Care Coordination as Part of the Discharge Plan to Support Community Reintegration of Individuals with Stroke Living in Appalachian Rural Communities

Studies indicate a high incidence of readmission within the first 12 months post-discharge home following stroke. In addition, there is a limited awareness of healthcare services, community resources, and lack of access to information in rural communities. Previous work from our group has demonstrated the need for community-based navigational support during community reintegration for survivors of stroke. The purpose of this study was to determine the effectiveness of providing community health navigation to facilitate continued communications with healthcare providers and linkages to services and community resources for survivors of stroke in Appalachian rural communities

Care Coordination for Community Transitions for Individuals Post-Stroke Returning to Low-Resource Rural Communities

High rates of hospital readmissions have been shown within 12 months post-discharge from inpatient rehabilitation following stroke. Multiple studies coupled with our previous work indicate a need for care support for stroke survivors’ transitions to the community. The Kentucky Care Coordination for Community Transitions (KC3T) program was developed to provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in Kentucky. This program assessment was conducted to determine the effectiveness of using a specially trained community health worker to support community transitions. Thirty acute stroke survivors were enrolled in this program between July 2015 and May 2016. Data collection included: incidence of comorbidities; access to healthcare, insurance, medical equipment (DME), and medications; type of follow-up education provided; and number of 30-day rehospitalizations and Emergency Department (ED) visits. Participants required navigation in their home and community transition with support in: patient-provider communication; insurance support; accessing follow-up care; education on managing chronic health conditions, the stroke process, transfers and mobility; and accessing DME and essential medications. There were no 30-day ED visits for the KC3T participants and only one 30-day hospital readmission, which was not stroke-related. Individuals returning to rural communities following a stroke require, but often don’t receive, follow-up education on chronic disease management, support in navigating the healthcare system and accessing essential resources. KC3T’s navigator program appears to be effective in supporting the community transitions of individuals poststroke

Pre-Operative Education for Total Knee Replacement: A Pilot Survey

Purpose: The structure of preoperative education programs used nationally for patients prior to total knee replacement (TKR) surgery has not been identified previously, thus hospitals across the United States lack a common standard for this preoperative education to ensure best patient outcomes. The purpose of this pilot survey study was to describe the content, providers, and delivery methods currently utilized to deliver preoperative education for total knee replacement in the United States. Method: Data were collected using an online survey developed by the authors based on review of literature and 3 preoperative programs and was distributed through the Research Electronic Data Capture (REDCap). The survey consisted of 16 questions, including 12 closed-ended and 4 open-ended items. Participants were identified through convenience sampling using contacts of the first author and an Internet search of hospitals that provided preoperative education. Seven professional participants from nursing, physical therapy, and occupational therapy completed the survey. Descriptive statistics were used for data analysis of the 12 quantitative questions to determine frequency and percentages of responses. Responses on the 4 open- ended survey items as well as participant responses of “other” for question items were recorded and collated from individual survey responses. Results: Preoperative education provider teams for total knee replacements most frequently consisted of nursing, physical therapy, and occupational therapy staff. Most education programs were provided 2 weeks prior to surgery in a group format with the majority of programs being delivered in a single session, lasting between 1 and 1.5 hours. Verbal and written instruction were the most commonly utilized methods to deliver education. Individual patient programs included a variety of topics, ranging from the expectations while in the hospital, self-care, adaptive equipment, and home safety, being some of the most commonly included content. Conclusions: With this pilot study, we have provided a framework to describe the structure of preoperative total knee replacement education nationally, which can be used to guide a future large-scale survey to fully describe the content, providers, and delivery methods of preoperative education for this population across the United States, using a representative sample

Pre-Operative Education for Total Knee Replacement: A Pilot Survey

Purpose: The structure of preoperative education programs used nationally for patients prior to total knee replacement (TKR) surgery has not been identified previously, thus hospitals across the United States lack a common standard for this preoperative education to ensure best patient outcomes. The purpose of this pilot survey study was to describe the content, providers, and delivery methods currently utilized to deliver preoperative education for total knee replacement in the United States. Method: Data were collected using an online survey developed by the authors based on review of literature and 3 preoperative programs and was distributed through the Research Electronic Data Capture (REDCap). The survey consisted of 16 questions, including 12 closed-ended and 4 open-ended items. Participants were identified through convenience sampling using contacts of the first author and an Internet search of hospitals that provided preoperative education. Seven professional participants from nursing, physical therapy, and occupational therapy completed the survey. Descriptive statistics were used for data analysis of the 12 quantitative questions to determine frequency and percentages of responses. Responses on the 4 open- ended survey items as well as participant responses of “other” for question items were recorded and collated from individual survey responses. Results: Preoperative education provider teams for total knee replacements most frequently consisted of nursing, physical therapy, and occupational therapy staff. Most education programs were provided 2 weeks prior to surgery in a group format with the majority of programs being delivered in a single session, lasting between 1 and 1.5 hours. Verbal and written instruction were the most commonly utilized methods to deliver education. Individual patient programs included a variety of topics, ranging from the expectations while in the hospital, self-care, adaptive equipment, and home safety, being some of the most commonly included content. Conclusions: With this pilot study, we have provided a framework to describe the structure of preoperative total knee replacement education nationally, which can be used to guide a future large-scale survey to fully describe the content, providers, and delivery methods of preoperative education for this population across the United States, using a representative sample

Pre-operative Education for Total Knee Replacement: A Pilot Survey

Purpose: The structure of pre-operative education programs used nationally for patients prior to total knee replacement (TKR) surgery has not been identified previously, thus hospitals across the United States lack a common standard for this pre-operative education to ensure best patient outcomes. The purpose of this pilot survey study was to describe the content, providers, and delivery methods currently utilized to deliver pre-operative education for total knee replacement in the United States. Method: Data were collected using an online survey developed by the authors based on review of literature and three pre-operative programs, and was distributed through the Research Electronic Data Capture (REDCap). The survey consisted of 16 questions, including 12 closed-ended and four open-ended items. Participants were identified through convenience sampling using contacts of the first author and an internet search of hospitals that provide pre-operative education. Seven professional participants total from nursing, physical therapy, and occupational therapy completed the survey. Descriptive statistics were used for data analysis of the 12 quantitative questions to determine frequency and percentages of responses. Responses on the four open-ended survey items, as well as participant responses of “other” for question items, were recorded and collated from individual survey responses. Results: Pre-operative education provider teams for total knee replacements most frequently consisted of nursing, physical therapy, and occupational therapy staff. Most education programs were provided two weeks prior to surgery in a group format, with the majority of programs being delivered in a single session lasting between 1 and 1.5 hours. Verbal and written instruction were the most commonly utilized methods to deliver education. Individual patient programs included a variety of topics, ranging from what to expect while in the hospital, self-care, adaptive equipment, and home safety being some of the most commonly included content. Conclusions: This pilot study provides a framework to describe the structure of pre-operative total knee replacement education nationally, and can be used to guide a future large scale survey to fully describe the content, providers, and delivery methods of pre-operative education for this population across the United States using a representative sample

Epithelial Overexpression of BDNF or NT4 Disrupts Targeting of Taste Neurons That Innervate the Anterior Tongue

AbstractBrain-derived neurotrophic factor (BDNF) and neurotrophin-4 (NT4) are essential for the survival of geniculate ganglion neurons, which provide the sensory afferents for taste buds of the anterior tongue and palate. To determine how these target-derived growth factors regulate gustatory development, the taste system was examined in transgenic mice that overexpress BDNF (BDNF-OE) or NT4 (NT4-OE) in basal epithelial cells of the tongue. Overexpression of BDNF or NT4 caused a 93 and 140% increase, respectively, in the number of geniculate ganglion neurons. Surprisingly, both transgenic lines had severe reduction in fungiform papillae and taste bud number, primarily in the dorsal midregion and ventral tip of the tongue. No alterations were observed in taste buds of circumvallate or incisal papillae. Fungiform papillae were initially present on tongues of newborn BDNF-OE animals, but many were small, poorly innervated, and lost postnatally. To explain the loss of nerve innervation to fungiform papillae, the facial nerve of developing animals was labeled with the lipophilic tracer DiI. In contrast to control mice, in which taste neurons innervated only fungiform papillae, taste neurons in BDNF-OE and NT4-OE mice innervated few fungiform papillae. Instead, some fibers approached but did not penetrate the epithelium and aberrant innervation to filiform papillae was observed. In addition, some papillae that formed in transgenic mice had two taste buds (instead of one) and were frequently arranged in clusters of two or three papillae. These results indicate that target-derived BDNF and NT4 are not only survival factors for geniculate ganglion neurons, but also have important roles in regulating the development and spatial patterning of fungiform papilla and targeting of taste neurons to these sensory structures

Perceived Exercise Habits of Individuals with Parkinson’s Disease Living in the Community

Context Exercise has been shown to improve gait in individuals with Parkinson’s disease (PD). Stepping practice at higher intensity levels has been suggested as a beneficial treatment option to improve gait in the neurological population. Unfortunately, this mode is poorly understood and underutilized within the PD population. Information on what individuals with PD are doing for exercise would be beneficial to help tailor exercise programs to improve gait and provide exercise options in the community for intensity-based exercise. Objective To investigate the current exercise habits of individuals living with PD in the community aimed at improving walking and to understand the impact of perceived intensity on daily exercise practices. Design, setting, participants One hundred thirty-eight individuals with PD living in the community were surveyed online regarding their current exercise habits. Main outcome measure A total of 22 questions aimed to understand exercise selection, focus, and perceived intensity. Questions asked basic demographic, symptom presentation and management of disease related symptoms that were present while living with PD. Exercise questions focused understanding participants current function level, practice exercise habits and perceived levels of exercise intensity during daily routines. Results Of the 138 individuals surveyed for this preliminary study, eighty-seven percent of individuals with PD participated in exercise with seventy-five percent choosing walking as a mode for exercise. Sixty-five percent of the respondents noted that despite exercise, their walking speed and endurance has worsened since diagnosis. Eighty-one percent perceived exercising at moderate intensity levels, however little provocation of intensity symptoms was noted. Conclusion Our preliminary study survey results suggest that individuals with PD are exercising but not at high enough intensity levels to promote improvements in gait performance. Individuals with PD may need to be pushed at higher intensity levels, beyond their voluntary limits, to induce gait performance changes. These findings can provide a foundation for future fitness interventions within this population to target improving gait

Living with Traumatic Brain Injury in a Rural Setting: Supports and Barriers Across the Continuum of Care

Purpose: Traumatic brain injury (TBI) is prevalent in Kentucky and comes with a high cost in care and quality of life for individuals and caregivers affected. Many people living with the condition of TBI have unmet needs. Research among people living with TBI in rural areas is limited. The purposes of this study were to (1) increase understanding of the lived experience of people with TBI and caregivers in rural regions of Kentucky across the continuum of their care and (2) provide their perspectives on barriers and facilitators of optimal function and well-being. Methods: A qualitative descriptive interview study was conducted by a multidisciplinary team. Content analysis was completed with data-derived coding and iterative modifications to analysis, coalescing codes into categories and themes. Results: Thirteen people with TBI and six caregivers participated in the interview. Categories that emerged in analysis included the experiences under each locus of care; themes included relationships, functional competence, and participation in meaningful activity. Conclusion: Relationships represented both barriers and facilitators of well-being. Major unmet needs persisted in terms of medical problems, support for caregivers, community linkages, and participation in meaningful activities. Recommendations are made regarding avenues for addressing unmet needs

Hemorrhagic stroke outcomes of KApSR patients with co-morbid diabetes and Alzheimer’s disease

Background: Vascular risk factors, such as diabetes mellitus (DM), are associated with poorer outcomes following many neurodegenerative diseases, including hemorrhagic stroke and Alzheimer’s disease (AD). Combined AD and DM co-morbidities are associated with an increased risk of hemorrhagic stroke and increased Medicare costs. Therefore, we hypothesized that patients with DM in combination with AD, termed DM/AD, would have increased hemorrhagic stroke severity. Methods: Kentucky Appalachian Stroke Registry (KApSR) is a database of demographic and clinical data from patients that live in Appalachia, a distinct region with increased health disparities and stroke severity. Inpatients with a primary indication of hemorrhagic stroke were selected from KApSR for retrospective analysis and were separated into four groups: DM only, AD only, neither, or both. Results: Hemorrhagic stroke patients (2,071 total) presented with either intracerebral hemorrhage (ICH), n=1,448, or subarachnoid hemorrhage (SAH), n=623. When examining all four groups, subjects with AD were significantly older (AD+, 80.9±6.6 yrs) (DM+/AD+, 77.4±10.0 yrs) than non AD subjects (DM-/AD-, 61.3±16.5 yrs) and (DM+, 66.0±12.5 yrs). A higher percentage of females were among the AD+ group and a higher percentage of males among the DM+/AD+ group. Interestingly, after adjusting for multiple comparison, DM+/AD+ subjects were ten times as likely to suffer a moderate to severe stroke based on a National Institute of Health Stroke (NIHSS) upon admission [odds ratio (95% CI)] compared to DM-/AD- [0.1 (0.02–0.55)], DM+ [0.11 (0.02–0.59)], and AD+ [0.09(0.01–0.63)]. The odds of DM+/AD+ subjects having an unfavorable discharge destination (death, hospice, long-term care) was significant (P Conclusions: In our retrospective analysis utilizing KApSR, regardless of adjusting for age, sex, and comorbidities, DM+/AD+ patients were significantly more likely to have had a moderate or severe stroke leading to an unfavorable outcome following hemorrhagic stroke

Effects of gabapentin on muscle spasticity and both induced as well as spontaneous autonomic dysreflexia after complete spinal cord injury

We recently reported that the neuropathic pain medication, gabapentin (GBP; Neurontin), significantly attenuated both noxious colorectal distension (CRD)-induced autonomic dysreflexia (AD) and tail pinch-induced spasticity compared to saline-treated cohorts 2–3 weeks after complete high thoracic (T4) spinal cord injury (SCI). Here we employed long-term blood pressure telemetry to test, firstly, the efficacy of daily versus acute GBP treatment in modulating AD and tail spasticity in response to noxious stimuli at 2 and 3 weeks post-injury. Secondly, we determined whether daily GBP alters baseline cardiovascular parameters, as well as spontaneous AD events detected using a novel algorithm based on blood pressure telemetry data. At both 14 and 21 days after SCI, irrespective of daily treatment, acute GBP given 1 h prior to stimulus significantly attenuated CRD-induced AD and pinch-evoked tail spasticity; conversely, acute saline had no such effects. Moreover, daily GBP did not alter 24 h mean arterial pressure (MAP) or heart rate (HR) values compared to saline treatment, nor did it reduce the incidence of spontaneous AD events compared to saline over the three week assessment period. Power spectral density (PSD) analysis of the MAP signals demonstrated relative power losses in mid frequency ranges (0.2–0.8 Hz) for all injured animals relative to low frequency MAP power (0.02–0.08 Hz). However, there was no significant difference between groups over time post-injury; hence, GBP had no effect on the persistent loss of MAP fluctuations in the mid frequency range after injury. In summary, the mechanism(s) by which acute GBP treatment mitigate aberrant somatosensory and cardiophysiological responses to noxious stimuli after SCI remain unclear. Nevertheless, with further refinements in defining the dynamics associated with AD events, such as eliminating requisite concomitant bradycardia, the objective repeatability of automatic detection of hypertensive crises provides a potentially useful tool for assessing autonomic function pre- and post-SCI, in conjunction with experimental pharmacotherapeutics for neuropathic pain, such as GBP