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From beneath a warm swaddling of blankets, Marisa Fine had no way of knowing that her newborn son had a foot deformity. But about 2 weeks after he was born, something looked odd during bath time.
When her son was 1 month old, Marisa and her husband decided to see a clinician to get answers as to why their son’s feet appeared deformed. At their local hospital in Israel, they received a diagnosis for their son: metatarsus adductus (MTA).
Treatment Options for MTA
MTA is a congenital condition that occurs in between 1 and 3 in 1000 births. In infants without MTA, a line that bisects the heel will also bisect the space between the second and third toe. In infants with mild MTA, the line will bisect the third toe; in moderate cases, the line will bisect the space between the third and fourth toe, and in severe cases, the line will bisect the space between the fourth and fifth toe.1
"
Dr Daizade is hopeful that patients around the world will benefit from access to orthotic devices to treat MTA.
Historically, parents have had 3 treatment options to correct their child’s MTA. Since the condition in many cases self-corrects, parents are often given the option to wait and see if treatment is necessary. If MTA does not self-correct or if parents elect to initiate treatment immediately, then the child can undergo a casting process to straighten their feet or opt for wearing modified shoes or braces.
“I didn’t want to take a gamble on my child's feet or legs,” she said. “If it doesn't correct itself, there could be a problem later on…I wanted to be able to do something. I didn't want to just wait and I didn't want to do casting. I looked into it and it's so painful for the child, it's uncomfortable, and it's not aesthetic… it's just very problematic.”
Marisa and her husband sought a second opinion and they learned there was a third option for their son: Universal Neonatal Foot Orthotics (UNFO) braces, a device similar to the Wheaton™ Brace and the Bebax™ Bootie.
Bracing Devices vs Casting for MTA
Not only are novel orthotic devices effective in treating MTA in children aged 10 months or younger,2 they are also more convenient for parents since they are easy to use and resemble an infant shoe, reducing social burden associated with MTA treatment.1
“The remarkable ease and simplicity in treating infants with UNFO orthotic splints introduces a new reality, allowing for the treatment of any type of MTA without age limitations and the risk of lifelong deformities,” said Izak Daizade, MD, a leading expert in orthopedic surgery with more than 30 years of experience dedicated to treating newborns, including Marisa’s son. “The considerable therapeutic success observed in extensive studies further validates this innovative approach. Comparatively, the method of treatment involving a series of casts pales in effectiveness when compared to the treatment with UNFO casts.”
Serial casting is typically completed over a 6 to 8-week span with casts changed every 2 weeks; Dr Daizade explained that this process is burdensome for infants with MTA and their parents.
“Muscles may temporarily weaken, and there may be joint stiffness after ankle and knee fixation,” Dr Daizade said. “Care must be taken to keep the cast dry during bathing, and pressure sores may develop beneath it. Swelling in the foot because of impaired blood flow and hygienic discomfort, especially with long leg casts, are common.”
Unlike casts, orthotic devices used to treat MTA operate below the ankle to allow the joint to move freely, preventing stiffness. Skin complications are less likely to occur in patients who use orthotics vs casts, as parents have the opportunity to monitor the infant’s skin daily during sock changes and bath time.
How to Use Novel Orthotic Devices for MTA
While protocol varies depending on the severity of the infant’s MTA, orthotic devices are meant to be used continuously for 6 to 8 weeks, followed by 6 to 8 weeks of nighttime use on average.3
On the first day of bracing, the device should be removed every 2 hours for 10 minutes; the brace should not be removed on the first night unless the brace causes irritation to the infant.3
The second day should follow the same pattern as the first with removal every 2 hours for 10 minutes; however, the brace can be removed after the infant’s evening bath on the second day. Over the next 12 days, the infant should wear the brace 24 hours a day except for 2 removals: once in the morning, during which the infant’s socks should be changed, and once in the evening for bath time.3
At 2 weeks, a clinician will determine optimal next steps. Typically, a second check-up occurs after 6 weeks of continuous use. At this point, the clinician will determine whether the infant still requires 24-hour therapy, or if the patient can switch to 15-hour overnight therapy. A third check-up should take place after 3 weeks of 15-hour overnight therapy; at this time, the clinician will determine if the patient can switch to 12-hour overnight therapy. After 3 weeks of 12-hour overnight therapy, a fourth check-up should take place to determine if the brace is no longer needed.3
If a parent or clinician observes regression at any point in the process, resumption of 24-hour therapy should be considered.3
Expanding Access to Novel Orthotic Devices
Dr Daizade is hopeful that patients around the world will benefit from access to orthotic devices to treat MTA. So far in the United States, patients in Miami and Baltimore have been successfully treated with the device.
With increased awareness of the condition and noninvasive treatment options available, Marisa hopes that more infants will have positive outcomes like her son.
“These children, they don't need to suffer,” Marisa said. “They don't need to have these uncomfortable casts that can be so traumatizing when they're little and there's a better option out there and it doesn't hurt. It's not invasive and it's easy to use. Why would you have your child go through that if they don't have to?”
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Kaiser Health News -- The Biden administration finalized nursing home staffing rules Monday that will require thousands of them to hire more nurses and aides — while giving them years to do so.
The new rules from the Centers for Medicare & Medicaid Services (CMS) are the most substantial changes to federal oversight of the nation’s roughly 15,000 nursing homes in more than 3 decades. But they are less stringent than what patient advocates said was needed to provide high-quality care.
Spurred by disproportionate deaths from COVID-19 in long-term care facilities, the rules aim to address perennially sparse staffing that can be a root cause of missed diagnoses, severe bedsores, and frequent falls.
“For residents, this will mean more staff, which means fewer ER visits potentially, more independence,” Vice President Kamala Harris said while meeting with nursing home workers in La Crosse, Wisconsin. “For families, it’s going to mean peace of mind in terms of your loved one being taken care of.”
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CMS estimated the rules will ultimately cost $6 billion annually, but the plan omits any more payments from Medicare or Medicaid.
When the regulations are fully enacted, 4 in 5 homes will need to augment their payrolls, CMS estimated. But the new standards are likely to require slight if any improvements for many of the 1.2 million residents in facilities that are already quite close to or meet the minimum levels.
“Historically, this is a big deal, and we’re glad we have now established a floor,” Blanca Castro, California’s long-term care ombudsman, said in an interview. “From here we can go upward, recognizing there will be a lot of complaints about where we are going to get more people to fill these positions.”
The rules primarily address staffing levels for 3 types of nursing home workers. Registered nurses, or RNs, are the most skilled and responsible for guiding overall care and setting treatment plans. Licensed practical nurses, sometimes called licensed vocational nurses, work under the direction of RNs and perform routine medical care such as taking vital signs. Certified nursing assistants are supposed to be the most plentiful and help residents with daily activities like going to the bathroom, getting dressed, and eating.
While the industry has increased wages by 27% since February 2020, homes say they are still struggling to compete against better-paying work for nurses at hospitals and at retail shops and restaurants for aides. On average, nursing home RNs earn $40 an hour, licensed practical nurses make $31 an hour, and nursing assistants are paid $19 an hour, according to the most recent data from the Bureau of Labor Statistics.
CMS estimated the rules will ultimately cost $6 billion annually, but the plan omits any more payments from Medicare or Medicaid, the public insurers that cover most residents’ stays — meaning additional wages would have to come out of owners’ pockets or existing facility budgets.
The American Health Care Association, which represents the nursing home industry, called the regulation “an unreasonable standard” that “creates an impossible task for providers” amid a persistent worker shortage nationwide.
“This unfunded mandate doesn’t magically solve the nursing crisis,” the association’s CEO, Mark Parkinson, said in a statement. Parkinson said the industry will keep pressing Congress to overturn the regulation.
Richard Mollot, executive director of the Long Term Care Community Coalition, a New York City-based advocacy nonprofit, said “it is hard to call this a win for nursing home residents and families” given that the minimum levels were below what studies have found to be ideal.
The plan was welcomed by labor unions that represent nurses — and whom President Joe Biden is counting on for support in his reelection campaign. Service Employees International Union President Mary Kay Henry called it a “long-overdue sea change.” This political bond was underscored by the administration’s decision to have Harris announce the rule with SEIU members in Wisconsin, a swing state.
The new rules supplant the vague federal mandate that has been in place since the 1980s requiring nursing homes to have “sufficient” staffing to meet residents’ needs. In practice, inspectors rarely categorized inadequate staffing as a serious infraction resulting in possible penalties, federal records show.
Starting in 2 years, most homes must provide an average of at least 3.48 hours of daily care per resident. About 6 in 10 nursing homes are already operating at that level, a KFF analysis found.
The rules give homes breathing room before they must comply with more specific requirements. Within 3 years, most nursing homes will need to provide daily RN care of at least 0.55 hours per resident and 2.45 hours from aides.
CMS also mandated that within 2 years an RN must be on duty at all times in case of a patient crisis on weekends or overnight. Currently, CMS requires at least 8 consecutive hours of RN presence each day and a licensed nurse of any level on duty around the clock. An inspector general report found that nearly a 1000 nursing homes didn’t meet those basic requirements.
Nursing homes in rural areas will have longer to staff up. Within 3 years, they must meet the overall staffing numbers and the round-the-clock RN requirement. CMS’ rule said rural homes have four years to achieve the RN and nurse aide thresholds, although there was some confusion within CMS, as its press materials said rural homes would have 5 years.
Under the new rules, the average nursing home, which has around 100 residents, would need to have at least 2 RNs working each day, and at least 10 or 11 nurse aides, the administration said. Homes could meet the overall requirements through 2 more workers, who could be RNs, vocational nurses, or aides.
Homes can get a hardship exemption from the minimums if they are in regions with low populations of nurses or aides and demonstrate good-faith efforts to recruit.
Democrats praised the rules, though some said the administration did not go nearly far enough. Rep. Lloyd Doggett (D-Texas), the ranking member of the House Ways and Means Health Subcommittee, said the changes were “modest improvements” but that “much more is needed to ensure sufficient care and resident safety.” A Republican senator from Nebraska, Deb Fischer, said the rule would “devastate nursing homes across the country and worsen the staffing shortages we are already facing.”
Advocates for nursing home residents have been pressing CMS for years to adopt a higher standard than what it ultimately settled on. A CMS-commissioned study in 2001 found that the quality of care improved with increases of staff up to a level of 4.1 hours per resident per day — nearly a fifth higher than what CMS will require. The consultants CMS hired in preparing its new rules did not incorporate the earlier findings in their evaluation of options.
CMS said the levels it endorsed were more financially feasible for homes, but that assertion didn’t quiet the ongoing battle about how many people are willing to work in homes at current wages and how financially strained homes owners actually are.
“If states do not increase Medicaid payments to nursing homes, facilities are going to close,” said John Bowblis, PhD, an economics professor and research fellow with the Scripps Gerontology Center at Miami University. “There aren’t enough workers and there are shortages everywhere. When you have a 3% to 4% unemployment rate, where are you going to get people to work in nursing homes?”
Researchers, however, have been skeptical that all nursing homes are as broke as the industry claims or as their books show. A study published in March by the National Bureau of Economic Research estimated that 63% of profits were secretly siphoned to owners through inflated rents and other fees paid to other companies owned by the nursing homes’ investors.
Charlene Harrington, a professor emeritus at the nursing school of the University of California-San Francisco, said: “In their unchecked quest for profits, the nursing home industry has created its own problems by not paying adequate wages and benefits and setting heavy nursing workloads that cause neglect and harm to residents and create an unsatisfactory and stressful work environment.”
This article is from a partnership that includes WBUR, NPR, and KFF Health News.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Read the original article.
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Consistent evidence supports a link between exposure to wildfire smoke and increased pulmonary morbidity, with multiple studies showing associations between levels of particulate matter 2.5 (PM2.5) from wildfires and rates of hospitalization and emergency department (ED) visits for respiratory illnesses such as acute bronchitis, asthma, and chronic obstructive pulmonary disease.1-3 Additionally, some studies have demonstrated associations between exposure to wildfire smoke and an increased risk for cardiovascular disease (CVD).
“Emerging data suggests that wildfire smoke exposure increases cardiovascular events such as heart attacks and cardiovascular hospitalizations, and elderly patients and patients with underlying comorbidities such as cardiovascular disease and respiratory conditions seem to be more susceptible,” explained American Heart Association (AHA) volunteer Sanjay Rajagopalan, MD, FACC, FAHA, chief of cardiovascular medicine and chief academic and scientific officer at University Hospitals Harrington Heart and Vascular Institute in Cleveland, Ohio. “The chemical composition of wildfire smoke suggests that it may be even more toxic than traditional fossil fuel-based emissions.”4
Findings on Wildfire Smoke and CVD Risk
In a study published in 2022 in Geohealth, stratified analyses showed an increase in unscheduled hospital visits in California for all CVDs, ischemic heart disease, and heart failure among non‐Hispanic White patients and patients older than 65 years on days with the highest concentrations of PM2.5 from wildfires. The study authors also reported that higher temperatures may interact with wildfire-derived PM2.5 and further increase hospital visits for CVD among individuals with pre-existing heart disease.1
Another California-based study observed higher rates of ED visits for various CV events, including myocardial infarction (RR, 1.42; 95% CI, 1.09-1.84), ischemic heart disease (RR, 1.22; 95% CI, 1.01-1.47), and heart failure (RR, 1.22; 95% CI, 1.10-1.35) on days with dense smoke, with the highest rates found among adults aged 65 years and older.5
In other studies, the risk for out‐of‐hospital cardiac arrest increased on days with heavy smoke due to California wildfires, and elevated levels of PM2.5 from Colorado wildfires were associated with increased rates of CVD hospitalization and CV mortality (OR, 1.478; 95% CI, 1.12–1.94).6,2
In a study published in 2022, post-wildfire physician visits among older adults increased by 11% (95% CI, 3%-21%) for congestive heart failure and 19% (95% CI, 7%-33%) for ischemic heart disease, and patients with diabetes demonstrated a higher risk for CV morbidity (relative risk [RR], 1.22; 95% CI, 1.01-1.46) and respiratory morbidity (RR , 1.35; 95% CI, 1.09-1.67) following wildfires in Calgary, Canada.7
Other recent research suggests a slight increase in the risk of CV mortality associated with wildfire smoke, with 2 studies showing that 0.55 and 0.56 of CV deaths were attributable to wildfire-related PM2.5 exposure during each study period.8,9
Overall, however, findings regarding the connection between wildfire smoke and CV outcomes are mixed.2 “While some studies have indicated an uptick in emergency room admissions for CVD post-wildfire, others have not,” noted Julio Lamprea Montealegre, MD, PhD, MPH, clinical instructor in the division of cardiology at the University of California San Francisco. “The specific types of cardiovascular events that are most likely affected by wildfire exposure also remain unclear.”
Clinical Implications and Next Steps
Although further research is needed to elucidate the relationship between CVD and wildfire smoke exposure, wildfire-related CV events may become more prevalent with the potential intensification of wildfires in the coming years, according to Dr Rajagopalan and Dr Montealegre. This possibility highlights the need for increased awareness and preparation among patients, providers, and health systems.
“Awareness is the first prerequisite for appropriate intervention, and the association between cardiovascular events and wildfire smoke needs to be widely promulgated amongst health care personnel,” Dr Rajagopalan said. Patient awareness of neighborhood air pollution levels during wildfire episodes is also important. Higher-risk patients, such as the elderly and those with prior CV or respiratory conditions, should be educated about protective measures, he advised.
“The US Environmental Protection Agency (EPA) has set forth recommendations to mitigate exposure to particle pollution, particularly for vulnerable groups including those with pre-existing cardiovascular diseases,” Dr Montealegre stated. “Recommendations encompass both indoor and outdoor measures, such as employing portable air cleaners and limiting outdoor activities during times when the Air Quality Index (AQI) indicates unhealthy levels.”10 Patients and providers can check AirNow.gov to monitor daily AQI forecasts.
As roughly 67% of exposure to PM2.5 from outdoor origins occurs inside the home due to infiltration of outdoor pollutants, efforts to improve indoor air quality are essential in reducing wildfire smoke exposure and related health risks.11
In a review published in 2022 in Circulation, Hadley et al recommended various measures to reduce wildfire smoke exposure and the associated CV impact in affected areas.12 On the individual level, for example, they recommend the use of particle respirators such as N95 masks among vulnerable patients.12
In the health care setting, they recommend that clinicians ensure the aggressive management of traditional CVD risk factors and optimization of medical therapy among at-risk patients prior to the start of each fire season.12
More broadly, they recommend that health care facilities strive for cleaner indoor air and that health systems “make preparations for wildfire season to protect their susceptible patients and avoid shortfalls in beds, supplies, human resources, and key partnerships,” as described in the paper.12
Dr Montealegre emphasized the crucial need for a deeper dive into research aimed at elucidating the CV consequences of wildfire smoke. “Priorities include enhanced exposure science that offers a precise evaluation of individual exposure levels, rigorous mechanistic studies elucidating the connection between pollutants from wildfire smoke and cardiovascular repercussions, and clinical trials assessing the efficacy of mitigation techniques such as air filters in curtailing cardiovascular events,” he said.
Beyond efforts to mitigate the adverse health effects of wildfire smoke in high-risk individuals, the most important broader measures needed in this area are “steps to prevent climate change, which include ongoing efforts at decarbonizing our economy and uncoupling CO2 emissions from economic activity,” Dr Rajagopalan stated. “In this regard, movement to a fossil fuel-free future is not only eminently possible, but may also be associated with better health, better economies, and hopefully better climate in the not-too-distant future.”
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A 43-year-old soldier presents with a 10-year history of neck pain. The patient believes that carrying heavy objects and wearing helmets for 20 years while in service may have played a role in his worsening neck pain. He describes intermittent headaches and neck pain over the center of his cervical spine that is made worse with range of motion and prolonged positioning such as when driving. He has no pain radiating down the arms or weakness in the upper extremities. To help with pain, the patient has tried massage therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxers for temporary relief. He rates his neck pain as 8 out of 10 on the numeric pain scale and notes that it affects his range of motion, which impacts activities of daily living. Imaging tests are performed (Figures 1-2) on the cervical spine that shows mild facet arthritis. Magnetic resonance imaging (Figure 3) of the neck shows mild facet inflammation but no evidence of nerve impingement.
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