Dissertationen zum Thema „Long-term fallow“

Falls and related injuries have affected residents in long-term care facilities for many years. It has been well-established that patient fall prevention includes staff education and hourly rounding in addition to adequate risk assessment. These steps, taken together, have the potential to decrease a 52.7% fall rate on the long-term care pilot unit. The purpose of this quality improvement project was to: (a) educate staff on the process of properly performing hourly rounding and (b) and achieve a decreased incidence of falls from the current fall rate. Thus, the practice-focused question for the project addressed whether rounding hourly on patients in a long-term care facility would decrease the numbers of falls and related injuries. The conceptual framework used for this evidence-based project was the Institute for Healthcare Improvement's rapid cycle improvement. A sample size of 40 residents' fall rates were compared for a 6-week period before the intervention of hourly rounding to the fall rates after 6 weeks of full implementation of the rounding process. A Wilcoxon Signed Ranks test (z = -4.169, p < .001) showed that there was a statistically significant improvement in staff knowledge when mean pretest scores (75.9%) were compared to posttest scores (94.5%). Nursing staff were also evaluated on competencies, and 100% of the staff successfully completed the competency checklist on the first attempt. Post project fall rates revealed a decreased fall rate by 22% over a 6-week period post implementation. Nursing leadership should ensure that staff are continually educated on policies being implemented to ensure an effective outcome. Having hourly rounding as a permanent policy can decrease the patient's fall rate and improve patient safety, a positive social change.

Residents in nursing facilities are more prone to falls than those living in the community. Injuries resulting from falls impact residents, their families, and healthcare costs. The gap in nursing practice was the lack of a comprehensive fall-prevention program in a long-term care facility that had experienced high fall rates among residents. This project addressed whether an educational program using the American Medical Directors Association's clinical practice guideline and the Centers for Disease Control and Prevention's STEADI (Stopping Elderly Accidents, Deaths, & Injuries) toolkit for fall- prevention improved the self-efficacy of direct-care staff in preventing falls among residents in a long-term care facility. The practice-focused question focused on whether education on the use of an integrated multifactorial fall-prevention guideline would increase confidence of long-term care staff in reducing falls in long-term care residents. The evaluation used the 11-item Self-Efficacy for Preventing Falls-Nurse scale for 5 licensed nursing staff and the 8-item Self-Efficacy for Preventing Falls-Assistant scale for 21 nursing assistants. The positive change in self-efficacy scores of nurses and nursing assistants after the education program was greatest for face-to-face team communication regarding fall risk and individual resident prevention plans. The use of best-practice guidelines that improve fall risk-assessment and use of fall precautions to decrease the number of falls and falls with injury has the potential to bring about positive social change by improving the nursing care of nursing home residents, resulting in improved resident safety and quality of life.

Although a great deal is known about the etiology of falls in elderly individuals, fall accidents continue to represent a significant burden to elders residing in long-term care facilities. It has been stated that 75% of deaths due to falls in the United States occur in the 13% of the population age 65 and over. The first objective of the study was to identify which fall-predictor variables acknowledged in the research literature are associated with increased fall frequency with the older population. Identifying specific predictor variables related to a high occurrence of falls in long-term care setting can assist in the redesign of tools and programs aimed to recognize fall risk, and prevent fall-related accidents and fatalities in the geriatric population. The second objective of the study was to identify which combination of predictor variables could better predict the frequency of falls. A history of falls variable was the only predictive variable that differed significantly between groups of residents who had sustained subsequent falls and those who had not. Other variables including age, mental status, day number of stay, elimination, visual impairment, confinement, blood pressure drop, gait and balance, and medication were found to not be statistically significant between groups of fallers and non-fallers. In this setting, the current design of the tool had limited accuracy and exhibited an inability to effectively discriminate between resident populations at risk of falling and those not at risk of falling. Consequently, the current fall risk assessment tool is not adequate for assessing fall risk in this clinical setting.
Master of Science

La tetralogia de Fallot és la cardiopatia congènita cianògena més freqüent. Des de que es va començar a reparar amb èxit a mitjans dels anys 50, els pacients amb aquesta cardiopatia tenen una esperança de vida més llarga incrementant el número de pacients que sobreviuen a l’edat adulta. La regurgitació valvular pulmonar severa és habitual en aquests pacients, requerint freqüentment substitució valvular pulmonar. Actualment, encara no hi ha consens en quin és el moment apropiat i l’abordatge quirúrgic adequat per la substitució valvular pulmonar, sobretot si es vol preservar la funció ventricular i millorar la capacitat funcional i el pronòstic a llarg termini. Aquesta Tesi estudia la supervivència, el risc de reintervenció i d’arítmia ventricular després de la substitució valvular pulmonar, junt amb l’impacte en la capacitat funcional i el rol de les noves tècniques ecocardiogràfiques en pacients amb tetralogia de Fallot reparada. En resum, els resultats d’aquesta Tesi mostren que els pacients amb tetralogia de Fallot reparada han estat operats de la vàlvula pulmonar tard en la seva evolució, i conseqüentment no s’ha aconseguit uns resultats quirúrgics òptims. Encara que subjectivament la classe funcional i les característiques ecocardiogràfiques mostren millora després de la substitució valvular pulmonar, la mesura objectiva tant de la classe funcional com mitjançant les noves tècniques ecocardiogràfiques no mostren una milloria clínica o estadísticament significativa. A més, la supervivència lliure d’esdeveniments de risc vital i la supervivència global són limitades als 15 anys de seguiment, essent per sota del 80% en una població jove, al voltant dels 30 anys d’edat en el moment de la substitució valvular pulmonar. Tot i això, el moment apropiat s’ha de sospesar amb el risc de reintervenció, ja que operar més aviat pot comportar més risc de reintervenció, especialment en menors de 18 anys. Preoperatòriament, la prova d’esforç pot ser convenient per fer una valoració objectiva de la classe funcional. A més, les noves tècniques ecocardiogràfiques poden ser d’ajuda per avaluar el moment òptim i per fer el seguiment d’aquests pacients, aportant un valor afegit a l’estratègia d’estudi vigent. Per últim, el millor moment i la millor estratègia quirúrgica per restaurar la funció valvular pulmonar en pacients amb tetralogia de Fallot reparada encara no està clar. Varis factors destacats en aquesta Tesi haurien de ser considerats i avaluats per un equip multidisciplinar.
Tetralogy of Fallot is the most common cyanotic congenital heart disease. Since the first successful repair on the mid 1950s, numerous contributions have been made leading to an increasing population of tetralogy of Fallot repair survivors. Severe pulmonary regurgitation is common in these patients, requiring pulmonary valve replacement (PVR) at some point during follow-up. Uncertainty remains on defining appropriate intervention referral and the optimal surgical approach aiming to preserve ventricular function and improve functional and vital outcomes in these patients. This Thesis studies survival, risk of reintervention, and risk of ventricular arrhythmia, impact on aerobic capacity and the role of novel echocardiographic techniques on a group of patients with repaired tetralogy of Fallot undergoing PVR. In summary, the results of this Thesis show that patients with repaired tetralogy of Fallot have been operated on the pulmonary valve late in their disease process to achieve ideal postoperative outcomes. Even though subjective functional class and qualitative echocardiography show improvement after pulmonary valve replacement, objectively measured exercise capacity and novel quantitative functional echocardiographic techniques show no clinically or statistically relevant improvement. In addition, freedom from life-threatening events and overall survival are poor at 15 year follow-up, being below 80% in a young population with a mean of 30 years of age at PVR. However, the appropriate moment for pulmonary valve replacement needs to be balanced with the risk of pulmonary valve reintervention. Operating sooner may lead to earlier need of reintervention, especially in patients younger than 18 years old. Exercise testing may be convenient preoperatively as an objective functional class assessment. Besides, novel deformational echocardiographic techniques may be helpful to determine optimal timing and can be valuable to ongoing serial evaluation, adding to the current imaging strategy. Importantly, the appropriate moment and the best surgical approach for restoring pulmonary valve function in patients with repaired tetralogy of Fallot are still not clear. Several aspects highlighted in this Thesis should be considered and evaluated by a comprehensive multidisciplinary team.

Falls and injuries related to falls are some of the most common and costly incidents that occur in the long-term care environment. Purposeful hourly rounding is a proactive way for nursing staff to identify patient needs and demonstrate positive fall prevention outcomes. This project examined a process improvement endeavor of a long-term care unit that experienced an increase in the number of falls over 3 months. The purpose was to evaluate whether staff education and implementation of an evidence-based hourly rounding program would affect the number of patient falls. The Johns Hopkins nursing evidence-based conceptual model, Kurt Lewin's change model, and the Shewhart cycle process improvement model were used to implement the change process as well as the Studer Group best practice hourly rounding tools. A sample of 40 residents was included in a quantitative descriptive design describing the implementation of hourly rounding. Staff were educated 30 days prior to implementation. Pre and post project fall rates were retrieved from the VA fall data management system and revealed a 55% decrease over 3 months post staff education. The use of evidence-based hourly rounding measures increased over the same time period. Nurse leaders must ensure rounding programs are evidence-based, clearly defined in policies, and include robust education plans. There are limited studies on the relationship between education and hourly rounding; therefore, future studies should focus on outcomes of initial and ongoing education for program success and sustainability. Falls are a healthcare concern nurses must address at any point-of-care to promote public safety through prevention and to facilitate positive social change by providing a safe hospital environment.

Falls are a serious issue for the elderly living in long-term care facilities, as falls contribute to significant health problems such as increased dependence, loss of autonomy, confusion, immobilization, depression, restriction in daily activities, and, in some cases, death. An estimated 424,000 fatal falls in elderly patients residing in long-term facilities occur annually in the United States costing $34 billion in direct medical costs. One way to reduce falls among elderly patients in long-term care is to assess for fall risk frequently and implement evidence-based strategies to prevent falls. Patients in this project site facility had been assessed for fall risk via the Briggs Fall Risk Assessment Tool with implementation of fall risk iinterventions only upon admission or when there was a fall. The purpose of this project was to assess whether changing to weekly use of the Briggs Fall Risk Assessment Tool with implementation of fall risk interventions by nursing staff could decrease fall rates in the elderly in long-term care in Harris County, Texas. The model of prevention served as the conceptual framework for this project. Thirty participants (20 females and 10 males) between the ages of 65-115 participated in the program. Pre-implementation data were collected for 1 month and post-implementation data were collected for 1 month. The total number of falls reported weekly was counted before and after the weekly implementation of the Briggs Fall Risk Assessment Tool. The number of falls decreased from 12(70.6%) before the implementation of the assessment tool to 5(29.4%) falls afterwards. A fall prevention program in long-term care may affect social change positively by reducing fall risk in long term care by reinforcing the importance of increased awareness of risk of falls to implement fall prevention strategies

The aim of this study was to investigate fall risk and predisposing factors for fall among the residents in long-term care institutions. Methods. Elderly care homes residents 48 men (mean ± SD, 78,6±7,0) and 101 women (mean ± SD, 81,6±6,4), all 149 residents, participated in the study. For investigation a questionnaire was used, which was made according literature and including following instruments: Environmental Falls Audit Tool – Individual, Falls Risk Assessment Tool and Risk Factor Checklist, Mini Mental State Examination. Results. The most frequently diseases among men and women were heart and vascular (89,6 % and 92,1 %) and eyes diseases (70,8 % and 75,2 %). Ambulatory aid was needed for a half of all residents (54,4 %); ambulatory aid, which respondents didn’t want to used were three times common for women than men (p=0,007). Most residents had low fall risk (72,5 %), but high fall risk was more common in women (14,9 %) than men group (4,2 %); there were no significant difference between groups. High fall risk significantly dominated among the residents older than 85 year in comparison with 65-74 and 75-84 year age groups. Residents who had lower education (p<0,001), were older (p=0,005) and took more medications (p=0,002) had higher fall risk scores evaluated by Fall Risk Assessment Tool. Residents who had such risk factors as unsafe mobility, over-reaches transfer, forgot gait aids, observed behavioural agitation, disorientation had more medium-high fall risk... [to full text]

Introduction: This study aimed to work with older people attending a regional falls and syncope service, older people with the falls-associated chronic liver disease primary biliary cirrhosis, relatives and local physiotherapy practitioners to develop a framework for physiotherapy practice to promote self-management and adherence with an exercise based falls prevention programme for older people with a long-term condition. Methods: Focus groups were conducted with older people attending a regional falls and syncope service (3 groups, total 12 participants), relatives (1 group, total 4 participants) and local physiotherapists (4 groups, total 18 participants). Participants were asked to propose strategies to promote self-management and adherence with an exercise-based falls prevention programme. These strategies were tested and refined in an experimental case-series for 10 older people with primary biliary cirrhosis. Findings: The older people participating in the focus group research expressed a long-term commitment to exercise-based falls prevention programmes. They valued approaches that promoted self-efficacy and self-management. The physiotherapists indicated that the older people they came into contact with were poorly motivated to participate in an exercise-based falls prevention programme. They demonstrated a limited awareness of strategies to promote self-efficacy and self-management. Visual analysis of the experimental case-series data revealed unstable baselines and fluctuations throughout the treatment and follow up phases in keeping with variations in disease-specific quality of life measures, suggesting that long-term conditions interact with measures that predict and monitor falls-risk and self-efficacy. The exercise-based falls prevention programmes had perceived benefit for older people with primary biliary cirrhosis. However, this was not evident in the measures selected, many of which demonstrated a ceiling effect in the population group under investigation. The self-management strategies had low levels of perceived acceptability. Participants indicated that they lacked the necessary skills to monitor their progress with an exercise-based falls prevention programme on completion of the experimental case-series. Conclusion: This study demonstrated that self-management does not sit comfortably within the philosophy of routine clinical practice. The framework for physiotherapy practice developed during the course of the current study has the potential to empower physiotherapists and older people with long-term conditions identified as being at increased risk of falling to work in partnership to challenge existing approaches to clinical service delivery.

The overall aim of this study was to illustrate the organizations importance to female staff within education, health and social care on return to work after long term sick leave due to mental illness. The aim of this study was also to identify improvement opportunities. A qualitative study was made with seven interviewees that had return to work after long term sick leave for mental illness. The material was analyzed with an inducitve thematic method. The main themes that emerged was: Information and consulting, Social support from managers and colleagues, Changed attitude and participation in the rehabilitation process and Improvement opportunities. The main result showed that the social support from managers and colleagues and the changed attitude towards the illness mattered the most to the interviewees for a successful return to work. The result also showed that the interviewees had a great need of information about the sick leave process. According to the interviewees the understanding and knowledge about mental illness has to increase.

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The present aging scenario brings about the need to adapt society to meet particularities of the individuals involved in this stage of the vital cycle. In Brazil the aging population has been growing considerably and the alternatives of assistance and resources for such population are still deficient. Families are seldom prepared to face the aging process of their relatives and, especially because of difficulties related to finances and home care, they eventually choose institutions. Living at a long term care institution can be the very elder s choice seeking to preserve their selves and their belongings so as to keep their life history alive. The natural aging process brings along numerous changes, with the loss or slowering of body response. Pathology prevention and symptom minimization allow aging people to attain a better quality of life, and various segments are assigned this task geriatric and gerontologic multidisciplinary teams, among them. Among the problems aging people face, the falls are relevant and worrying because of their consequences. Because falls are frequent and can bring injuries to the elderly, the present study gathered institutional fall protocols from the residents of the Residencial Israelita Albert Einstein who were involved in falls during a pre-established period and analyzed the number of falls, the form of their occurrence and who were involved in this type of event with the purpose of preventing new episodes as well as providing post-fall assistance
O atual cenário do envelhecimento traz consigo a necessidade de adaptação da sociedade visando atender as particularidades dos indivíduos envolvidos nessa etapa do ciclo vital. No Brasil o número de idosos tem crescido consideravelmente e as opções de assistência e recursos que prestam atendimento a essa população ainda encontram-se deficientes. As famílias muitas vezes não estão preparadas para enfrentar o processo de envelhecimento de seus entes e diante das dificuldades que podem ser de vários motivos entre eles de natureza financeira ou deficiência para prestar assistência ao idoso em suas residências, acabam por buscar a institucionalização. A opção de morar em uma instituição de longa permanência pode partir do próprio idoso que busca nesta nova moradia poder preservar um pouco do seu eu e mediante a presença de alguns pertences pessoais manter viva a sua história de vida. O processo de envelhecimento natural é acompanhado de inúmeras alterações que levam a perda ou diminuição da capacidade de resposta do organismo. A prevenção para as patologias que possam vir a surgir e a minimização dos sintomas decorrentes desse processo possibilitam ao idoso uma melhor qualidade de vida, cabendo esse trabalho a vários seguimentos que atuam na velhice entre eles a equipe multidisciplinar geriátrica e gerontológica. Inúmeras são as complicações que podem acometer o idoso entre elas as quedas ocupam um papel importante e preocupante pelas conseqüências desastrosas que podem deixar. Por ser um evento não pouco freqüente e que pode trazer vários danos ao idoso o presente estudo reuniu protocolos de quedas institucionais dos moradores do Residencial Israelita Albert Einstein que estiveram envolvidos em queda em período pré-estabelecido, e procurou analisar o número de quedas, como ocorrem e quem são os idosos envolvidos nesse tipo de evento, buscando contribuir na prevenção de novos episódios assim como na assistência pós-queda

Le nombre d'adultes porteurs de cardiopathies congénitales, de plus en plus sévères est constante progression. A moyen voire long terme certain d’entre eux posent des problèmes d’insuffisance cardiaque et de troubles du rythme parfois létaux. La physiologie de ces complications est multi factorielle et s’écarte souvent des schémas habituels. L’asynchronisme ventriculaire présentent chez un nombre important d’entre eux est connu pour favoriser un remodelage ventriculaire conduisant à l’insuffisance cardiaque sur cœur sain.Dans ce travail en couplant données expérimentales animales et études cliniques, nous avons étudié : 1) l’impact aigu puis chronique de la resynchronisation biventriculaire sur un modèle animal d’insuffisance cardiaque droite mimant la tétralogie de Fallot et sur une population de patients ; 2) le rôle et la conséquence d’une stimulation conventionnelle sur une physiologie de ventricule droit systémique ; 3) l’effet délétère de la stimulation VD prolongée sur un modèle de cœur animal en cours de développement.Nous avons appris que 1) la resynchronisation biventriculaire permet un bénéfice hémodynamique significatif chez l’animal mais aussi sur une population de Fallot implantées ; 2) que l’asynchronisme généré par la stimulation conventionnelle est délétère pour la fonction du ventricule systémique mais aussi pour le cœur de l’enfant en cours développement. La resynchronisation est un traitement prometteur pour traiter l’insuffisance cardiaque mais pourrait aussi l’être pour en prévenir sa survenue. De nouvelles techniques d’implantation nous permettent aujourd’hui d’implanter des patients qui présentent beaucoup d’obstacles anatomiques et d’éviter nombre de complications grave de la stimulation
The number of adults with severe congenital heart disease is constantly growing. At medium to long-term follow up, these patients may present with heart failure or conduction disorders, which may lead to death. The pathophysiology and clinical course of these complications is multi-factorial and may be different from that in patients without congenital heart disease. In normal hearts, electromechanical dyssynchrony is known to induce ventricular remodeling and heart failure. Ventricular asynchrony is also present in a substantial number of adults with congenital heart disease. In this study, we combined animal experiments and clinical studies to investigate: 1) the acute and chronic effect of biventricular resynchronization therapy on cardiac function in an animal model mimicking right ventricular heart failure in Tetralogy of Fallot, as well as in patients with Tetralogy of Fallot; 2) the consequences of conventional ventricular pacing in patients with ‘systemic right ventricle physiology’; 3) the effects of chronic right ventricular pacing in an animal model of the developing heart.We found that: 1) biventricular resynchronization induces significant hemodynamic benefit in the animal model of Tetralogy of Fallot as well as in Fallot patients; 2) ventricular asynchrony induced by conventional ventricular pacing is deleterious to the function of the systemic right ventricle; 3) chronic right ventricular pacing is harmful to the developing (pediatric) heart with normal biventricular anatomy. Cardiac resynchronization therapy is promising as a treatment for heart failure, but may also prevent heart failure. Nowadays, new implantation techniques allow us to implant pacing devices in patients with limited anatomical access due to prior surgery and help to avoid numerous severe complications of conventional pacing therapy

博士
國立臺灣大學
臨床醫學研究所
101
Background Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. With the advances in surgical techniques and medical care, over 90% of the patients could survive to adulthood, resulting in progressive increase in the prevalence of TOF in adults. However, patients with repaired tetralogy of Fallot (rTOF) pose unique challenges for medical professionals since these patients are at increased risk for long-term functional deficits regarding to cardiac function, exercise function, and psychosocial function. Previous studies have demonstrated that right ventricular (RV) fibrosis is common in rTOF patients. Although accumulating evidence indicates the role of circulating biomarkers of collagen metabolism in left ventricular fibrosis, such data in rTOF are lacking. In the first part of this thesis, we examined the expression profile and clinical relevance of circulating biomarkers of collagen type I metabolism in rTOF patients. As to exercise function, we have little evidence regarding to the relationships between types of ventricular remodeling and exercise performance. In the second part of this thesis, we sought to use quantitative data from cardiac magnetic resonance (CMR) and cardiopulmonary exercise testing (CPX) to examine the relationship between types of ventricular remodeling and exercise performance. We also examined our longstanding observation: rTOF patients with mild RV outflow tract (RVOT) obstruction tend to have better cardiac function. Aside from medical problems related to cardiac dysfunction and exercise intolerance, these patients also faced a new set of psychosocial challenges, including issues pertaining to quality of life (QoL). Therefore, in the third part of this thesis, we assessed the QoL in adults with rTOF, as well as in a cohort of adults with congenital heart disease (ACHD), and to explore the relationships between objective measurements of cardiac function and QoL, as well as potential biopsychosocial determinants of QoL. Methods and Results Part I: Circulating biomarkers of collagen type I metabolism in adults with rTOF Serum biomarkers of collagen type I synthesis (carboxy-terminal propeptide of procollagen type I, PICP), degradation (carboxy-terminal telopeptide of collagen type I, CITP), and enzymes regulating collagen degradation (matrix metalloproteinases, MMP, and type I tissue inhibitor, TIMP-1) were measured in 70 rTOF patients (≥ 18 years) and 91 age- and sex-matched healthy adults. All patients had complete clinical data and received CMR with late gadolinium enhancement (LGE). Compared to the controls, rTOF patients had higher PICP levels (P < 0.001), PICP:CITP ratios (P < 0.001), and TIMP-1 concentrations (P < 0.001). MMP-9 level was lower in rTOF patients (P = 0.001). Increasing PICP levels correlated with higher RV LGE scores (r = 0.427, P < 0.001), lower peak oxygen consumption (the percentage of predicted peak VO2) (r = -0.428, P = 0.002), and significant RV dilatation. Furthermore, stepwise multivariate linear regression analysis identified RV end-diastolic volume index (RVEDVi) > 150 mL/m2 (β = 40.52, P = 0.016), RV LGE score (β = 3.94, P = 0.008), and age (β = -1.77, P = 0.011) as independent correlates of circulating PICP levels. Using multivariate logistic regression with fulfilling the indication for pulmonary valve replacement (PVR) as the outcome variable, higher serum PICP level significantly linked to the presence of PVR indication (odds ratio 1.80 per 10 ng/mL, P = 0.003) after B-type natriuretic peptide and right ventricular mass index were adjusted for. Furthermore, Kaplan-Meier survival analysis revealed that patients with high PICP level (higher than the 90th percentile value of the PICP concentrations in control subjects, 102.7 ng/mL) had significantly greater risk for receiving PVR (log-rank test P = 0.005) after a mean follow-up duration of 3.7 years. Part II: Effect of mild RVOT obstruction on ventricular remodeling and exercise function in rTOF patients with significant PR In our institutional database, 155 rTOF patients have ever received both CMR and CPX within 6 months. Patients with significant additional hemodynamic residuals other than pulmonary regurgitation/stenosis, having received cardiovascular intervention between total correction and study enrollment, and those with inadequate exercise effort were excluded. A total of 85 cases with a PR fraction ≥ 20% and a peak RVOT pressure gradient ≤ 50 mmHg (assessed by echocardiography) were enrolled in the following analysis. Although PR fraction was similar, patients with combined PR and mild RVOT obstruction (peak pressure gradient ≥ 20 mmHg but ≤ 50 mmHg, n = 29) had significantly better RV function than those with isolated PR (peak pressure gradient < 20 mmHg, n = 56): RVEDVi (median 115.5 vs 123.4 mL/m2, P = 0.029), RV end-systolic volume index (RVESVi) (median 66.7 vs 75.8 mL/m2, P = 0.011), and RV ejection fraction (42.3±6.7 vs 38.8±5.9%, P = 0.016). Patients with combined PR and RVOT obstruction also had smaller RVOT diameter Z score (−0.57±1.35 vs 0.46±1.10, P < 0.001) even though the prevalence of RVOT aneurysm was similar between these two patient groups. In multivariate analysis, the beneficial effect of RVOT obstruction on RV remodeling seemed to be mediated by smaller RVOT diameter rather than differences in RV hypertrophy or PR severity. Furthermore, patients with combined PR and mild RVOT obstruction exhibited better exercise performance as evaluated by the percentage of predicted peak VO2 (a maximal exercise parameter) (75.5±12.5 vs 66.7±12.7%, P = 0.003) and the percentage of predicted oxygen uptake efficiency slope (a submaximal exercise parameter) (90.9±27.1 vs 73.4±16.3%, P < 0.001). In multivariate analysis, we demonstrated positive and independent effect of mild RVOT obstruction on both the percentage of predicted peak VO2 (β = 7.29, P = 0.007) and the percentage of predicted oxygen uptake efficiency slope (β = 12.62, P = 0.003). Part III: Quality of life in adults with rTOF The QoL of 138 adults with rTOF (age: 31.4 ± 10.1 years; 46% men) was investigated using the Taiwanese version of the QoL questionnaire designed by the World Health Organization, which assesses 4 domains of QoL (physical, psychological, social, and environmental domains). Women with rTOF had significantly lower QoL scores in the physical and psychological domains compared to the age-matched general population, whereas such differences were not observed between rTOF men and the general population. A subset of patients (n = 92) received CPX immediately after the assessment of QoL and self-estimated exercise capacity. We found that self-estimated exercise capacity and QoL could hardly predict actual exercise capacity. Similarly, CMR-derived data of ventricular function (n = 78) and other disease-related variables had no relationships with QoL. We further evaluated 289 consecutive ACHD in our clinics. Personality, psychological distress, and family support were also assessed. We found that sex-related differences in QoL were also observed in this ACHD cohort, suggesting that sex discrepancy in QoL was not unique for rTOF. Multivariate analysis showed that female gender was associated with poorer physical QoL, and the sex difference in the psychological QoL was mediated by psychological distress. Interaction analysis revealed that the effect of family support on the psychological domain of QoL may be different by sex. The determinants of QoL varied between different domains. Extroversion personality trait, psychological distress, and family support were common determinants of most domains of QoL. Conclusions We demonstrated that patients with rTOF exhibited a profibrotic state with excessive collagen type I synthesis and dysregulated degradation. Elevated circulating PICP levels might reflect RV fibrosis, and link to adverse markers of clinical outcome. Utilizing quantitative data of CMR and CPX, our study results confirmed that mild RVOT obstruction was beneficial for RV function and exercise function in rTOF patients with significant PR. As to the psychosocial function, we found that female gender was associated with poor physical and psychological QoL, both in rTOF and overall ACHD population. Objective measurements of ventricular function and exercise function had little relationship with patients’ QoL and self-estimated exercise capacity. The common denominators for QoL were primarily personality trait, psychological distress, and family support but not disease-related factors. In summary, patients with rTOF exhibited a wide variety of functional outcomes. Multidisciplinary approaches using quantitative tools are mandatory to detect subtle changes in each functional aspect, and to stratify risks for unfavorable functional outcomes.

碩士
國立臺灣大學
臨床醫學研究所
102
Background Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease all over the world. There is still a debate about the optimal timing of total correction. Some experts recommend total repair before 3 months-old. Others suggest repair at the age between 6 months-old to 12 months-old. Before total repair of TOF, patients experience long term hypoxemia and PS related right ventricular (RV) pressure overload, so that myocardial function deteriorates gradually. At the time of surgical repair, cardiopulmonary bypass and intraoperative cardioplegia are another factors leading to possible myocardial injury. After total repair, patients usually have pulmonary valvular insufficiency, which will cause RV volume overload. Either before or after surgical repair, TOF patients always face the threat of RV dysfunction and ventricular arrhythmia. Even though patients receive total repair at older age, and have longer period of hypoxemia befor erpair, they experience shorter period of RV volume overload. That’s why we would like to know the association between surgical age and longterm cardiopulmonary function. TOF patients may have exercise restriction and subnormal cardiopulmonary function at long term follow-up because of post-op residual PS, pulmonary regurgitation (PR), VSD, myocardial dysfunction and ventricular arrhythmia. With the advances in surgical techniques and postoperative care, total correction is now mostly performed in infancy or early childhood. Based on our previous study and clinical experience, ventricular dysfunction also seems to be a threat for patients who had their cardiac defects repaired relatively late. However, there is no published data regarding cardiopulmonary function and clinical outcomes in those repaired in adolescence or adulthood. The purpose of this study is to investigate influence of surgical age on longterm outcome, such as high grade ventricular arrhythmia, ventricular function/size, and cardiopulmonary exercise capacity in TOF patients. We try to answer the question “ when is the optimal timing for total repar.” Methods Every patient receives 12-lead EKG to obtain QRS duration; 24-hour Holter monitor to evaluate severe ventricular arrhythmia at rest; echocardiography to assess pulmonary stenosis, pulmonary regurgitation (PR), residual ventricular septal defect and myocardial dysfunction; Cardiac magnetic resonance to quantify biventricular size and PR fraction; Cycle ergometer cardiopulmonary exercise test to obtain cardiopulmonary exercise capacity parameters, including peak oxygen consumption, ratio of minute ventilation and CO2 production (VE/VCO2), Oxygen Uptake Efficiency Plateau (OUEP). In this study, 158 TOF patients will be evaluated. Regression analysis was applied to analyze the association between repair age and exercise cardiopulmonary parameters. Regression analysis was also used to realize the association between resting myocardial function and exercise cardiopulmonary function. We also divided patients into 3 subgroups according to their surgical age (< 5 year-old, 5 to 10 year-old, > 10 year-old). ANOVA was applied to compare the differences in cardiopulmonary exercise parameters between these three subgroups. Results The mean age of surgery among the 158 TOF patients was 7.75 ± 9.05 (0.08 – 49.19) years old, and the mean age of follow-up was 29.48 ± 12.23 (6.97 – 56.99) years old. Nity-two patients underwent surgical correction before 5 years old, 31 patients between the age of 5 and 10, and 32 patients after 10 years old. Twenty-four (15.2%) patients developed Lown grade 3, 4, 5 ventricular arrhythmia on 24-hour Holter tracing. Fourteen (8.7%) experienced Lown grade 3, 4, 5 ventricular arrhythmia while doing cycle ergometer exercise test. By using logistic regression analysis, high grade ventricular arrhythmia was not related to surgical age. However, high grade ventricular arrhythmia was strongly related to age at follow-up (p=0.036), right ventricular outlet tract obstruction (p=0.005), PR fraction (p=0.033), right ventricle end-diastolic volume index (p<0.001), right ventricle end-systolic volume (p<0.001), right ventricle mass index (p=0.008). Inadequate acceleration of heart rate during exercise (chronotropic incompetence) occurred in 56% of patients. Chronotropic incompetence was related to age at follow-up (p=0.006), right ventricular end-diastolic volume index (p=0.005), right ventricular end-systolic volume index (p=0.016), right ventricle mass index (p=0.040). Surgical age was not a predictor of chronotropic incompetence. Cardiac magnetic resonance (CMR) was performed at resting state. All the parameters measured on resting CMR, including left ventricular volume, right ventricular volume, biventricular ejection raction and pulmonary regurgitation fraction, were not related to surgical age. However, we found exercise cardiopulmonary function was related to surgical age. Among the 158 TOF patients, mean peak oxygen consumption was 68% of predicted value. Mean OUEP was 90% of predicted value. Mean VE/VCO2 slope was 27. Surgical age (p=0.034) and PR fraction (p=0.036) were inversely related peak oxygen consumption with a linear relationship. Surgical age (p=0.002) and PR fraction (p=0.003) were also inversely related to OUEP. Conclusion Based on our study, cardiac rhythm disorder, including high grade ventricular arrhythmia and chronotropic incompetence, was not related to surgical age. Resting ventricular function, which was inspected with CMR and echocardiography, was not related to surgical age, either. However, peak oxygen consumption and Oxygen Uptake Efficiency Plateau were inversely related to surgical age. Severity of PR was also a significant parameter that inversely related to longterm exercise cardiopulmonary outcome. This study tried to find out when is the optimal timing for total correction. We found age at total repair was as important as PR severity. To answer the question “when will be the best timing of total correction”, we should take both PR and surgical age into consideration. 1.If significant post-op PR is not avoidable, we would rather postpone total repair to 6 to 12 months old. Although they have longer period of hypoxemia, the effects on longterm cardiopulmonary function are only mild. (Based on our study, postponing surgery for every 1 year leads to decrement of peak oxygen consumption 0.293%, and decrement of OUEP 0.377%.) 2.If significant PR can be avoid, early total correction is recommended in order to achieve better long-term exercise function.

碩士
亞洲大學
經營管理學系碩士在職專班
105
With population structure of senior of, fell hurt of occurred, has been to future is long-term care institutions in the often see of accident event, China currently 65 age above elderly accounted for population number of 10.76%, live Yu long-term care institutions of elderly accounted for old population proportion 1.65%, dang live people fell Hou on institutions care caused is big of human cost spending, and care Shang of complex degrees increased, and live people of health sequelae and the follow-up of prognosis problem, more indirect caused medical care resources large spending. This study was to explore the experience and risk factors of falls in long-term care institutions,to analyze factors related to the fall of residents, and to develop preventive measures to strengthen the caregiver's quality and management. This research object to past one years within had fell or almost fell of experience, and by assessment for future has fell tendencies who, and has vision fuzzy, and see not clear, effect daily function who, and taking four species above drug or anti-blue spirit class drug who and the 65 age and the above of live people, questionnaire asked residents, package for the Social Science analysis through the retrieved 50copies of questionnaire. Carries on the variation number using the SPSS statistics software to analyze and made the meanvalue analysis. The results of this study can be used as prevention of falls among the elderly in the implementation of institutional reference,to provide to the institution of the formulation for the residents fall of preventive measures,on institutional care and to reduce the human and the injury after a fall caused by medical expenses and costs of care.

碩士
國立陽明大學
臨床暨社區護理研究所
103
Abstract Background：Falls is a common and causes injury among elderly people in long-term care facilities. From past studies, activities of daily living (ADL) and depressive symptoms are two major risks for predicting falls among institutionalized edlers.. However, when investigating factors relating to falls, few studies are futher analyzed the direct effects of depressive symptoms on fall for institutionalized edlers after control for the effect of their physical function. Objective：The purpose of this study is to investigate the effects of ADL and depressive symptoms on falls among elderly people in long-term care facilities and to examine whether depressive symptoms are mediator between ADL and falls for elderly people in long-term care facilities. Methods：This study utilized a cross-sectional study design and purposely sampled 150 elderly people in long-term care facilities to collect their information of ADL, depressive symptoms, and falls by using a structured questionnaire. Independent t-test, chi-square test, and binary logistic regression were used to analyze the important predictors for falls. In addition, Sobel test was- utilized to analyze the mediation effects of depressive symptoms between ADL and falls. Results：From results of this study, age, the number of chronic diseases, ADL, and depressive symptoms were significant predictors of falls among subjects in this study. Among these significant factroes, depressive symptoms was a significant mediating factor (21.76%) between ADL and falls among subjects. However, the mediating effect was low with only 21.76%. Conclusion：According to results of this study, the priority strategy to prevent the fall among institutionalized elders is to decrease their depressive symptoms and to decrease their deterioration of ADL functions as the other important strategy. For the long-term care clinical practice, it should be the mandate regulation to assess regularly residents’ depressive symptoms and activities of daily living status in order to prevent their falls.

It is well established that there are many intrinsic and extrinsic risk factors associated with falls in older adults. Less well-known is what risk factors predict falls in more vulnerable populations, such as those with neurological conditions living in long-term care homes or receiving home care services. Furthermore, evidence comparing those with neurological conditions to those without is lacking in the literature. The primary purpose of this thesis was to determine risk factors for falls in long-term care residents and home care clients with no recent history of falls to determine if risk factors differed between individuals with dementia or Parkinson’s disease and those without any neurological conditions. Secondary data analysis was performed on a database of standardized health assessments completed for long-stay home care clients and long-term care residents in Ontario. Within each major diagnostic group, observations were stratified based on ambulatory status (ambulatory vs. non-ambulatory). Bivariate analyses followed by generalized estimating equations were used to determine statistically significant predictors of falls in each group within each care setting. The results of multivariable analyses showed that there is not a distinct set of risk factors associated with falls in home care clients and long-term care residents with dementia or Parkinson’s disease that is systematically different from risk factors associated with falls in clients and residents not diagnosed with any of the neurological conditions in this study. These results suggest that a common set of risk factors may effectively predict falls in all clients and residents with no recent falls history, regardless of certain neurological diagnoses.

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Background & Aims: Acute aortic dissection (AD) of the ascending aorta (type A) is a severe condition that generally prompts emergent surgical repair due to its associated life-threatening complications. Debate continues regarding the optimal approach to treating this condition. We sought to analyse the perioperative outcomes and long-term surgical results as well as to determine predictors of mortality.Patient population and methods: From January 1989 to October 2018, a total of 213 patients aged 20-85 years (mean 61.1±12.6 years), 70.4% (n=150) of which males, underwent surgery for acute Stanford type A AD. Of these, 87.3% (n=186) had DeBakey type I AD. Survival curves were plotted using Kaplan-Meier methods and early and late mortality predictors were determined by logistic regression or Cox regression models, respectively. Average follow-up time was 8.1±6.7 years (median 6.7 years, maximum 29.9 years). Results: Perioperative mortality was 8%, with the most frequent causes being acute myocardial infarction and abdominal ischemia. Haemorrhage was the most common postoperative complication. Chronic renal failure (HR, 26.90; 95% CI, 1.77-408.50; p=0.02) and extracorporeal (ECC) time (HR, 1.03; 95% CI, 1.01-1.04; p=0.001) were the two found predictors of early mortality. Death after hospital discharge occurred in 34.7% (n=68) of patients, mostly due to sudden death and cerebrovascular accident (CVA). Median survival time was 13.53±1.99 (95% CI, 9.63-17.43). At the completion of this study 60.1% (n=128) of patients were alive. Patients with AD showed a 2-fold decrease in life expectancy (Standard mortality rate: 2.11; 95% CI, 1.65-2.69; p<0.0001) relatively to the age- and gender-adjusted general population. Age (HR, 1.07; 95% CI, 1.05-1.10; p<0.001), chronic renal failure (HR, 11.62; 95% CI, 3.38-39.99; p<0.001), aortic valve homograft surgery (HR, 8.22; 95% CI, 2.29-29.51; p=0.001), ECC time (HR, 1.01; 95% CI, 1.01-1.02; p<0.001) and postoperative acute renal failure (HR, 5.22; 95% CI, 1.82-15.00; p=0.002) were the definitive independent predictors of overall mortality in our study population. Residual patent false lumen was present in 59.4% (n=82) of the 138 patients that had follow-up CT records. Conclusions: Surgery for acute type A AD is associated with an acceptable mortality. However, these patients have impaired late survival in comparison with the general population and an important percentage still carries residual disease over time. Regular postoperative follow-up is mandatory for early detection and treatment of late complications and alternative surgical procedures should be pursued to keep improving long-term outcomes.
Background & Aims: Acute aortic dissection (AD) of the ascending aorta (type A) is a severe condition that generally prompts emergent surgical repair due to its associated life-threatening complications. Debate continues regarding the optimal approach to treating this condition. We sought to analyse the perioperative outcomes and long-term surgical results as well as to determine predictors of mortality.Patient population and methods: From January 1989 to October 2018, a total of 213 patients aged 20-85 years (mean 61.1±12.6 years), 70.4% (n=150) of which males, underwent surgery for acute Stanford type A AD. Of these, 87.3% (n=186) had DeBakey type I AD. Survival curves were plotted using Kaplan-Meier methods and early and late mortality predictors were determined by logistic regression or Cox regression models, respectively. Average follow-up time was 8.1±6.7 years (median 6.7 years, maximum 29.9 years). Results: Perioperative mortality was 8%, with the most frequent causes being acute myocardial infarction and abdominal ischemia. Haemorrhage was the most common postoperative complication. Chronic renal failure (HR, 26.90; 95% CI, 1.77-408.50; p=0.02) and extracorporeal (ECC) time (HR, 1.03; 95% CI, 1.01-1.04; p=0.001) were the two found predictors of early mortality. Death after hospital discharge occurred in 34.7% (n=68) of patients, mostly due to sudden death and cerebrovascular accident (CVA). Median survival time was 13.53±1.99 (95% CI, 9.63-17.43). At the completion of this study 60.1% (n=128) of patients were alive. Patients with AD showed a 2-fold decrease in life expectancy (Standard mortality rate: 2.11; 95% CI, 1.65-2.69; p<0.0001) relatively to the age- and gender-adjusted general population. Age (HR, 1.07; 95% CI, 1.05-1.10; p<0.001), chronic renal failure (HR, 11.62; 95% CI, 3.38-39.99; p<0.001), aortic valve homograft surgery (HR, 8.22; 95% CI, 2.29-29.51; p=0.001), ECC time (HR, 1.01; 95% CI, 1.01-1.02; p<0.001) and postoperative acute renal failure (HR, 5.22; 95% CI, 1.82-15.00; p=0.002) were the definitive independent predictors of overall mortality in our study population. Residual patent false lumen was present in 59.4% (n=82) of the 138 patients that had follow-up CT records. Conclusions: Surgery for acute type A AD is associated with an acceptable mortality. However, these patients have impaired late survival in comparison with the general population and an important percentage still carries residual disease over time. Regular postoperative follow-up is mandatory for early detection and treatment of late complications and alternative surgical procedures should be pursued to keep improving long-term outcomes.

Objective: determine whether accreditation through Accreditation Canada is associated with more favorable resident safety in Ontario LTC homes and which facility characteristics are predictive of accreditation. Methods: logistic regression was used to determine predictors of accreditation. To examine the association between accreditation and safety, safety was operationalized as five MDS-RAI quality indicators: prevalence of falls, restraints, catheters, pressure ulcers, and infections. Separate multivariable models were developed for each indicator. Results: the odds of accreditation were approximately six times smaller for municipal (p < 0.001) and non-profit facilities (p < 0.001) relative to for-profits; three times greater for chains relative to non-chains (p < 0.001); and twice as large for urban relative to rural facilities (p = 0.04). Of the five quality indicators examined, only one (falls) was associated with accreditation. After adjusting for confounders, accredited homes were estimated to have 8% lower fall rates than non-accredited homes (p = 0.01).

Westmin's Myra Falls Operations has the one single largest environmental problem facing the mining industry today. The tailings and waste rock materials are acid generating. A review of existing literature indicates that there are a number of technologies that can be used and developed for the prevention and control of acid generation in sulphidic mine tailings and waste rock. The majority of the ARD control technologies are centered around the curtailment of oxygen and water to the waste material. The most promising technology for Westmin's Myra Falls Operations is engineered soil covers. An initial cover design evaluation using local till materials indicated that the materials were not suitable for the proposed application. However, the soils were modified with a selection of amendments and the laboratory results showed significant improvements. The results suggest that local till materials amended with either flyash or bentonite can be used in soil cover construction. Westmin intends to conduct field trials to evaluate the performance of a short list of soil cover variations to determine the final cover system design as a result of the encouraging laboratory and soil-atmosphere modelling results. This paper summarizes the results of the laboratory characterization of the potential cover and waste materials and presents the soil-atmosphere numerical modelling used to design the field test plots. Construction aspects, instrumentation, vegetation, two-dimensional flow and in general the scope of the project will be briefly discussed. The successful use of local till material ameliorated with a fine grained material will provide a positive impact to the mining industry. This application to the design of soil cover systems is a novel approach which offers an economic alternative for decommissioning smaller waste rock piles and tailings management facilities.