Shilpa Krishnan

A Computational, Tissue-Realistic Model of Pressure Ulcer Formation in Individuals with Spinal Cord Injury.

People with spinal cord injury (SCI) are predisposed to pressure ulcers (PU). PU remain a significant burden in cost of care and quality of life despite improved mechanistic understanding and advanced interventions. An agent-based model (ABM) of ischemia/reperfusion-induced inflammation and PU (the PUABM) was created, calibrated to serial images of post-SCI PU, and used to investigate potential treatments in silico. Tissue-level features of the PUABM recapitulated visual patterns of ulcer formation in individuals with SCI. These morphological features, along with simulated cell counts and mediator concentrations, suggested that the influence of inflammatory dynamics caused simulations to be committed to “better” vs. “worse” outcomes by 4 days of simulated time and prior to ulcer formation. Sensitivity analysis of model parameters suggested that increasing oxygen availability would reduce PU incidence. Using the PUABM, in silico trials of anti-inflammatory treatments such as corticosteroids and a neutralizing antibody targeted at Damage-Associated Molecular Pattern molecules (DAMPs) suggested that, at best, early application at a sufficiently high dose could attenuate local inflammation and reduce pressure-associated tissue damage, but could not reduce PU incidence. The PUABM thus shows promise as an adjunct for mechanistic understanding, diagnosis, and design of therapies in the setting of PU.

Predictors of 30-Day Readmission Following Inpatient Rehabilitation for Patients at High Risk for Hospital Readmission

Background The proposed Centers for Medicare & Medicaid Services (CMS) 30-day readmission risk standardization models for inpatient rehabilitation facilities establish readmission risk for patients at admission based on a limited set of core variables. Considering functional recovery during the rehabilitation stay may help clinicians further stratify patient groups at high risk for hospital readmission. Objective The purpose of this study was to identify variables in the full administrative medical record, particularly in regard to physical function, that could help clinicians further discriminate between patients who are and are not likely to be readmitted to an acute care hospital within 30 days of rehabilitation discharge. Design This study used an observational cohort with a 30-day follow-up of Medicare patients who were deconditioned and had medically complex diagnoses and who were receiving postacute inpatient rehabilitation in 2010 to 2011. Methods Patients in the highest risk quartile for readmission (N=25,908) were selected based on the CMS risk prediction model. Hierarchical generalized linear models were built to compare the relative effectiveness of motor functional status ratings in predicting 30-day readmission. Classification and regression tree analysis was used to create a hierarchical order among predictors based on variable importance in classifying patients based on readmission status. Results Approximately 34% of patients in the high-risk quartile were readmitted within 30 days. Functional outcomes and rehabilitation length of stay were the best predictors of 30-day rehospitalization. A 3-variable algorithm classified 4 clinical subgroups with readmission probabilities ranging from 28% to 75%. Limitations Although planned readmissions were accounted for in the outcome, potentially preventable readmissions were not distinguished from unpreventable readmissions. Conclusion For older patients who are deconditioned and have medically complex diagnoses admitted to postacute inpatient rehabilitation, information on functional status measures that are easily monitored by health care providers may improve plans for care transition and reduce the risk of hospital readmission.

Early Detection of Pressure Ulcer Development Following Traumatic Spinal Cord Injury Using Inflammatory Mediators.

OBJECTIVE To identify changes in concentrations of inflammatory mediators in plasma and urine after traumatic spinal cord injury (SCI) and before the occurrence of a first pressure ulcer. DESIGN Retrospective; secondary analysis of existing data. SETTING Acute hospitalization and inpatient rehabilitation sites at a university medical center. PARTICIPANTS Individuals with a pressure ulcer and plasma samples (n=17) and individuals with a pressure ulcer and urine samples (n=15) were matched by age and plasma/urine sample days to individuals with SCI and no pressure ulcer (N=35). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Plasma and urine samples were assayed in patients with SCI, capturing samples within 4 days after the SCI to a week before the formation of the first pressure ulcer. The Wilcoxon signed-rank test was performed to identify changes in the inflammatory mediators between the 2 time points. RESULTS An increase in concentration of the chemokine interferon-γ-induced protein of 10kd/CXCL10 in plasma (P<.01) and a decrease in concentration of the cytokine interferon-α in urine (P=.01) were observed before occurrence of a first pressure ulcer (∼4d) compared with matched controls. CONCLUSIONS Altered levels of inflammatory mediators in plasma and urine may be associated with pressure ulcer development after traumatic SCI. These inflammatory mediators should be explored as possible biomarkers for identifying individuals at risk for pressure ulcer formation.

Association between presence of pneumonia and pressure ulcer formation following traumatic spinal cord injury

Objective: To determine if the presence of pneumonia and pressure ulcers are associated in individuals with an acute spinal cord injury during acute care and rehabilitation hospitalizations. Design: Retrospective, secondary analyses of data obtained from the Spinal Cord Injury Model Systems enrolled from 1993 until 2006 Setting: Acute care hospitalization and inpatient rehabilitation facilities Participants: A cohort of individuals hospitalized in acute care (n = 3,098) and inpatient rehabilitation (n = 1,768) was included in the analysis. Frequencies of pressure ulcer formation and episodes of pneumonia were noted in both settings. Interventions: Not applicable. Outcome Measures: Pressure ulcer formation and diagnosis of pneumonia Results: The development of pressure ulcers, including stage I, was 20.3% acute care and 21.1% during in inpatient rehabilitation. Multivariate logistic regression analyses revealed a significant association of pneumonia with occurrence of pressure ulcers (P ≤ 0.001, OR = 2.3 and 2.2 respectively), the American Spinal Injury Association Impairment Scale grades (P < 0.001), and utilization of mechanical ventilation (P < 0.01) in both settings. Conclusion: A higher presence of pressure ulcers was found in individuals with pneumonia, after adjusting for injury severity, age, sex, and utilization of mechanical ventilation. Impaired inflammatory response and decreased mobility in individuals with pneumonia may predispose these individuals to develop pressure ulcers. Surveillance and preventive measures for pressure ulcers should be rigorous in individuals with SCI and pneumonia.

Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study

Study design:Secondary analysis of data from a prospective cohort study.Objectives:The objective of this study was to identify the medical and demographic factors associated with the development of pressure ulcers during acute-care hospitalization and inpatient rehabilitation following acute spinal cord injury.Setting:The study was carried out at acute hospitalization, inpatient rehabilitation and outpatient rehabilitation sites at a university medical center in the United States.Methods:Adults with acute traumatic spinal cord injury (n=104) were recruited within 24–72 h of admission to the hospital. Pressure ulcer incidence was recorded.Results:Thirty-nine participants out of 104 (37.5%) developed at least one pressure ulcer during acute-care hospitalization and inpatient rehabilitation. Univariate logistic regression analyses revealed significant association of pressure ulcer incidence for those with pneumonia and mechanical ventilation (P=0.01) and higher injury severity (ASIA A) (P=0.01). Multiple logistic regression showed that the odds of formation of a first pressure ulcer in participants with ASIA A was 4.5 times greater than that for participants with ASIA B, CI (1–20.65), P=0.05, and 4.6 times greater than that for participants with ASIA C, CI (1.3–16.63), P=0.01.Conclusion:Among individuals with acute traumatic SCI, those with high-injury severity were at an increased risk to develop pressure ulcers. Pneumonia was noted to be associated with the formation of pressure ulcers.

Coping With Caregiver Burnout When Caring for a Person With Neurodegenerative Disease: A Guide for Caregivers

Caring for a person with a neurodegenerative disease (eg, Alzheimer disease, Parkinson disease, multiple sclerosis, amyotrophic lateral sclerosis, Huntington disease) can be extremely challenging. The challenges grow as the disease gets worse. If you are a caregiver of a person with a neurodegenerative disease, there are steps you may need to consider to decrease the risk or amount of caregiver burnout. This may help maintain or improve your health and wellness. It is important for you to know if you have caregiver burnout, or the common triggers that may cause your burnout. By recognizing and addressing these factors, you will be able to take healthy and manageable control over your caregiver duties.

Preferences for Communicating about Breast Cancer Screening Among Racially/Ethnically Diverse Older Women

ABSTRACT Differences exist across breast cancer screening guidelines regarding frequency of screening and age of discontinuation for older women (≥70 years) at average risk for breast cancer. These differences highlight concerns about the benefits and harms of screening, and may negatively impact older women’s ability to make informed screening decisions. This study examined preferences for communicating about screening mammography among racially/ethnically diverse, older women. In-depth interviews were conducted with 59 women with no breast cancer history. Non-proportional quota sampling ensured roughly equal numbers on age (70–74 years, ≥75 years), race/ethnicity (non-Hispanic/Latina White, non-Hispanic/Latina Black, Hispanic/Latina), and education (≤high school diploma, >high school diploma). Interviews were audio-recorded, transcribed, and analyzed using NVivo 10. Thematic analyses revealed that rather than being told to get mammograms, participants wanted to hear about the benefits and harms of screening mammography, including overdiagnosis. Participants recommended that this information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in senior groups). Results were consistent regardless of participants’ age, race/ethnicity, or education. Findings revealed that older women desire information about the benefits and harms of screening mammography, and would prefer to learn this information through discussions with healthcare providers and multiple other formats.

Patient-centered mobility outcome preferences according to individuals with stroke and caregivers: a qualitative analysis

Abstract Purpose: To explore the mobility-related preferences among stroke survivors and caregivers following post-acute rehabilitation at inpatient or skilled nursing facilities. Methods: In this cross-sectional study; semi-structured, qualitative interviews of stroke survivors (n = 24) and informal caregivers (n = 15) were conducted. The participants were recruited from the community. Results: Comparative content analysis was used to identify themes by two independent coders. The survivors (68 years) and caregivers (58 years) mentioned mobility-related consequences including inability to walk, balance, drive, and transfer; and increased falls. The survivors (63%) and caregivers (73%) also mentioned the use of assistive devices. The common rehabilitation activities included: walking (62%); followed by standing and mobility; strength and balance; and wheelchair skills. Some stroke survivors were dissatisfied as their rehabilitation was not patient-centered. Frequently mentioned outcome preferences by survivors were ability to walk (88%), move, and balance. They also wanted to acquire assistive devices to move independently. Caregivers were concerned with the survivor’s safety and wanted them to drive (53%), prevent falls, have home accommodations, and transfer independently. Caregivers (40%) also expressed the importance of receiving realistic information. Conclusions: This study suggests a need to consider the stroke survivors’ and caregivers’ mobility outcome preferences to improve the patient-centered rehabilitation care. Implications for Rehabilitation Stroke survivors and caregivers tend to differ in their outcome preferences. Caregivers expressed concern for transfers, driving, fall prevention, home modifications, and wished for realistic information. Incorporating stroke survivors and their families’ perspectives during rehabilitation may enhance patient-centered outcomes.

Impact of Multiple Chronic Conditions on Activity Limitations Among Older Mexican-American Care Recipients

Introduction Older Mexican Americans are living longer with multiple chronic conditions (MCCs). This has placed greater demands on caregivers to assist with basic activities of daily living (ADL) or instrumental activities of daily living (IADL). To understand the needs of older Mexican-American care recipients, we examined the impact of MCC on ADL and IADL limitations. Methods We analyzed data from 485 Mexican American care-receiving/caregiving dyads. Selected MCCs in the analysis were diabetes, hypertension, stroke, heart disease, arthritis, emphysema/chronic obstructive pulmonary disease, cognitive impairment, depression, and cancer. Care recipients were dichotomized as having 3 or more conditions or as having 2 or fewer conditions. Three comorbidity clusters were established on the basis of the most prevalent health conditions among participants with comorbid arthritis and hypertension. These clusters included arthritis and hypertension plus: diabetes (cluster 1), cognitive impairment (cluster 2), and heart disease (cluster 3). Results Care recipients with 3 or more chronic conditions (n = 314) had higher odds of having mobility limitations (OR = 1.98; 95% CI, 1.34–2.94), self-care limitations (OR = 2.53; 95% CI, 1.70–3.81), >3 ADL limitations (OR = 2.00; 95% CI, 1.28–3.17), and >3 IADL limitations (OR = 1.88; 95% CI, 1.26–2.81). All clusters had increased odds of ADL and severe ADL limitations. Of care recipients in cluster 2, those with arthritis, hypertension, and cognitive impairment had significantly higher odds of mobility limitations (OR = 2.33; 95% CI, 1.05–5.24) than those with just arthritis and hypertension. Conclusion MCCs were associated with more ADL and IADL limitations among care recipients, especially for those with hypertension and arthritis plus diabetes, cognitive impairment, or heart disease. These findings can assist in developing programs to meet the needs of older Mexican-American care recipients.

Predictive validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) in acute care and inpatient rehabilitation in individuals with traumatic spinal cord injury

OBJECTIVE To evaluate the validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) by determining critical cutoff points and assessing the ability to predict risk for pressure ulceration (PrU). DESIGN Retrospective. METHODS Sensitivity, specificity, and area under the curve (AUC) for the receiver operating characteristic were determined for the scales ability to predict PrU 2-3 and 5-7 days after administrating the SCIPUS during acute care, and 5-7 and 14-21 days after administrating the SCIPUS during inpatient rehabilitation. RESULTS During acute hospitalization, SCIPUSs ability to assess risk for PrUs within 2-3 days was determined at cutoff score of 15 with 100% sensitivity and 75% specificity, AUC = 0.85. The scale was unable to assess PrU risk at 5-7 days, AUC < 0.6 at cutoff score of 13. During inpatient rehabilitation, the scale was unable to assess PrU risk at 5-7 and 14-21 days, AUC < 0.6 at cutoff score of 9. CONCLUSIONS The SCIPUS could predict PrU occurring within 2-3 days following administration during acute, but unable to predict over a longer term within acute or inpatient rehabilitation. Improved PrU risk assessment following SCI may be possible with modification to the SCIPUS.