile" problem of physician payment theory. Achieving fundamental goals of integrative, patient-centered primary care depends on thoughtful financial support. This commentary describes the nature and importance of innovative primary care payment programs.

Ipilimumab is an approved anti-cytotoxic T-lymphocyte-associated antigen-4 monoclonal antibody introducing immune responses in melanoma patients. Treatment experiences from named-patient programs support the evaluation of the efficacy and tolerability of new medicines under usual circumstances of health care practice. Here, the largest ever reported cohort treated with ipilimumab 3 mg/kg alone is described. This report retrospectively analyzes data of 198 patients who were followed up in 15 hospital centers in Germany between April 2010 and March 2013. Patients had received prior therapy for unresectable stage III or IV melanoma before receiving ipilimumab (4 doses of 3 mg/kg every 21 d). Routine staging and tumor response evaluation procedures were applied. Of the patients, 119 received the planned 4-course therapy schedule; in further 79 patients, the number of doses was reduced mainly because of toxicity or fast progression. In all, 196 patients were eligible for evaluation of the efficacy of ipilimumab under routine care conditions. Median overall survival (OS) was 6.8 months [95% confidence interval, 5.6-10.3] from the start of therapy. OS differed significantly among patients who received 4 doses (n=119) and those receiving <4 doses (n=79) (14.2 vs. 2.0 mo; P<0.0001). The overall response rate (ORR) of 11% was in the same range as reported from previous clinical trials; and stable disease (SD) was observed in 11% resulting in a disease control rate (ORR+SD) of 22%. In 23 of the 79 patients with reduced dosing, dose omission was most probably caused by toxicity, whereas 56 patients had progressive disease before receiving all 4 treatment cycles. Immune-related adverse events (irAE) were reported in 30% of all treated patients, the occurrence of irAE correlated significantly with the probability of response to therapy and prolonged OS. In this named-patient program including heavily pretreated patients, the efficacy and tolerability of ipilimumab 3 mg/kg corresponds with findings from the confirmatory clinical trial.

ZusammenfassungDer demographische Wandel in unserer Gesellschaft führt zu einer Zunahme des Anteils alter Menschen. Die mit dem Alter einhergehende Multimorbidität resultiert häufig in einer Polypharmakotherapie, die das Risiko für unerwünschte Arzneimittelwirkungen birgt. Im Alter kommt es zu entscheidenden Veränderungen der Pharmakokinetik und ‐dynamik, allen voran einer Abnahme des Körperwassers, einem veränderten Verhältnis von Muskel‐ zu Fettgewebe und einer reduzierten Nierenfunktion. Zudem konnten Veränderungen der Magen‐Darm‐Passage, der Plasmaproteinbindung, der hepatischen Metabolisierung und eine erhöhte Anfälligkeit für Medikamenten‐induzierte kognitive Störungen nachgewiesen werden. All dies muss bei der dermatologischen Pharmakotherapie im Alter berücksichtigt werden, um iatrogene Komplikationen durch Über‐ oder Unterdosierung und Arzneimittelinteraktionen zu minimieren.

Psychiatric patients need educational interventions that help them recover and increase their ability to live and work independently following discharge from the hospital. The psychosocial rehabilitation treatment mall model is designed to meet this educational need. Treatment malls are a new approach to psychosocial rehabilitaion for patients in state psychiatric hospitals. Treatment malls provide psychoeducation and skill-building activities in a centralized, school-like setting for participants from all patient care units. It differs from traditional strategies that use decentralized one-on-one or unit-based models. Treatment malls provide a self-directed learning experience that meets the person-centered needs of participants. Evidence is increasing that this psychosocial educational model can provide lasting benefits for psychiatric patients, including symptom management, reduced psychiatric hospital readmission rates, and improved quality of life.

Despite a growing consensus that seclusion or restraint should never be used with children or adolescents, there are a few patients who are resistant to treatment, and are persistently violent. The purpose of this study was to measure the efficacy of installing a padded seclusion room to decrease the use of mechanical restraints, a potentially more emotionally traumatic and dangerous intervention than seclusion. After padded room installation, the number of monthly mechanical restraint events per 1000 patient days decreased by 93.7%, from 21.2 to 1.3. A padded seclusion room may offer a safer, albeit a less than desirable alternative to mechanical restraint.