bluuebunny/crossref_metadata_2025 huggingface dataset:
Incorporating Patient-Centeredness Into Case Management Practice
Authors: Garrett Michael B.
Published: November 2018

Purpose of Manuscript:

Patient-centeredness is a cornerstone of case management practice. Professional case managers must conduct a clinical assessment to develop a care plan that addresses the clinical issues as well as the patient's needs, preferences, values, and choices. To achieve patient-centeredness, the case manager must engage with the patient in order to build a relationship that supports the patient-identified goals and addresses gaps in care. This article provides information on key terms in patient-centeredness, such as patient satisfaction, patient experience, and patient empowerment. The article ends with two case examples to show how the interventions outlined can be applied in specific situations.

Primary Practice Setting:

Patient-centeredness applies to all settings and levels of care.

Implications for Case Management:

The case manager will learn about successful organizational strategies that can be deployed to support patient-centeredness. The article also identifies several key case-specific strategies that can be deployed when case managers work with patients. The metrics used in evaluating and improving patient-centeredness are also described.
Long-Term Services and Supports
Authors: Treiger Teresa M.
Published: November 2018

Purpose/Objectives:

The Centers for Medicare & Medicaid (CMS) announced that, beginning in 2019, Medicare Advantage health plans may begin offering additional benefits for nonmedical home services. In 2019, this change impacts the Long-Term Services and Supports (LTSS) landscape dramatically. This two-part article describes LTSS, its traditional demographic and health care footprint, the regulatory and accreditation landscape, quality measurement and outcomes, and the critical importance of maintaining care continuity for individuals receiving LTSS. The objectives are to:

define LTSS,

identify client demographics,

identify delivery models,

discuss regulation and accreditation environments,

discuss quality improvement and outcomes initiatives,

identify promising practices and best practices, and

identify useful resources.

Primary Practice Setting(s):

Applicable to all health care sectors where case management is practiced.

Findings/Conclusions:

Historically, once Medicare recognizes a product or service, managed health plans and commercial insurance carriers follow suit. Professional case managers must become fluent in the language of LTSS, the implications of these CMS changes, and the impact on case management practice across the care continuum.

Implications for Professional Case Management Practice:

Professional case managers should understand LTSS, especially as it pertains to care transitions and continuity of health care services to our most vulnerable clients.
A Novel Model Demonstrates Variation in Risk-Adjusted Mortality Across Pediatric Cardiac ICUs After Surgery*
Authors: Tabbutt Sarah , Schuette Jennifer , Zhang Wenying , Alten Jeffrey , Donohue Janet , Gaynor J. William , Ghanayem Nancy , Jacobs Jeffrey , Pasquali Sara K. , Thiagarajan Ravi , Dimick Justin B. , Banerjee Mousumi , Cooper David , Gaies Michael
Published: November 2018

Objective:

To develop a postoperative mortality case-mix adjustment model to facilitate assessment of cardiac ICU quality of care, and to describe variation in adjusted cardiac ICU mortality across hospitals within the Pediatric Cardiac Critical Care Consortium.

Design:

Observational analysis.

Setting:

Multicenter Pediatric Cardiac Critical Care Consortium clinical registry.

Participants:

All surgical cardiac ICU admissions between August 2014 and May 2016. The analysis included 8,543 admissions from 23 dedicated cardiac ICUs.

Interventions:

None.

Measurements and Main Results:

We developed a novel case-mix adjustment model to measure postoperative cardiac ICU mortality after congenital heart surgery. Multivariable logistic regression was performed to assess preoperative, intraoperative, and immediate postoperative severity of illness variables as candidate predictors. We used generalized estimating equations to account for clustering of patients within hospital and obtain robust ses. Bootstrap resampling (1,000 samples) was used to derive bias-corrected 95% CIs around each predictor and validate the model. The final model was used to calculate expected mortality at each hospital. We calculated a standardized mortality ratio (observed-to-expected mortality) for each hospital and derived 95% CIs around the standardized mortality ratio estimate. Hospital standardized mortality ratio was considered a statistically significant outlier if the 95% CI did not include 1. Significant preoperative predictors of mortality in the final model included age, chromosomal abnormality/syndrome, previous cardiac surgeries, preoperative mechanical ventilation, and surgical complexity. Significant early postoperative risk factors included open sternum, mechanical ventilation, maximum vasoactive inotropic score, and extracorporeal membrane oxygenation. The model demonstrated excellent discrimination (C statistic, 0.92) and adequate calibration. Comparison across Pediatric Cardiac Critical Care Consortium hospitals revealed five-fold difference in standardized mortality ratio (0.4–1.9). Two hospitals had significantly better-than-expected and two had significantly worse-than-expected mortality.

Conclusions:

For the first time, we have demonstrated that variation in mortality as a quality metric exists across dedicated cardiac ICUs. These findings can guide efforts to reduce mortality after cardiac surgery.
Local Boards of Health as Linkages Between Local Health Departments and Health Care and Other Community Organizations
Authors: Shah Gulzar H. , Leep Carolyn J.
Published: November 2018

Introduction:

Efficient provision of essential public health services may be influenced by collaborative capacity of local health departments (LHDs). Local boards of health (LBoHs) are well positioned to facilitate partnerships.

Objectives:

We examined the degree to which LBoHs serve as a linkage between LHDs and 2 types of community organizations, health care providers and local government agencies, and the LBoH characteristics associated with tendency of LBoHs to perform such linkage function.

Methods:

We analyzed data from a recent cross-sectional survey, the 2015 National Survey of Local Boards of Health. This survey used a probability sample of 685 LHDs stratified by the state of LHD location and the population size of LHD jurisdiction, resulting in 394 responses for a response rate of 58%. We used multivariate logistic regression to pursue the study objectives.

Results:

LHD respondents reported that LBoHs served as a linkage with hospitals or other health care providers for 20% of LHDs and with local government agencies for 19% of LHDs. Significant association of LBoHs' performance of governance functions existed with their chances of linking LHDs with hospitals or other health care providers (adjusted odds ratio [AOR] = 1.25; P < .001) and with local government agencies (AOR = 1.23; P < .001). Among the factors associated with LBoHs serving as the linkage, the governance function oversight was the strongest, followed by governance functions policy development, continuous improvement, and resource stewardship. Legal authority had weakest association with both types of linkages. A strong positive association existed between LBoHs seeking community input from elected officials and LBoHs' tendency of serving as the linkage with both health care providers and local government agencies.

Conclusions:

The role of LBoHs in linking with hospitals, other health care providers, and government agencies could be further maximized, particularly given the high proportion of LBoHs that include members who are health care professionals.
State Tobacco Excise Taxation, Comprehensive Smoke-free Air Laws, and Tobacco Control Appropriations as Predictors of Smoking Cessation Success in the United States
Authors: Dahne Jennifer , Nahhas Georges J. , Wahlquist Amy E. , Cummings K. Michael , Carpenter Matthew J.
Published: November 2018

The purpose of the present study was (1) to examine demographic differences between smokers who successfully quit (n = 1809), who relapsed (n = 6548), and who did not attempt to quit (n = 11 102) within the last year, and (2) to examine state-level tobacco policies/programs as predictors of quit success. Data were utilized from the 2014-2015 Tobacco Use Supplement to the Current Population Survey, which were paired with 2014 data on taxation, appropriations, and smoke-free air laws. As compared with smokers who relapsed, those who successfully quit were more likely to be white, married, more highly educated, of higher income, and heavier smokers. Compared with those who did not attempt to quit, those who attempted to quit, regardless of success, were younger and more likely to be Hispanic. State comprehensive smoke-free air laws and tobacco excise taxation significantly predicted quit success. Thus, expansions of these policies should be considered to promote successful quitting.
Opioid Abuse Prevention and Treatment: Lessons From South Carolina
Authors: Arnold Jason F. , Arshonsky Joshua H. , Bloch Kiera A. , Holzman Emily , Sade Robert M.
Published: November 2018

Context:

Opioid-related overdoses in the United States have increased by 33% over the past 5 years. America's opioid crisis is increasing across demographic groups and spreading geographically. South Carolina is one of the states in the southern region of the United States that experiences an unusually high rate of opioid-related deaths. In 2016, 616 deaths occurred in South Carolina from drug overdoses from prescription opioid drugs, up 9% from 2015. South Carolina residents filled nearly 4.5 million opioid prescriptions in 2015, which is greater than 1.5 times the national average.

Implementation:

In 2017, the governor of South Carolina declared a statewide public health emergency in response to the growing opioid crisis. In response, a committee of the South Carolina House of Representatives released a report in January 2018 on its opioid abuse prevention study and made recommendations on ways to reduce the number of opioid-related deaths.

Evaluation:

This article examines the strengths and weaknesses of South Carolina's state action plan to combat opioid-related deaths in the context of what other states have done to address opioid abuse, as well as the scientific literature on pain management. Several state opioid action plans, including South Carolina's and West Virginia's, were identified and evaluated.

Discussion:

This article describes (1) several legislative and nonlegislative strategies being considered in South Carolina for addressing the crisis, (2) an assessment of the strengths and weaknesses of these proposals and how they compare with other states that have also implemented response plans, and (3) an examination of the scientific literature to determine best practices for treating patients who are currently taking opioids, as well as discussing alternative approaches to pain management. The authors make several recommendations to improve upon South Carolina's opioid abuse prevention plan, such as engaging communities and encouraging multistakeholder collaboration to expand access to treatment, particularly among the most vulnerable populations.
Cost Comparison Between 2 Responses to Hepatitis A Virus Incidents in Restaurant Food Handlers—New York City, 2015 and 2017
Authors: Baum Sarah E. , Reddy Vasudha , Vora Neil M. , Balter Sharon , Daskalakis Demetre , Barbot Oxiris , Misener Mark , Rakeman Jennifer , Rojas John , Starr David , Waechter HaeNa , Zucker Jane , Lee David
Published: November 2018

Context:

While the New York City Department of Health and Mental Hygiene (DOHMH) can use agency-wide emergency activation to respond to a hepatitis A virus–infected food handler, there is a need to identify alternative responses that conserve scarce resources.

Objective:

To compare the costs incurred by DOHMH of responding to a hepatitis A case in restaurant food handlers using an agency-wide emergency activation (2015) versus the cost of collaborating with a private network of urgent care clinics (2017).

Design:

We partially evaluate the costs incurred by DOHMH of responding to a hepatitis A case in a restaurant food handler using agency-wide emergency activation (2015) with the cost of collaborating with a private network of urgent care clinics (2017) estimated for a scenario in which DOHMH incurred the retail cost of services rendered.

Results:

Costs incurred by DOHMH for emergency activation were $65 831 ($238 per restaurant employee evaluated) of which DOHMH personnel services accounted for 85% ($55 854). Costs of collaboration would have totaled $50 914 ($253 per restaurant employee evaluated) of which personnel services accounted for 6% ($3146).

Conclusions:

Accounting for incident size, collaborating with the clinic network was more expensive than agency-wide emergency activation, though required fewer DOHMH personnel services.
The Role of State Context in Promoting Service Coordination in Maternal, Infant, and Early Childhood Home Visiting Programs
Authors: West Allison , Duggan Anne K. , Gruss Kelsey , Minkovitz Cynthia S.
Published: November 2018

Context:

The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program provides funding to states to promote health and development of at-risk expectant families and families with young children. MIECHV programs are required to coordinate services within a larger system of care; yet, little is known about state-level factors that support coordination.

Objective:

This study examined state-level supports and barriers for coordination of home visiting with other entities within the early childhood system of care.

Methods:

A Web-based survey was distributed in 2016 via e-mail to MIECHV administrators in all 50 states, 5 US territories, and the District of Columbia. The survey elicited information on 5 domains shown by theory and prior research to support coordination: MIECHV leadership, state leadership, shared goals across sectors, data systems, and finance. Respondents also rated their perceptions of state-level coordination.

Results:

Forty-two (75%) of the MIECHV administrators participated in the survey. States and territories varied widely within and across the 5 domains of support for coordination. MIECHV leadership was an area of relative strength, whereas data systems and finance showed the most room for improvement. State leadership and shared goals were associated with stronger perceptions of state-level coordination.

Conclusions:

The findings indicate opportunities for shared learning among states to enhance coordination infrastructure. Such efforts should include multiple stakeholder perspectives and consideration of local and organizational contexts. This work could be facilitated using the service coordination toolkit developed as part of this project.
A Public Health Performance Excellence Improvement Strategy: Diffusion and Adoption of the Baldrige Framework Within Tennessee Department of Health
Authors: Roberts Micky , Reagan David R. , Behringer Bruce
Published: November 2018

In 2011, Tennessee was faced with poor state health rankings with newly elected officials promoting customer-focused government. To refocus, the Tennessee Department of Health chose a multiyear plan to adopt, diffuse, and integrate the Malcolm Baldrige Performance Excellence framework. Senior leaders changed the organizational culture using participatory strategic planning coupled with introduction of performance improvement initially led by departmental staff who volunteered for training by the state Baldrige affiliate. New tools and processes were diffused across the department's central and regional offices and county health departments. Departmental units documented performance improvement through hundreds of internal projects and more than 100 innovation-driven Baldrige achievement awards. Over time, performance improvement approaches were integrated into existing departmental programs and new initiatives, leading to additional successful process changes and population health improvements. The department's approach included multiple steps: adopt Baldrige Performance Excellence as means to promote culture change with a goal of improved organizational and population health performance; use the visual Baldrige framework and its categories to underscore inclusiveness, comprehensiveness, and synergies of desired change; choose, invest in, and implement multiple evidence-based management strategies to support culture change toward improvement; and continuously evaluate outcomes, linked to required reports to suppliers (governor and legislators) and customers (public, patients, and partners). The Baldrige Performance Excellence framework was found to be an effective approach to promote culture change through emphasizing improvement in a public health organization.
Effect of Regional Hospital Market Competition on Use Patterns of Free Flap Breast Reconstruction
Authors: Cerullo Marcelo , Lee Clara , Offodile Anaeze C.
Published: November 2018

Background:

Market competition is believed to promote patient access and health care delivery. The authors examined the relationship between market competition and use of surgical services for cancer, using free flap immediate breast reconstruction as a model scenario.

Methods:

This retrospective cross-sectional analysis of the 2008 to 2011 Nationwide Inpatient Sample identified female patients undergoing immediate breast reconstruction. The Herfindahl-Hirschman Index was used to describe hospital markets as competitive or consolidated. The relationship between market competition and free flap immediate breast reconstruction use was explored using a hierarchical model before and after race stratification.

Results:

Seven thousand three hundred seventy-two (10.7 percent) of 68,966 patients underwent free flap immediate breast reconstruction. A consolidated market was associated with 35 percent lower odds of free flap immediate breast reconstruction (95 percent CI, 0.43 to 0.97). Undergoing an operation in a later year [OR, 1.40; 95 percent CI (per year), 1.21 to 1.63], nonwhite race (OR, 1.33; 95 percent CI, 1.10 to 1.60), private insurance (OR, 2.09; 95 percent CI, 1.59 to 2.76), and teaching hospital status (OR, 2.67; 95 percent CI, 1.73 to 4.13) were associated with higher rates of free flap reconstruction. Market consolidation was associated with 48 percent lower odds of undergoing free flap immediate breast reconstruction in nonwhite patients only (95 percent CI, 0.29 to 0.92).

Conclusions:

A hospital’s willingness to provide surgical services may be subject to market pressures. Market competition is associated with increased odds of free flap immediate breast reconstruction and higher use by racial minorities.
Fat Graft Safety after Oncologic Surgery: Addressing the Contradiction between In Vitro and Clinical Studies
Authors: Orbay Hakan , Hinchcliff Katharine M. , Charvet Heath J. , Sahar David E.
Published: November 2018

Background:

The authors investigate the in vitro and in vivo interaction of human breast cancer cells and human adipose-derived stem cells to address the controversy on the safety of postmastectomy fat grafting.

Methods:

The authors co-cultured human adipose-derived stem cells and MDA-MB-231 breast cancer cells in an in vitro cell migration assay to examine the migration of breast cancer cells. In the in vivo arm, the authors injected breast cancer cells (group I), human breast cancer cells plus human adipose-derived stem cells (group II), human breast cancer cells plus human fat graft (group III), and human breast cancer cells plus human fat graft plus human adipose-derived stem cells (group IV) to the mammary fat pads of female nude mice (n = 20). The authors examined the tumors, livers, and lungs histologically after 2 weeks.

Results:

Migration of breast cancer cells increased significantly when co-cultured with adipose-derived stem cells (p < 0.05). The tumor growth rate in group IV was significantly higher than in groups I and II (p < 0.05). The tumor growth rate in group III was also higher than in groups I and II, but this difference was not statistically significant (p > 0.05). Histologically, there was no liver/lung metastasis at the end of 2 weeks. The vascular density in the tumors from group IV was significantly higher than in other groups (p < 0.01).

Conclusion:

The injection of breast cancer cells, fat graft, and adipose-derived stem cells together increases breast cancer xenograft growth rates significantly.
“Brazilian Butt Lift” under Local Anesthesia: A Novel Technique Addressing Safety Concerns
Authors: Chia Christopher T. , Theodorou Spero J. , Dayan Erez , Tabbal Georges , Del Vecchio Daniel
Published: November 2018

Background:

The gluteal lift (“Brazilian butt lift”) has improved significantly in technique and in outcomes. Some postulate that fat embolism occurs because of damage to veins superficial to the gluteus muscles and that fat must be injected intramuscularly to achieve satisfactory aesthetic results. The purpose of this article is to present data where gluteal lift is performed under local anesthesia, address safety concerns, and clarify these speculations.

Methods:

All patients underwent gluteal lift under local anesthesia using oral medications and tumescent infiltration. Fat was harvested by closed-system liposuction, separated by gravity, injected using a peristaltic pump and reticulating basket cannulas.

Results:

Thirty-two female patients with an average age of 38.6 years and a body mass index of 24.8 kg/m2 underwent 47 gluteal lift operations under local anesthesia over 52 months. The average volume of injected fat was 359 ml per buttock. There were no deaths or complications.

Conclusions:

Recent concerns regarding buttock injections have been raised due to death from fat embolism. Despite numerous theories on the mechanism of entry, the fact that venous injury occurs with the introduction of boluses of fat in enough quantities to cause mechanical disruption of the cardiopulmonary circuit is not in dispute. The authors believe this cannot occur in the awake patient without the surgeon being acutely aware of a misguided cannula. These data suggest that buttock fat grafting under local anesthesia is a safe and effective procedure with an excellent safety profile and durable results.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis
Authors: Offodile Anaeze C. , Boukovalas Stefanos , Muldoon Lawrence , Lee Clara N.
Published: November 2018

Background:

Safety-net hospitals serve vulnerable populations; however, care delivery may be of lower quality. Microvascular immediate breast reconstruction, relative to other breast reconstruction subtypes, is sensitive to the performance of safety-net hospitals and an important quality marker. The authors’ aim was to assess the quality of care associated with safety-net hospital setting.

Methods:

The 2012 to 2014 National Inpatient Sample was used to identify patients who underwent microvascular immediate breast reconstruction after mastectomy. Primary outcomes of interest were rates of medical complications, surgical inpatient complications, and prolonged length of stay. A doubly-robust approach (i.e., propensity score and multivariate regression) was used to analyze the impact of patient and hospital-level characteristics on outcomes.

Results:

A total of 858 patients constituted our analytic cohort following propensity matching. There were no significant differences in the odds of surgical and medical inpatient complications among safety-net hospital patients relative to their matched counterparts. Black (OR, 2.95; p < 0.001) and uninsured patients (OR, 2.623; p = 0.032) had higher odds of surgical inpatient complications. Safety-net hospitals (OR, 1.745; p = 0.005), large bedsize hospitals (OR, 2.170; p = 0.023), and Medicaid patients (OR, 1.973; p = 0.008) had higher odds of prolonged length of stay.

Conclusions:

Safety-net hospitals had comparable odds of adverse clinical outcomes but higher odds of prolonged length of stay, relative to non–safety-net hospitals. Institution-level deficiencies in staffing and clinical processes of care might underpin the latter. Ongoing financial support of these institutions will ensure delivery of needed breast cancer care to economically disadvantaged patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Uptake and Tracer Kinetic of O-(2-(18)F-fluoroethyl)-L-Tyrosine in Meningioma
Authors: Basse Victor , Dissaux Gurvan , Seizeur Romuald , Bourhis David , Querellou Solène
Published: November 2018

18F-fluoroethyltyrosine (FET) is a well-established PET tracer for the imaging of cerebral gliomas. Recent studies reported interest in meningiomas. A study published by Cornelius et al concludes that FET PET may provide additional information for noninvasive grading of meningiomas. Indeed, the combination of tumor background ratio with a cutoff value of 2.3 associated with time activity curve pattern slightly improved the differentiation of high-grade from low-grade meningiomas (accuracy, 92%; P = 0.001). We present the case of a 75-year-old man that underlined the need to confirm the performance of these tools (curve pattern, tumor background ratios) to characterize meningiomas.
Gastric Ulcer Mimicking Malignancy on FDG PET/CT
Authors: Zhang Shumao , Shao Fuqiang , Chen Yue
Published: November 2018

A 52-year-old woman with newly diagnosed cervical carcinoma was referred an 18F-FDG PET/CT for staging. The PET/CT images demonstrated the known carcinoma and multiple enlarged lymph nodes with increased FDG activity. In addition, there was a focus of intense FDG activity characteristic of hypermetabolic malignancy in the region of gastric antrum. Finally, this lesion was confirmed as gastric ulcer by biopsy. This patient responded well to antiulcer treatment.
Implementing Colon Cancer Screening Guidelines Into the Primary Care Setting
Authors: Kaiser Vivian
Published: November 2018

Colon cancer is the second leading cause of all cancers deaths. Despite public awareness, many healthcare providers and patients remain uninformed about colon cancer screening options alternative to colonoscopy. Research supports the lack of providers' education and patient knowledge. At a clinic for veterans in Central Florida, 2 educational presentations were delivered to primary care providers (N = 46) on the clinical pathway for colon cancer screening options. A pilot study with a quantitative pretest–post-test design was used to evaluate differences between screening orders 3 months before and after the presentations. A 10-item survey on the usefulness of the educational information was also administered to providers. Results of a 1-way analysis of variance indicated no significant differences between the two 3-month periods. However, with exclusion of the lowest month, a significance level resulted of .087, 91.3% confidence level. Survey responses indicated a positive impact, with most answers ranging from agree to strongly agree. The study revealed that the educational clinical pathway contributed to providers' increased recommendations of screening options and the educational information was useful. Additional research is recommended on the effectiveness of education and providers' use of screening options for colon cancer for average-risk veterans in healthcare institutions.
Women's Experiences of Intimate Relationships While Living With Irritable Bowel Syndrome
Authors: Nguyen Megan , Malone Margaret M. , Bailey Annette , Lapum Jennifer
Published: November 2018

Irritable bowel syndrome is a chronic digestive disorder that commonly affects women. Research has shown that the illness experience of irritable bowel syndrome can disrupt social relationships. However, the area of intimate relationships has yet to be explored despite the deep involvement that intimate partners often have in the experience of living with chronic illness. Using a critical feminist lens, a narrative methodology was employed to explore women's experiences of intimate relationships while living with irritable bowel syndrome. Data collection methods included semistructured interviews and an arts-informed activity. The women's narrative accounts and artistic pieces reflected the emotional, physical, and interpersonal aspects of intimacy while living with irritable bowel syndrome. The findings indicated that women's experiences were deeply emotional and involved laborious and gendered emotion work. Their body concept complicated their relationship experiences. Women's emotional and social well-being was fostered by their partners' provision of acceptance, understanding, and support. The findings highlighted the need to implement and further explore the inclusion of emotional support and counselling as well as dyadic and gendered approaches to irritable bowel syndrome management.
Nursing Interventions on Medication Adherence During Hepatitis C Treatment
Authors: Williams Sheila A.
Published: November 2018

Hepatitis C virus is a common cause of liver disease nationally and globally. Medication adherence to hepatitis C treatment is important for viral eradication and the prevention of chronic disease. The purpose of this article is to identify a nursing middle-range theory to guide research on the impact of nursing interventions on medication adherence during hepatitis C treatment and to apply the theory to practice by providing examples of the theory application. A gap in the literature is identified as the lack of research using theories or models as a guide to investigate nursing interventions and hepatitis C treatment. The lack of theory-based research may contribute to medication nonadherence. The self-regulation model provides the most complete guide for nursing interventions during hepatitis C treatment. Nursing interventions and hepatitis C research, guided by theory, generate knowledge specific for nursing.
Textbook Outcomes Among Medicare Patients Undergoing Hepatopancreatic Surgery
Authors: Merath Katiuscha , Chen Qinyu , Bagante Fabio , Beal Eliza , Akgul Ozgur , Dillhoff Mary , Cloyd Jordan M. , Pawlik Timothy M.
Published: November 2018

Objective:

To define and test “Textbook Outcome” (TO)—a composite measure for healthcare quality—among Medicare patients undergoing hepatopancreatic resections. Hospital variation in TO and Medicare payments were analyzed.

Background:

Composite measures of quality may be superior to individual measures for the analysis of hospital performance.

Methods:

The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. TO was defined as: no postoperative surgical complications, no prolonged length of hospital stay, no readmission ≤ 90 days after discharge, and no postoperative mortality ≤ 90 days after surgery. Medicare payments were compared among patients who achieved TO versus patients who did not. Multivariable logistic regression was used to investigate patient factors associated with TO. A nomogram to predict probability of TO was developed and validated.

Results:

TO was achieved in 44% (n = 5919) of 13,467 patients undergoing hepatopancreatic surgery. Adjusted TO rates at the hospital level varied from 11.1% to 69.6% for pancreatic procedures and from 16.6% to 78.7% for liver procedures. Prolonged length of hospital stay represented the major obstacle to achieve TO. Average Medicare payments were substantially higher among patients who did not have a TO. Factors associated with TO on multivariable analysis were age, sex, Charlson comorbidity score, previous hospital admissions, procedure type, and surgical approach (all P > 0.05).

Conclusions:

Less than one-half of Medicare patients achieved a TO following hepatopancreatic procedures with a wide variation in the rates of TO among hospitals. There was a discrepancy in Medicare payments for patients who achieved a TO versus patients who did not. TO could be useful for the public reporting of patient level hospital performance and hospital variation.
Clinical Factors Associated With Practice Variation in Discharge Opioid Prescriptions After Pancreatectomy
Authors: Newhook Timothy E. , Vreeland Timothy J. , Dewhurst Whitney L. , Wang Xuemei , Prakash Laura , Feng Chun , Bruno Morgan L. , Kim Michael P. , Aloia Thomas A. , Vauthey Jean-Nicolas , Lee Jeffrey E. , Katz Matthew H. G. , Tzeng Ching-Wei D.
Published: November 2018

Objective:

To characterize opioid discharge prescriptions for pancreatectomy patients.

Background:

Wide variation in and over-prescription of opioids after surgery contribute to the United States opioid epidemic through persistent use past the postoperative period. Objective strategies guiding discharge opioid prescriptions for oncologic surgery are lacking, and factors driving prescription amount are not fully delineated.

Methods:

Characteristics of pancreatectomy patients (March 2016–August 2017) were retrospectively abstracted from a prospective database. Discharge opioids prescriptions were converted to oral morphine equivalents (OME). Regression models identified variables associated with discharge OME.

Results:

In 158 consecutive patients, median discharge OME was 250 mg (range 0–3950). Discharge OME was labeled “low” (<200 mg) for 33 patients (21%) and “high” (>400 mg) for 38 (24%). Only shorter operative time (odds ratio [OR]—0.14, P = 0.004) and inpatient team (OR—15.39, P < 0.001) were independently associated with low discharge OME. Older age was the only variable associated with high discharge OME. Fifty-seven patients (36%) used zero opioids in the last 24-hours predischarge, yet 52 of 57 (91%) still received discharge opioids. Older age (OR—1.07), grade B/C pancreatic fistula (OR—3.84), and epidural use (OR—3.12) were independently associated with zero last-24-hours OME (all P ≤ 0.040).

Conclusions:

The wide variation in discharge opioid prescriptions is heavily influenced by provider routine/bias and not by objective criteria such as last-24-hours OME. Quality improvement strategies could include aggressive weaning protocols to increase the proportion of patients with zero/near-zero last-24-hour OME and limiting prescriptions to a conservative multiplier of the last-24-hour OME.
Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma
Authors: Yeung Lawrence L. , McDonald Amy A. , Como John J. , Robinson Bryce , Knight Jennifer , Person Michael A. , Lee Jane K. , Dahm Philipp
Published: November 2018

BACKGROUND

The diagnostic evaluation and clinical management of bladder injuries caused by blunt force trauma are variable. We aim to formulate a practice management guideline using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

METHODS

The working group, patient, intervention, comparator, outcome (PICO), formulated four questions regarding the following topics: (1) diagnostic evaluation based on patient baseline risk of bladder injury (computed tomography cystography vs. no imaging); (2) management of intraperitoneal bladder injuries (operative versus nonoperative); (3) management of extraperitoneal bladder injuries based on complexity of injury (operative vs. nonoperative); and (4) diagnostic follow-up of bladder injuries based on complexity of repair (cystography vs. no cystography). A systematic review of the MEDLINE database for English language articles with adult patients was undertaken. RevMan 5 (Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) and GRADEpro (GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University, 2015) software were used. Recommendations were voted on by working group members. Consensus was obtained for each recommendation.

RESULTS

Three hundred ninety-three articles were screened, resulting in a full-text review of 64 articles. Seventeen articles were used to formulate the recommendations of this guideline. Several recommendations are made. The need for initial computed tomography cystography after trauma depends on characteristics of the trauma itself, but it is not recommended in patients without gross hematuria. In general, patients with intraperitoneal bladder ruptures should undergo operative repair. This is not routinely necessary in those with extraperitoneal ruptures unless the injury is complex. The need for follow-up cystography after bladder repair depends on the risk of urine leak. Those with low risk of urine leak do not require a follow-up study.

CONCLUSION

Using the GRADE process, the panel made nine recommendations based on four PICO questions concerning the evaluation and management of blunt force bladder injuries.
Outcome of Liver Transplant Patients With High Urgent Priority: Are We Doing the Right Thing?
Authors: de Boer Jacob D. , Braat Andries E. , Putter Hein , de Vries Erwin , Strassburg Christian H. , Máthé Zoltán , van Hoek Bart , Braun Felix , van den Berg Aad P. , Mikulic Danko , Michielsen Peter , Trotovsek Blaz , Zoller Heinz , de Boer Jan , van Rosmalen Marieke D. , Samuel Undine , Berlakovich Gabriela , Guba Markus
Published: November 2018

Background.

About 15% of liver transplantations (LTs) in Eurotransplant are currently performed in patients with a high-urgency (HU) status. Patients who have acute liver failure (ALF) or require an acute retransplantation can apply for this status. This study aims to evaluate the efficacy of this prioritization.

Methods.

Patients who were listed for LT with HU status from January 1, 2007, up to December 31, 2015, were included. Waiting list and posttransplantation outcomes were evaluated and compared with a reference group of patients with laboratory Model for End-Stage Liver Disease (MELD) score (labMELD) scores ≥40 (MELD 40+).

Results.

In the study period, 2299 HU patients were listed for LT. Ten days after listing, 72% of all HU patients were transplanted and 14% of patients deceased. Patients with HU status for primary ALF showed better patient survival at 3 years (69%) when compared with patients in the MELD 40+ group (57%). HU patients with labMELD ≥45 and patients with HU status for acute retransplantation and labMELD ≥35 have significantly inferior survival at 3-year follow-up of 46% and 42%, respectively.

Conclusions.

Current prioritization for patients with ALF is highly effective in preventing mortality on the waiting list. Although patients with HU status for ALF have good outcomes, survival is significantly inferior for patients with a high MELD score or for retransplantations. With the current scarcity of livers in mind, we should discuss whether potential recipients for a second or even third retransplantation should still receive absolute priority, with HU status, over other recipients with an expected, substantially better prognosis after transplantation.
The deSUMOylase SENP2 coordinates homologous recombination and non-homologous end joining by independent mechanisms
Authors: Garvin Alexander J. , Walker Alexandra K. , Densham Ruth M. , Chauhan Anoop Singh , Stone Helen R. , Mackay Hannah L. , Jamshad Mohammed , Starowicz Katarzyna , Daza-Martin Manuel , Morris Joanna R.
Published: November 2018

SUMOylation in the DNA double-strand break (DSB) response regulates recruitment, activity and clearance of repair factors. However, our understanding of a role for deSUMOylation in this process is limited. Here we identify different mechanistic roles for deSUMOylation in homologous recombination (HR) and non-homologous enjoining (NHEJ) through the investigation of the deSUMOylase SENP2. We find regulated deSUMOylation of MDC1 prevents excessive SUMOylation and its RNF4-VCP mediated clearance from DSBs, thereby promoting NHEJ. In contrast we show HR is differentially sensitive to SUMO availability and SENP2 activity is needed to provide SUMO. SENP2 is amplified as part of the chromosome 3q amplification in many cancers. Increased SENP2 expression prolongs MDC1 foci retention and increases NHEJ and radioresistance. Collectively our data reveal that deSUMOylation differentially primes cells for responding to DSBs and demonstrates the ability of SENP2 to tune DSB repair responses.
A Teensy microcontroller-based interface for optical imaging camera control during behavioral experiments
Authors: Romano Michael , Bucklin Mark , Mehrotra Dev , Kessel Robb , Gritton Howard , Han Xue
Published: November 2018

Background

Systems neuroscience experiments often require the integration of precisely timed data acquisition and behavioral monitoring. While specialized commercial systems have been designed to meet various needs of data acquisition and device control, they often fail to offer flexibility to interface with new instruments and variable behavioral experimental designs.

New method

We developed a Teensy 3.2 microcontroller-based interface that offers high-speed, precisely timed behavioral data acquisition and digital and analog outputs for controlling sCMOS cameras and other devices.

Results

We demonstrate the flexibility and the temporal precision of the Teensy interface in two experimental settings. We first used the Teensy interface for reliable recordings of an animal’s directional movement on a spherical treadmill, while delivering repeated digital pulses that can be used to control image acquisition from a sCMOS camera. In another example, we used the Teensy interface to control temporally precise delivery of an auditory stimulus and a gentle eye puff in a trace conditioning eye blink behavioral paradigm, while delivering repeated digital pulses to initiate camera image acquisition.

Comparison with existing methods

This interface allows high-speed and temporally precise digital data acquisition and device control during diverse behavioral experiments.

Conclusion

The Teensy interface, consisting of a Teensy 3.2 and custom software functions, provides a temporally precise, low-cost, and flexible platform to integrate sCMOS camera control into behavioral experiments.
Charting the diversity of Uncultured Viruses of Archaea and Bacteria
Authors: Coutinho Fh , Rodríguez-Valera F
Published: November 2018

Viruses of Archaea and Bacteria are among the most abundant and diverse biological entities on Earth. Unraveling their biodiversity has been challenging due to methodological limitations. Recent advances in culture-independent techniques, such as metagenomics, shed light on viral dark matter, revealing thousands of new viral genomes at an unprecedented scale. However, these novel genomes have not been properly classified and the evolutionary associations between them were not resolved. Here, we performed phylogenomic analysis of nearly 200,000 viral genomic sequences to establish GL-UVAB: Genomic Lineages of Uncultured Viruses of Archaea and Bacteria. GL-UVAB yielded a 44-fold increase in the amount of classified genomes. The pan-genome content of the identified lineages revealed their infection strategies, potential to modulate host physiology and mechanisms to escape resistance systems. Furthermore, using GL-UVAB for annotating metagenomes from multiple ecosystems revealed elusive habitat distribution patterns of viral communities. These findings expand the understanding of the diversity, evolution and ecology of viruses of prokaryotes.
Integrated ligand and structure-based investigation of structural requirements for silent information regulator [SIRT1] activation
Authors: Gupta Amit K. , Choi Sun
Published: November 2018

A series of imidazothiazole and oxazolopyridine derivatives as human silent information regulator (SIRT1) activators were subjected to the integrated 2D and 3D QSAR approaches. The derived 3D QSAR models yielded high cross validated q2 values of 0.682 and 0.628 for CoMFA and CoMSIA respectively. The non-cross validated correlation values of r2training = 0.89; predictive r2test = 0.69 for CoMFA and r2=0.87; predictive r2test =0.67 for CoMSIA reflected the statistical significance of the developed model. The steric, electrostatic, hydrophobic and hydrogen bond acceptor interactions have been found important in describing the variation in human SIRT1 activation. Further, 2D QSAR model for the same dataset yielded high statistical significance and derived 2D model’s parameters corroborated with 3D model in terms of features. The developed model was also validated through the available active conformation structure of SIRT1. Developed models may be useful for the identification of potential novel human SIRT1 activators as therapeutic agent.
NanoARG: A web service for identification of antimicrobial resistance elements from nanopore-derived environmental metagenomes
Authors: Arango-Argoty G. A. , Dai D. , Pruden A. , Vikesland P. , Heath L. S. , Zhang L.
Published: November 2018

Direct selection pressures imposed by antibiotics, indirect pressures by co-selective agents, and horizontal gene transfer are fundamental drivers of the evolution and spread of antibiotic resistance. Therefore, effective environmental monitoring tools should ideally capture not only antibiotic resistance genes (ARGs), but also mobile genetic elements (MGEs) and indicators of co-selective forces, such as metal resistance genes (MRGs). Further, a major challenge towards characterizing potential human risk is the ability to identify bacterial host organisms, especially human pathogens. Historically, short reads yielded by next-generation sequencing technology has hampered confidence in assemblies for achieving these purposes. Here we introduce NanoARG, an online computational resource that takes advantage of long reads produced by MinION nanopore sequencing. Specifically, long nanopore reads enable identification of ARGs in the context of relevant neighboring genes, providing relevant insight into mobility, co-selection, and pathogenicity. NanoARG allows users to upload sequence data online and provides various means to analyze and visualize the data, including quantitative and simultaneous profiling of ARG, MRG, MGE, and pathogens. NanoARG is publicly available and freely accessible at http://bench.cs.vt.edu/nanoARG.
One-dimensional networks formedviathe self-assembly of anthracenedibenzoic acid with zinc(II)
Authors: Rabon Allison M. , Goolsby Kayla L. , Young Michael C.
Published: November 2018

Self-assembly of metal–organic coordination polymers occurs because of enthalpically favorable interactions. In the case of the bulky 4,4′-(anthracene-9,10-diyl)dibenzoic acid ligand (abdH2), we demonstrate that the presence of numerous π–π and C—H...π interactions outweigh the formation of saturated coordination complexes with zinc, leading to the formation of a dimethylformamide (DMF) solvate, namely 4,4′-(anthracene-9,10-diyl)dibenzoic acid dimethylformamide disolvate, C28H18O4·2C3H7NO or[(abdH2)(DMF)2], at low concentrations of zinc. Meanwhile, at higher zinc concentrations, the abdH2ligand gives rise to the nonporous one-dimensional coordination polymercatena-poly[[bis(dimethylformamide-κO)zinc(II)]-μ-4,4′-(anthracene-9,10-diyl)dibenzoato-κ2O:O′], [Zn(C28H16O4)(C3H7NO)2]nor[Zn(abd)(DMF)2]n, when assembled in dimethylformamide, while a related compound is observed whenN,N-dimethylacetamide (DMA) is used as the solvent, namelycatena-poly[[[bis(N,N-dimethylacetamide-κO)zinc(II)]-μ-4,4′-(anthracene-9,10-diyl)dibenzoato-κ2O:O′]N,N-dimethylacetamide monosolvate], {[Zn(C28H16O4)(C4H9NO)2]·C4H9NO}nor{[Zn(abd)(DMA)2]·DMA}n. Attempts to use other amide-based solvents did not give rise to any other assembled structures.